Dear Dr. West,
Let me begin by thanking you and the other faculty members for offering such a wonderful resource for cancer patients and their families. I am writing on behalf of my mother who is 69 years old and was diagnosed with multifocal BAC last month. She was diagnosed with pneumonia in 12/12 with classic symptoms which resolved with antibiotic therapy. Her follow up chest imaging showed a persistent lingular infiltrate which appeared slightly improved in appearance on follow up chest CT in 4/13 compared to 12/12. Due to its persistence, she was scheduled for bronchoscopy which showed adenocarcinoma of the lung with an appearance consistent with BAC. Her PET CT showed areas of uptake in bilateral lungs as well as right paratracheal and subcarinal lymph nodes and bilateral hilar nodes with SUVs between 3 to 5 in the areas of uptake. There was no uptake noted outside the chest on the scan.
The tumor was TTF-1 positive, CK7 positive, CK20 negative, and napsin positive. Molecular profiling to date has shown the tumor to be EGFR wild type and KRAS mutated with Gly12Val substitution. She has no symptoms whatsoever other than an intermittent cough. Her performance status is 0 on the ECOG scale and her PFTs were within normal limits with SpO2 of 100% on room air. She had very minimal tobacco exposure (less than 3 cigarettes per day) in her 20s and has not smoked at all since 1981. Her past medical history is remarkable for hypothyroidism and hyperlipidemia as well as ITP with platelet counts mostly in the 90-110K range.
I understand that she is likely to be a non-responder to Tarceva given her molecular profiling results but would like to know if there are any trials of agents that would target her KRAS mutation. If not, what is your opinion of watchful waiting versus immediate chemo in such a case? I am concerned about the spread of the tumor beyond the chest with a watchful waiting approach.
Thank you again for sharing your expertise and time.
Reply # - June 3, 2013, 05:24 AM
Reply To: BAC
Hi baharjoon,
I'm sorry to hear of your mother's diagnosis, although it's good to hear that she has such minimal symptoms. Here are links to some of Dr. West's previous posts on BAC:
http://cancergrace.org/lung/2013/01/20/mf-bac-algorithm/
http://cancergrace.org/lung/2011/11/29/bac-today/
http://cancergrace.org/lung/2010/07/09/basics-of-bac/
http://cancergrace.org/lung/2010/03/02/watching-ggos-over-time/
http://cancergrace.org/lung/2010/01/28/interview-with-dr-matthew-horton…
As far as trials, a search of clinicaltrials.gov did not turn up any trials specific to the combination of BAC and a KRAS mutation, but you can search for KRAS trials and find many that are being conducted.
JimC
Forum moderator
Reply # - June 3, 2013, 07:58 PM
Reply To: BAC
I'm sorry about her recent diagnosis. There are a few emerging trials of a class of drugs called MEK inhibitors, with selumetinib being the one furthest along in testing, being combined with Taxotere (docetaxel) in second line therapy. There may be a stray trial somewhere of a MEK inhibitor in first line, but you could exhaust yourself looking for one.
Standard chemo would be the main treatment approach, and many might favor a combination of a platinum drug (cisplatin or carboplatin) with Alimta (pemetrexed), as the latter is definitely among the better tolerated and also has particular activity in adenocarcinomas (of which BAC is a subtype), and there is even a very small amount of evidence suggesting that Alimta may be a strong choice for KRAS mutant NSCLC as well.
As for whether to start treatment now or later, that is primarily a recommendation I base on the pace of the cancer progressing over time, the patient's symptoms or lack thereof, and the patient's anxiety level about feeling a need to be on or preferring to be off therapy. If someone is without symptoms, has apparently indolent disease, and is not debilitated by anxiety about not being on treatment right this minute, I consider attentive clinical and imaging follow up a fine, arguably preferable, approach.
Good luck.
-Dr. West
Reply # - June 4, 2013, 07:58 PM
Reply To: BAC
Thank you for this very useful information. I truly appreciate your guidance.
