Slight or Diffuse Spread? - 1256396

chebird
Posts:104

I just listened to several podcasts on acquired resistance here which seemed to be in agreement that unless the progression is diffuse, The patient should stay on the TKI therapy.

So my question is, would two mets to inside the dura of the spine constitute slight progression or diffuse spread?

The thought of "Tarceva flare" is frightening. My husband has done extremely well on Tarceva with little side effects. He is egfr positive.

Thank you again for the wealth of information here.

Holly

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Reply # - May 12, 2013, 09:38 AM

Dr West
Posts: 4735

If there is any ambiguity (i.e., more than one lesion), it's entirely a question of judgment. The reason I asked the question of many experts is that it's no so straightforward that anyone can be dogmatic about an answer.

To me, the question really boils down to whether there are areas of disease that have responded well to EGFR inhibitor therapy and haven't shown that they're growing now. If it appears that the EGFR inhibitor is still inhibiting much disease compared with what you'd expect without it, then I'm generally inclined to continue it. But we can't answer the question for any specific case that we aren't directly involved in.

Good luck.

-Dr. West

Reply # - May 12, 2013, 02:53 PM

carrigallen
Posts: 194

One general option might be to do spinal surgery (if it is just inside the dura, it may be surgically accessible) followed by radiation to the resected tumor bed. That resected tumor tissue could be sent for additional resistance mutation testing.

Another general option might be radiation alone - it depends on the location of the tumor. The best person to answer this question is a neurosurgeon.

If the rest of the body is not active with cancer, then it seems reasonable that he could stay on the pill. That is difficult to assess in someone who has received lung radiation. Sometimes, what appears to be scar tissue may really be cancer, or vice versa - it depends on how its appearance has changed over time.

The idea of 'EGFR flare' has recently been promoted by some groups, however I understand that there is little consensus on exactly what it is, who gets it, or how it occurs. Most guidelines do not advocate continuing TKI if additional chemotherapy is being added, because any combined benefit (unproven) does not seem to outweigh the known increase in toxicity. Hope this helps.

Reply # - May 12, 2013, 04:52 PM

chebird
Posts: 104

Thank you both. Both replies are extremely helpful. The doctors here are unbiased and compassionate.

He is starting external beam radiation tomorrow and still taking Tarceva for the met at T9 ( I mistakenly said T5 earlier). His original Pancoast responded beautifully to chem/rads, and the T12 neural sheath tumor had identical pathology. The neurosurgeon said he could get the one at T9 out, but it is in a trickier spot than the T12 was, with a greater risk of permanent disability. He said he would like to see the whole spine receive radiation, but the radiation oncologist said he can't radiate T1/T2 which have already received radiation. But we may go the way of surgeryif the radiation doesn't do the trick.

Forgive me, one more question (I'm trying to make this not case-specific). Would radiation on the spine (not ck) possibly take further surgery off the table for someone with an intradural met?

Thank you again for this site; it is an amazing resource.

God bless you all,

Holly

Reply # - May 14, 2013, 07:40 PM

laya d.
Posts: 714

Hi Holly. . .

Just wanted to say hi and to wish your hubby lots of luck. I'm also hoping to bump this thread back up cause I think you still have a question or two pending.

Much Love,
Laya

Reply # - May 14, 2013, 08:40 PM

Dr West
Posts: 4735

I appreciate that you're trying not to be case-specific, but these situations are always taken on a case-by-base basis, which is why we couldn't give a real answer. There are no general rules, but in general, prior radiation leads to a good amount of resistance to doing subsequent surgery around the spinal cord within the radiated field.

-Dr. West

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