A spot has appeared on liver after 40 months of no chemo - 1255850

Lindy,

I'm very sorry to hear about this development, but if it's a single nodule after such a long interval, I think there's good reason to be hopeful she'll continue to do quite well, and I think that local treatment of that single lesion makes sense.

I do think that her situation is likely to be unique, so don't be surprised if you don't have someone else report their experience in a similar situation: there is likely to be nobody around here who has faced a similar one.

Good luck.

-Dr. West

Hi Lindy, I'm sorry to hear this.
I find this link to be very helpful when picturing treatment for indolent lung cancer. http://cancergrace.org/lung/2013/01/23/acquired-resistance-algorithm/

Let us know how the team meeting goes.
All best,
Janine

Lindy:

Hi my dear. . .I had been thinking of you and of M recently. . .and was actually feeling quite overjoyed that we had not heard from you in quite some time. I also was wondering about the new baby :o) ...

But I'm so sorry to read about this new development. Upon reading what you'd written, I immediately thought that this is "another" solitary met (given that so much time has passed since the last time she had anything light up) and that it just needs to be hacked off.

So very very sorry you all are going through this. . .And, I have my fingers crossed that this issue will be resolved very quickly for M.

Much Love. . .xoxox,
Laya

Lindy, I'm no doctor but I think that these recurrences all seem to be only one nodule here and there and to me that would be better than overall progression all at once. She could still do well for a long time with Xalkori. Wishing her all the best. Take care, Judy

Lindy,

ROS1 not ALK? Even better. ;-)

Just kidding. They are similar.

The genes are on different chromosomes but are 49% similar according to this article:
http://www.ncbi.nlm.nih.gov/pubmed/22500682
And in their ATP binding site (where the cascade through biochemical pathways to cancerous behavior begins) they are 77% alike, according to a Dr. Shaw presentation last year.

Given the similarities, it makes sense that some inhibitor drugs for ALK fusion mutation might work on ROS1 fusion mutations, too. And one particular pre-clinical experiment showed an IC50 potency of Xalkori (crizotinib) against the most-common ROS1 fusion (CD74-ROS1) of 4, compared to 21 against EML4-ALK. Since lower is better, this was a very good showing.

The down-side is that not all 2nd generation drugs work well against ROS1. For example, a recent AACR presentation poster by Ariad included data for Chugai CH5424802 against ROS1 fusions that didn't look very effective at all. IC50 potency of 757 to more than 10,000 (yuk!) for a few variants of ROS1, vs. 17 to 132 for crizotinib against those in their lab experiments. Fortunately there are a couple of other experimental ALK drugs that still seem promising.

Another down-side is that there aren't as many ROS1ers, so research on ROS1 might attract less funding and donations than more common ones. So I hope it can ride on the coattails of ALK for a long way.

Best hopes,

Craig

Lindy,

I'm sorry to hear of your Mum's complications. I hope that her doctors can resolve these problems soon, and that the biopsy will be negative for cancer.

The main reason to worry about spreading cancer cells from one part of the body to another is when the cancer is localized to the original organ (in this case her lung) and in the course of some form of invasive procedure cancer cells are spread outside of that organ.

Hopefully the biopsy will show that the spot on her liver is not cancer. If that's the case, then there are no cancer cells to spread. If it is cancer, that means that the cancer cells traveled through the bloodstream from the lung to the liver prior to the biopsy procedure, so that procedure did not cause the cancer cells to spread from the lung.

JimC
Forum moderator

Bleeding can certainly happen with a liver biopsy, but it's a much less risky procedure than a resection. I'm sorry she had that complication, but it's just something that can happen a small fraction of the time. Now that they know what's happening, hopefully they'll see her doing well and not need to intervene. Good luck.

-Dr. West

Sorry to hear this - very stressful for you and of course for your mother. Hope she is being well looked after.

FYI - if the primary tumor was ALK-driven and not previously treated with Xalkori and you're not sure about whether mets have ALK, then . . .

. . . I might be misunderstanding this article, but I think it indicates that in their study the driving mutation (e.g., ALK) was 94% likely to be the same in mets as in the original tumor. However I don't know from this research news article whether they went down to the specific variant rather than just knowing both passed the ALK fusion FISH test (which different variants of ALK could do).
http://www.medpagetoday.com/HematologyOncology/LungCancer/38752

Best hopes,

Craig

I would be very cautious about using this kind of research to guide clinical decisions. The numbers of patients and biopsies is very small, and it's just one small piece of a picture, so I think very few, if any, experienced clinical oncologists would consider this as appropriate to shape patient management.

-Dr. West

Lindy,

FWIW, I doubt an oncologist would re-biopsy unless they thought the results (e.g., the type of drug resistance that is in the frontrunner cancer) might change treatment plans.

For example, if someone had progression after Xalkori for ALK, even if it is still ALK some oncologists will get value in knowing that rather than guessing that (i.e., 2nd generation ALK drug might be worth trying vs. ALK not found in the frontrunner cancer). And knowing the specific variant of ALK could be useful to some oncologists (if they have knowledge of which common variants do or don't usually respond to each of the promising 2nd generation drugs). And if the mechanism of resistance is very different (e.g., SCLC after Tarceva for EGFR-driven cancer), treatment plans might change. So not only is the 94% only part of the story, but you might not want to be wrong that other 6% of the time if it's avoidable.

That's my guess.

Best hopes,

Craig

A different scenario then, Lindy: If early stage cancer was removed surgically, and cancer appeared more than 3 years later, I can imagine some doctors wanting to test a biopsy sample of the new appearance to see if test results suggest it is a recurrence of the original or a new primary tumor. (I'd rather have had two early-stage primaries than stage IV -- preferable treatment options are different.)

That said, I understand complication from biopsies occur, but usually minor. When nasty complications occur I wonder what could have been done differently to avoid that, and how they can be prevented for other people in the future who need similar biopsies.

Best hopes,

Craig

Liver biopsies can bleed, so there's definitely some risk involved, though it's rare to have it become a very serious complication.

As Craig suggested, the two main reasons to do a biopsy would be to ensure that the new lesion is a metastatic lesion from the original cancer (likely, but less of a given when there's a single metastatic lesion and much time has passed since the original diagnosis), or to see if the molecular marker pattern might yield to a unique treatment plan that wouldn't otherwise be recommended.

-Dr. West

That's part of why it makes sense to be judicious about focusing on things that have an established value. Sometimes our treatments are worse than the disease, especially if we're doing them because we're just itching to do something.

Good luck.

-Dr. West

Hi Lindy:

So sorry to read of this complication for M. Hope she is faring OK right now.

I am keeping all of you very very very close!

Much Love,
Laya