Good evening Dr. West:
My husband has completed three cycles of his chemo doublet and had his first CT Scan since the assessment phase in Dec 2013. The oncologist told us that the cancer is stable.
While being assessed, the PET scan showed two possible mets to the brain and the hip. MRI were done on both. The results of the hip MRI came back suspicious for cancer. We were told it was worded this way as one cannot conclusively say cancer without a biospy. (The brain mets have been treated with open brain surgery and Cyberknife.)
His diagnosis was:Stage IV NSCLC Adenocarcinoma with focal sarcomatoid differentiation, T2a , N0, M1 to brain and right acetabulum.
The latest CT scan shows absolutely nothing on his hip. How can this be? It is my understanding that if it is a result of the chemo then there should be some calcification on the bone. Could his initial diagnosis be wrong? The nodes were all clear. Is this normal in metastatic disease?
Thank you,
TriciaM
Reply # - April 28, 2014, 07:33 PM
Reply To: Mets to hip not seen in CT Scan
It sounds like the diagnosis of bone metastases was equivocal, so I don't know that it's possible to surmise what happened. Perhaps the original findings were an overcall. Perhaps there was a response in the bone and nothing residual is detected. But the key point is that it probably doesn't matter. There isn't a clear need to change treatment/add anything for the questionable bone disease if there's nothing to see now, whether there was ever something present or not.
Good luck.
-Dr. West
Reply # - April 28, 2014, 08:12 PM
Reply To: Mets to hip not seen in CT Scan
Dr West:
My concern is from the metastases to the hip was the factor which changed my husband's prognosis from curative to pallative. The doctors had said if the spot on the hip was not cancer then they would remove his upper right lobe and treat the brain metastases.
The brain metastases was treated as it was felt that it would cause paralysis of his right side but there are no plans to treat the lung tumours. If the cancer is localized would if not be optimal to go ahead with the surgery?
Thanks,
TriciaM
Reply # - April 28, 2014, 09:29 PM
Reply To: Mets to hip not seen in CT Scan
Hi TriciaM,
It appears that the concept upon which your husband's doctors considered surgery to remove his RUL and treat the brain mets is that of the precocious metastasis, which has been discussed previously by Dr. West: http://cancergrace.org/cancer-101/2012/04/06/broadening-precocious-met/…
It would seem that the main concern with performing the surgery now is that, should his cancer prove to be truly metastatic (cancer cells have spread throughout the bloodstream) and you perform this significant surgery, if the cancer begins to progress he may still be debilitated by the effects of that surgery and be unable to tolerate the chemo he would need at that point.
Has radiation to the lung tumor(s) ever been mentioned as an option? Although it is not risk or symptom-free, it can be easier to handle than surgery.
At any rate, this is certainly something worth discussing with his doctors, who can make their recommendations based on a thorough review of his situation.
JimC
Forum moderator
Reply # - April 29, 2014, 09:35 PM
Reply To: Mets to hip not seen in CT Scan
I must confess that I think that the probability of a "precocious metastasis" situation with a realistically curative outcome is much reduced when there are two or more lesions. I can't speak to what the bone lesion represented, and in general we favor "giving the patient the benefit of the doubt" when there is room for doubt about whether an equivocal lesion is metastatic. In such a case, you need to prove it with a biopsy or would generally treat with optimism that the questionable spot isn't cancer.
As I say, I would be concerned that even just a second brain metastasis makes it much less likely to be a truly "precocious metastasis" situation, even independent of the equivocal bone lesion; however, as Jim noted, there is a lot of potential opportunity between heroic but potentially futile surgery and "no treatment at all". One could, as Jim suggested, consider a potentially curative radiation approach for the disease in the chest. Alternative, starting systemic therapy and seeing what happens really burns no bridges -- if the cancer progresses, it's unfortunate, to be sure, but it saves him from an unhelpful local therapy; while if the cancer shrinks and doesn't spread elsewhere over several months of systemic therapy, it makes the argument for local therapy (either surgery or radiation) far more compelling. With a high risk cancer (which this would certainly be, even if surgery were done), systemic therapy would be likely to be favored anyway, so it makes sense to consider doing it early and using the time to test what the cancer does.
-Dr. West