Recurrence of NSCLC T1N2M0 - 1261406

falstaff
Posts:12

Hi, my father underwent surgery (SPN 1.6cm on CT) on Feb 2010 where they diagnosed him with adenocarcinoma Stage 3A (moderately differentiated, station 4 lymph node positive for metatastic adeno) after an open biopsy that resulted in a RUL. He received carbo/taxol and radiation after surgery. He also has CLL which has been controlled every year with chemotherapy and is at this moment awaiting FDA approval for ibrutinib (WBC 150,000 now but otherwise good hgb and platelet count) as his CLL is worsening. Last week in a follow up pet/ct scan they discovered a 1.8cm spiculated nodule at the lower surgical margin of the lobectomy with a SUV of 10. The oncologist referred him to thoracic for possible open biopsy and resection/lobectomy. He also states that it could be scar tissue or fungal lesion or even a new primary cancer. The conundrum we are facing is whether surgery is the indication for stage 3a recurrence if it is a local recurrence as this one appears to be. I've read many journal articles that state to act aggressively but others that chemo might be best. His oncologist is very positive and recommends surgery but I can't find guidelines for recurrence at this late stage. I'm also worried of him receiving adjuvant lung chemo and CLL ibrutinib (if approved) or arzerra (chemo) at the same time after surgery. It is important to emphasize that he has been asymptomatic throughout this 5 year period(all incidental findings) and has been very responsive to treatment. Please advise on protocol/guidelines for treatment of recurrence and post-op chemo options. Thanks for sharing your expertise.

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Reply # - January 8, 2014, 03:11 PM

catdander
Posts:

Below are blog posts from our library that speak to recurrences and treatment of lung cancers. The first thing that comes to mind about treating stage III nsclc is there are no standards or guidelines and is often said to be the most controversial of cancers to treat. As far as how you treat them concurrently depends on the interaction between the drugs and how much if any real data exist about the combos you're talking about. Ill ask Dr. Walko if she has any input about pharmacodynamics. Targeting the disease most likely to cause harm first is treated first if sequencing is done. My husband is sensitive to chemo so my speck of data says we should consider mounting side effects.

Wishing for the best,
Janine

The first link one is dedicated to treatment and may be what youre looking for.

http://cancergrace.org/cancer-101/2007/11/01/rx-of-recurrences/

http://cancergrace.org/lung/2011/08/19/when-do-recurrences-of-lung-canc…
http://cancergrace.org/lung/2007/10/30/recurrence-and-new-cancers-after…

Reply # - January 8, 2014, 03:46 PM

Dr West
Posts: 4735

With an interval of >3 years since initial diagnosis and an appearance of a solitary spiculated nodule, I would say that most experts would favor treating this as a potential second, unrelated lung cancer or an isolated recurrence that could be treated with curative intent (and the former is probably more likely). Chemotherapy alone wouldn't be curative.

The main reason to even do imaging after surgery or chemo/radiation for earlier stage lung cancer is to potentially identify a recurrence that hasn't demonstrated distant spread. In such a case, some combination of surgery, chemotherapy, and/or radiation may potentially be done with a possible chance for cure. If a cancer recurs in the liver, bones, adrenal glands, brain, etc., it's not curable, but if it's in a lymph node or adjacent to the prior local therapy, it's not unrealistic to treat the cancer with curative intent.

Bear in mind, also, that people with a history of lung cancer are at higher risk than the general population for developing another lung cancer, even independent of the first one. It's possible for people to develop 2 or even more independent lung cancers, and if they're unrelated, they can each be treated with curative intent.

Good luck.

-Dr. West

Reply # - January 8, 2014, 05:05 PM

falstaff
Posts: 12

Thank you very much for your prompt replies. The thoracic surgeon called after posting my question and he will perform surgery next monday. He believes after seeing the pet scan it might be a second primary lung cancer but thinks it's much more aggressive than the adenocarcinoma based on SUV values. (Adeno presented in 2009 with 3.43 SUV, this new nodule's uptake is 10). Thanks again for all your help!

Reply # - January 8, 2014, 05:12 PM

catdander
Posts:

Ummm I love that answer. Thanks Dr. West, and Thanks falstaff for the question. Makes me wonder what my husband would do if his recurred. Why not be hopeful that the best will happen, the hard part is not try review too many possibilities. The list is endless.

Had nice but unexpected guest and just now emailing pharmacologist input. so sorry.

All best,
Janine

Reply # - January 8, 2014, 05:28 PM

falstaff
Posts: 12

Thanks Janine! The pharmacologists' input would be greatly appreciated. Oncologist said he's never given both CLL and lung cancer chemo to anyone at the same time. We are confident the best will happen moving forward, he's done it before! I'll keep you posted on the progress!

Reply # - January 9, 2014, 09:50 AM

dr walko
Posts: 102

We have a few patients who have had CLL or related conditions that we have also treated for solid tumors. The biggest concern is combined toxicity to the blood cells, especially the white blood cells. Generally, we have either lowered the doses of the chemotherapy or done more frequent monitoring of the blood cells.

Best wishes,
Dr. Walko

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