Moving forward - 1252591

I understand, Dr. West. Thank you.
Today we met the oncologist, the radiologist and the radiotherapist and we had the chance to discuss the MRI findings. So, there are 3 confirmed metastatic lesions (7, 6 and 3mm) and an "unclear" local leptomeningeal involvement of the brain furrows (sulci) nearby one of these lesions.
They cannot exclude that it might be focal leptomeningeal carcinomatosis at a very early stage as direct extension from the contiguous brain met, but there is not enough data to get a clear conclusion.
We are certainly scared of this possibility.

Based on your experience with lung cancer patients, can leptomeningeal carcinomatosis be induced locally from a contiguous brain met or is it more likely to have a systemic development?

By the way, we have agreed that it makes sense for now, being the disease mostly asymptomatic, to go through the 3rd round of Taxotere and have a CT scan to check the response. Also, we will possibly have another MRI in about 1 month to better understand the evolution of these lesions in the brain and consider gamma-knife.

Mike

Quick update and happy to share some good news with the rest of the community.
My dad has just had a CT scan after 3 cycles of Taxotere. Results:

- Almost complete regression of all the 3-4mm nodules in the right lung
- All lymph nodes (mediastinal, superclavear and axillary) back to normal size, except one (13mm, hilo-pulmonary)
- One lesion in the liver reduced to 4mm (from 10mm in Dec.), two more lesions stable at 4mm.
- Osteolytic lesion in the XI rib no longer detected
- Brain mets slightly reduced, although not significantly. They were 7.5mm and 6mm, now 6mm and 4.7mm.

I understand this might be interpreted as a good response and we are excited with it!
Taxotere is being tolerated well, with just some fatigue and mild leukopenia mostly limited to days 4-8 after the infusion. His oncologist is keen to keep him on the 75% dose, being this well tolerated and, apparently, fairly effective. We’ll go through 3 more cycles now.

Still open the debate on the brain mets. As they seem to be stable and still asymptomatic (nobody was really expecting a significant improvement from Taxotere on them), one option is to do nothing for now and possibly try to treat them with Tarceva at a later stage. The other option would be to do cyberknife. Any idea on what is really common practice in a situation like this would be appreciated.

The CT scan has also detected a blood clot in the right femoral vein and this is now being treated. He has just started Fluxum (parnaparin) and, once again, we are a bit concerned about the impact on his renal insufficiency. I’ve learned from GRACE that Lovenox is usually the choice, but I don’t know if there is much difference with Fluxum. Is Lovenox more appropriate for lung cancer patients?
We are trying to get an opinion from a nephrologist about the usage of this kind of anticoagulants in patients with renal insufficiency, but it is really difficult to find competence for such a specific situation.

Thanks for your valuable support. Mike

Thanks Dr. Weiss.
We'll go on with Parnaparin and try to monitor closely the kidney function. If we are lucky, after 7-10 days we might be able to reduce the dose to the maintenance level.

In the meantime, we also need to take a decision about the brain mets...treat them with cyberknife or just wait and see if they stay stable and asymptomatic.
I'm actually also concerned, based on what I've read on GRACE, about the possible effect of the anticoagulant on the brain mets. I don't really know if that applies to this specific situation.

Thank you. Mike

Yes, thanks so much for sharing your thoughts.
That's our main doubt today. Our radiotherapist would like to avoid WBR for now. Considering that we have identified only 3 brain mets, which seem to be small and asymptomatic, it may be wise to take arrangements for cyberknife instead, which would certainly give less or no side effects. The other option, reasonably valid too, is to monitor them for some time, given that there is no clear sign of progression for now.
Difficult decision to take again, especially because I believe no clear protocol seems to exist for situations like this.

Has anyone experienced severe dyspnea with Taxotere?
Dad is currently dealing with it and it's difficult to identify the real cause... considering that he is on both taxotere and parnaparin (...and, not less important, he is living with just one lung).

Thank you.

Just decided not to proceed with the 6th cycle of Taxotere, which was planned for next Tuesday. We'll take a break, as side effects are now being hardly tolerated. Dad is really tired these days and he is spending most of his time laying down in bed. The most significant problem is the dizziness, when he stands up, and we are not completely sure it is associated with Taxotere. Any experience with this?
He is being administered dexamethasone, which might somehow help.

The next step is to have a MRI as soon as possible and check the state of his brain mets (they might be also inducing dizziness?). Then a CT scan to check the rest of lesions and possibly start Tarceva.

I'll keep you posted.

Thanks Dr. West for the clear answer.
We'll investigate the situation a bit more in depth over the next few days.
He's certainly not eating/drinking well, and he is also having some episodes of vomiting and diarrhea. I don't know whether this can be a possible cause of the dizziness, but it is certainly not helping him recover.

Unfortunately, I have to say that my main concern relates to that "unclear local leptomeningeal involvement of the brain furrows" near one of the lesions that were found in the brain in the previous MRI.

Thank you. Mike

Janine, Dr. West,

Thank you both for your replies. Sorry I didn’t manage to write back until now.

