My father (65) was recently diagnosed with lung cancer. x-ray and CT-scan showed masses in his lungs. PET scan showed masses in lungs, lymph nodes and lesions in bones and liver. Bronchoscopy was done followed by biopsy. Frozen section of biopsy report said NSCLC Adenocarcenoma. A week later paraffin section of biopsy, immunohistochemistry report said NSCLS with squamous lineage (I am assuming that is squamous cell carcinoma). By that time his chemo regimen was started with Carboplatin + Pemetrexed. The oncologist did not change the drugs for second cycle although the IHC report did not show adenocarcinoma. To avoid confusion, he ordered a review of IHC + a couple of mutation tests. The review report came yesterday and it showed SCLC (repeat SCLC and not NSCLC).
Now I am totally confused. Three tests gave three different diagnoses. Which one to go by?
Is the chemotherapy drugs going to be same irrespective of the type of lung cancer?
What should be my next course of action?
Thanks,
Shankar
Reply # - June 14, 2013, 09:30 AM
Reply To: Conflicting diagnosis of Lung Cancer
I'm very sorry to hear your father has been dx with lung cancer. Knowing what type though does sound very confusing. Unfortunately it does matter what type of chemo is given. Pemetrexed is only used in adeno nsclc so until this is worked out there are other options that have efficacy in all three. Carbo is given with all three cancers in the first line of treatment. Etoposide is a partner drug to carbo that can have efficacy in all 3 types.
Have you or the oncologist thought about having the tissue looked at at a larger cancer research hospital with specialties in lung cancer?
I will ask a doctor to respond to your post.
All best,
Janine
forum moderator
Reply # - June 14, 2013, 10:14 AM
Reply To: Conflicting diagnosis of Lung Cancer
It's not that rare to see a combination of SCLC and NSCLC (seen about 5% of the time), so I wouldn't necessarily consider these to be conflicting results. In either case, pemetrexed (Alimta) is a poor choice of chemo for either SCLC or squamous NSCLC, though there are many other chemo agents that would be reasonable choices to cover both. A combination of a platinum agent (cisplatin or carboplatin) with etoposide would often be among the most favored choices to treat both the SCLC and NSCLC component, but other chemo agents than etoposide would be reasonable for treating SCLC as well as NSCLC. Pemetrexed in particular would be the main standout as a poor choice here.
Good luck.
-Dr. West
Reply # - June 23, 2013, 01:05 PM
Reply To: Conflicting diagnosis of Lung Cancer
The situation you describe is surprisingly not as unusual situation as one may think, for a variety of reasons:
1) There is some overlap in IHC test results between these cancers
2) Poorly differentiated cancers can be difficult to discern regarding squamous vs. adeno since they lack features of either.
3) Above all, the pathologist is limited by the amount and quality of the tumor tissue submitted.
In cases of very small bronchoscopic biopsies with tumors that don't have much distinctive features of any subtype, it can be something of a guessing-game. It's like looking at a fuzzy, grainy, black & white photo and trying to say whether it's a dog or a wolf or a cat. It's definitely a four-legged animal (cancer), but the exact species is not always easy to tell.
If he has already received two cycles of treatment, it may be reasonable to repeat his films, and if a good response is achieved, continue whatever has worked so far. The fact is, this is not an exact science. If a drug is working, and it is being tolerated well, it is reasonable to continue it. Good luck!
Reply # - June 23, 2013, 01:38 PM
Reply To: Conflicting diagnosis of Lung Cancer
Thank you so much Dr. Creelan for your input. I especially like the analogy, I always do better with several perspectives from which to develop an understanding.
As a layperson who thought she knew and thing or 2, I didn't, I am still taken aback by how much judgement is involved to make treatment decisions for any given individual, there are so many moving parts and all individual.
Thanks again for jumping in,
Janine