Does the presence of bilateral lymph node involvement indicate an invasive form of BAC that has a greater likelihood of spreading beyond the chest? Or does this finding have no particular prognostic significance? Would chemotherapy potentially be recommended now rather than later to prevent possible distant metastasis?
Thank you again for your dedication to educating us about this relentless disease.
Reply # - June 4, 2013, 08:33 PM
Reply To: BAC
Hi baharjoon,
With regard to BAC which has spread to lymph nodes, Dr. West has said:
"I would say that BAC doesn’t typically spread to lymph nodes, so if it has spread to a contralateral lymph node, it might very appropriately be treated like other lung adenocarcinomas. Here, the standard approach would be chemo and radiation without surgery. However, it’s fair to consider a unique approach for unusual cases. I think it’s reasonable to develop an individualized plan, but I couldn’t speculate on how to pursue that as someone who has none of the relevant details." - http://cancergrace.org/lung/topic/bronchioalveolar-cell-carcinoma/#post…
JimC
Forum moderator
Reply # - June 4, 2013, 10:14 PM
Reply To: BAC
The key point is exactly the issue Jim unearthed. If it's involving the lymph nodes, it's not behaving like a BAC, so it should almost certainly just be treated as a conventional (invasive) adenocarcinoma.
-Dr. West
Reply # - June 4, 2013, 10:43 PM
Reply To: BAC
Thank you so very much for the replies. The lymph node involvement is suspected based on the PET CT findings but the relatively low SUV uptake along with the pathology results from the biopsy showing no clear invasion were thought to be consistent with BAC. I realize that BAC may present mixed with a component of invasive adenocarcinoma. In such instances when there is a lack of clear progression on chest CT over several months and a lack of clear symptoms due to the tumor, could the watchful waiting approach still be considered? in other words, does the presence of possible thoracic lymph node involvement without distant metastases preclude consideration of watchful waiting when all other factors point to a more indolent course?
Thank you again for taking the time to read and respond to these questions.
Reply # - June 5, 2013, 06:33 AM
Reply To: BAC
The answer is that while you won't find the answer in any book, I and many other experts would at least strongly consider and very possibly favor an approach of watchful waiting if repeat scans over time, perhaps combined with a low SUV on PET, indicated an indolent cancer. This applies whether a cancer is BAC or an invasive cancer, and whether it's in a limited location, in lymph nodes, or even obviously metastatic. The actual clinical behavior should be the most important factor guiding these decisions.
-Dr. West
Reply # - June 5, 2013, 03:54 PM
Reply To: BAC
Hello baharjoon, I just wanted to add my husband's experience in having an indolent nsclc. His histology, squamous, is usually a bit faster moving cancer than adeno and especially BAC and there are less options for treatment but his cancer has shown such an indolent and receptive to treatment biology that his scans are beginning to look an awful lot like something we can treat for a long time. While we have no good idea of how it will play out we feel confident that we can treat it with an ample supply of watchful waiting.
I say this because I want to emphasize that every case is individual and all the stats have out-layers that are now being looked at with individualized treatment in mind. We are looking at treatment as a process that can take my husband out much longer than stats had us first believing would happen.
I know that we have a lot of unknowns and anything can happen but I want to emphasize that there are those who have to take the place of best possible outcomes and hopes for a better tomorrow are always always there.
We have been lucky, very lucky, and even with all the physical and emotional difficulties that keep him from leading what he built as a normal life we are thankful for occupying this position.
All this only became known to us through time and watchful waiting.
I wish all Grace the grace we have been given. No matter how long it lasts we are honored to be in this position.
Reply # - June 5, 2013, 07:22 PM
Reply To: BAC
Much thanks to all of you for your input and guidance. It is much appreciated during this difficult time. I am so glad to know there is such a supportive network for patients and family members facing lung cancer. You are a true treasure!
Reply # - June 5, 2013, 08:53 PM
Reply To: BAC
baharjoon. . .
Just wanted to join the chorus in welcoming you to GRACE. . .
Laya