Dear doctors, researchers, patients, and family members,
My dad (61 years old) has been diagnosed with stage IIIA squamous cell lung cancer with a tumor in his lower left lobe. Based on what I've learnt from various educational sources on lung cancer, this is quite a controversial stage. However, his doctor and him decided to proceed with pneumonectomy because it involves the bronchus. After the surgery, they found that the tumor has invaded his esophagus. So the staging after surgery actually becomes T4N2M0 instead of T2N2M0 before surgery. All affected lymph nodes were dissected during surgery as well. Thinking back, I wish we would have had a 2nd opinion. Perhaps, in this case, chemo before surgery would have been a better option.
So now, my question is, whether he should start radiotherapy first to treat his esophagus, or start chemo first to treat lymph nodes metastatic.
His genetic testing shows no obvious mutations. So I'm assuming traditional chemo would be the way to go.
Thank you very much.
Reply # - October 30, 2013, 06:57 PM
Reply To: Chemo first or radiotherapy first after surgery in
There isn't any ironclad standard. However, because postoperative chemo has a proven survival benefit but postoperative radiation doesn't, we generally prioritize the chemotherapy, giving it before radiation, if radiation if given at all. Radiation is sometimes given concurrent with chemo in very fit patients (but it's very hard to do concurrent chemo/radiation after a big lung surgery, so we don't do that for most patients). It's likely to be extremely tough after a pneumonectomy.
That analysis presumes that the resection was complete and that the surgical margins were negative. If the surgery was incomplete and the margins are positive, that would be a real shame becuase the surgery was probably of very limited or no value. In such a situation, radiation becomes a higher priority, but it's hard to prioritize over chemo and make any kind of general suggestions. It becomes necessary to address on a case by case basis.
Good luck.
-Dr. West
Reply # - November 6, 2013, 01:24 PM
Reply To: Chemo first or radiotherapy first after surgery in
Thanks very much Dr West. It is a R1 resection because the esophagus was invaded and they suspect there might be cancer cell remaining. Do you think radiation should take priority in this case? Thank you again.
Reply # - November 6, 2013, 08:51 PM
Reply To: Chemo first or radiotherapy first after surgery in
An R2 resection is when gross (visible) disease is left behind. An R1 resection is when microscopic disease is left behind, but nothing visible.
I'm sorry that I am not legally permitted to provide a medical recommendation for such a unique case that I'm not directly involved in. I can only provide general information, but the medical recommendations need to come from the doctors directly involved.
-Dr. West
Reply # - November 7, 2013, 06:01 AM
Reply To: Chemo first or radiotherapy first after surgery in
Thanks again dr. West. I completely understand where you come from.
In his case the r1 comes from one his lymph node pressing on his esophagus. They were able to dissect the node but wasn't sure the margin was negative. His doctors recommended radiation first because it might also help with the local lymph nodes involvement. They also said squamous cell also tends to have local reoccurrence rather than distant metastatic, so radiation is more urgent. We just want to seek a second opinion.
Reply # - November 7, 2013, 06:07 AM
Reply To: Chemo first or radiotherapy first after surgery in
Both of those are very good points. Yes, we do generally think of squamous NSCLC as often tending to stay local for longer, and radiation moves higher up as a treatment priority when we know or suspect that there is cancer left behind in the area of the primary tumor.
-Dr. West