Janine: you don’t have to apologize for just sharing your view and thoughts on this situation. They are so precious for us and the rest of the community.
I’m not sure whether we are quite at the point of considering hospice home care, but I need to be realistic as sooner or later we might have to do that. The main problem we may have in the region in Italy where my parents live is that it is not really common practice and it may be difficult to find a good centre. I’ll investigate, as I absolutely agree with you that it may be a very good option for both the patient and the family.

Dr. West: we found low red blood cell counts and low haemoglobin a couple of weeks ago, so the dizziness can certainly, at least partially, be associated with this and the fact that dad is not eating/drinking well. However, we cannot exclude there’s something also related to the brain mets. Dizziness is intermittent during the day, often associated with asthenia, and in addition to this we have noted some loss of hearing and a certain difficulty in the expression (language).
Last week, he had a CT scan and the situation is generally stable, with just the three 4mm-lesions left in the liver, which I believe are absolutely asymptomatic. The brain mets look stable too, but this week he’ll have a MRI to get a clearer picture of the situation.

His oncologist wants to start Tarceva, hoping for a resensitization to the EGFR TKI after the acquired resistance to Iressa last year. Hopefully, Tarceva may also help with the brain mets, but we cannot exclude cyberknife (can they be combined?)

I’ll keep you posted. Mike

We'll consider that, Dr. West.

I was just wondering whether in a setting like this, where a patient has completed a 4-month chemo-based treatment with relatively good response and the disease seems fairly stable, it would also make sense to take some time off from drugs, especially to save the precious "one-try" re-challenge with Tarceva for later, when the disease may start progressing firmly again.

It might be an interesting option, also becasue the "visible" disease at this stage could also be potentially treated only with cyberknife (both the liver and the brain lesions).

I believe it is again a difficult decision to take.

Dr. West, in line with what you pointed out in your previous post, we were seriously considering the possibility of taking a break and delaying the re-challenge with Tarceva at a later stage.
Unfortunately, last week the MRI to the head showed the presence of a new small lesion (6mm) to the brain. The other 3 are stable since they were detected in early January (7mm, 6mm and 3mm).
No doubt they will need to be treated and we are already in conversations with a hospital where we can get cyberknife treatment.

But, if the real tendency is to create more brain mets, although it would seem in a relatively slow manner, what options do exist to prevent that? Chemo hasn't helped, as we expected, so we may really need to try Tarceva as soon as possible and see whether we are able to stop new brain lesions from coming out.
The other option would be WBR (instead of or after cyberknife), but considering the possible consequences, can we keep it for later?

I would have liked to come back to write here with a clearer picture of the situation, but I'm afraid that might take a few weeks more, so I've decided to write a few lines anyway and share with you at least what we know that has happened during the last 3 months.

After the 5th cycle of Taxotere in March, dad went through a very challenging period with a number of debilitating problems that forced him to spend quite a lot of time in bed. We weren’t sure really that his condition was necessarily a consequence of the chemo. He tolerated Taxotere quite well until then and we couldn’t understand how those side effects could come out all together after the 5th dose. The response had been relatively good, with only his brain mets, as expected, not getting any significant benefit. We also thought that his dizziness, weakness, aphasia, etc.. could potentially be more associated with the brain mets (3mm, 6mm and 7mm), rather than being side effects of Taxotere.

At the beginning of May, we took arrangements for Cyber Knife and started a re-challenge with Tarceva, after being 6 months off from Iressa.
So far, we still haven’t been able to get a new CT/MRI as Tarceva seems to be seriously affecting his renal parameters (we had to cancel the CyberK treatment too), but I’m happy to say that after only 1 week on Tarceva his physical condition has incredibly improved. Since May, he is now living a relatively normal life and, until we are able to perform the CT/MRI to clarify the situation, we are assuming that Tarceva is probably having a good response in his brain. I believe that shouldn’t be that unusual for an EGFR+ patient.

Last week, he reduced Tarceva to 150mg every other day and his renal parameters seem to be improving.
Our objective now is to achieve acceptable figures for his creatinine level, so that the radiologists can perform a CT scan with relatively low risk for his kidney.

I will keep you posted and I really hope Tarceva will keep him fit for some time...

Thank you Dr. West and Laya. Hopefully in September we shall be able to perfom the CT scan and have a clearer picture of the situation.

Dr. West: I found your recent post on Afatinib extremely interesting and I'm looking forward to the next "chapter" in which you will review its potential in EGFR+ patients with acquired resistance to other EGFR inhibitors. That's potentially our next option for when Tarceva will be no longer effective.

I was actually wondering whether, in my dad's specific case, it may also make sense to go back to Taxotere, considering that the previous treatment (5 cycles) was relatively effective (at least, outside the head) and was stopped "only" because it happened to be no longer tolerated. Is it a good choice to go back to a chemo drug that might still be effective if the cancer has never really progressed on it?

And if what is really happening now is a successful re-challange with an EGFR TKI, possibly due to a re-sensitization after the acquired resistance, can that happen again after a new period off from it?
Is this what is usually called "sequential therapy" or "switch maintenance"?

Just some thoughts...