Adenocarcinoma (approx 1.5 years) - 1265732

Hello,

Of the three, Tomotherapy is the newest radiation technique. But the choice depends more on your individual circumstances than the method used. You may find these comments by Dr. Loiselle helpful:

"I would say that all radiation therapy options are on the table – the optimal treatment depends on the prior radiation dose, the prior radiation target areas, and the current location of the mass.
...

3D conformal radiation is a phrase which describes using multiple radiation beams with varying orientations to the body to deliver radiation to targets based on Catscan delineated 3 dimensional anatomy.

IMRT and Tomotherapy are advances in radiation oncology over 3D conformal treatment in which computer planning allows sophisticated manipulations of multiple radiation beamlet configurations which are cross-fired from multiple angles to deliver a sculpted radiation target dose. IMRT typically uses typically 7 to 9 fixed beam angles, whereas tomotherapy can leverage more of an infinite angular arrangement through treatment with an arcing, modulated beam. Technical stuff aside, Tomotherapy is like super-IMRT.

Finally, “SBRT”, stereotactic body radiation therapy, offers high dose, short course image guided radiation to a target. SBRT can be done on multiple platforms – cyberknife and linear accelerator based stereotactic radiation as examples. Given the steep dose falloff and image guidance, significantly higher biologically equivalent doses of radiation can potentially be delivered than with other conventially fractionated approaches. In some scenarios, this can lend a cancer control advantage.

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"Again, it all depends on the anatomy of the recurrence and the extent and dose of your prior radiation treatment. Hopefully your physician team can advise you on the best chance for control with the least risk for complications given your specific situation." - http://cancergrace.org/radiation/topic/preferred-radiation-technology-f…

Dr. West has also offered this opinion:

"Tomotherapy definitely isn't a standard of care at this time, but rather one of many new techniques that seems to me, as an outsider, to be in some part a marketing arms race of different centers trying to lure patients with the idea that their machine/technique is better than everyone else's. I'm pretty skeptical of that. First, I think a very good radiation oncologist with average equipment can do a better job than a less talented radiation oncologist with the newest and supposedly greatest equipment. Though it sounds pithy, I really believe that the most important equipment is between the ears of the radiation oncologist." - http://cancergrace.org/forums/index.php?topic=7152.msg51484#msg51484

JimC
Forum moderator

Also, as far as using afatinib after progression on an EGFR TKI such as Iressa, these comments show that Dr. West does not believe there is good evidence that Afatinib is effective after EGFR mutation-positive patients have developed acquired resistance:

"As for using it in EGFR mutation-positive patients with acquired resistance, the data included in the press release is the definition of damning with faint praise. The response rate was under 10% in the best data they could dredge up in the world, and other experiences have been less favorable than not. There are no doubt rare patients who may benefit from it more than other EGFR TKIs, but every patient I’ve ever treated with afatinib after progressing on Tarceva has only experienced progression at the earliest scan afterward, along with greater toxicity than they ever had with Tarceva. Also, trials that have looked at Tarceva after Iressa or even progression after prior Tarceva and an interval off of it have experienced response rates comparable to what you see with afatinib.

So while I agree it’s an option to consider, I think it’s incorrect to infer or to believe any claims that it’s anything more than another EGFR TKI with comparable activity and greater toxicity than other options, except perhaps in very occasional patients." – http://cancergrace.org/topic/afatinib-approved-by-fda#post-1257889

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On the other hand, later in the same thread Dr. West offered these comments about the combination of Afatinib and Cetuximab:

"I’d distinguish my more pessimistic comments above from my perspective on the afatinib and cetuximab combination, which I think there’s more reason to be hopeful about. However, that work is still very early, and the side effect profile remains a very real concern as well think about broadening our experience with this regimen to a population of patients that don’t necessarily have the health, motivation, or resources to travel to the few sites offering the phase I/II trials. I look forward to seeing more research with this combination, but between now and then, I suspect it may be an uphill battle to get insurers to pay for cetuximab (and perhaps afatinib) outside of their approved settings, given their cost."

He recently reiterated those comments (in the context of following Tarceva with afatinib):

"I’m completely unimpressed with afatinib alone after Tarceva and don’t think it merits being used anywhere near as much as it is, seemingly baed on a combination of reflex and desperation. I’m more hopeful about afatinib and cetuximab, though I think much more information is needed before we can really consider that a clear choice outside of a trial." - http://cancergrace.org/topic/navelbine-good-decision#post-1265633

JimC
Forum moderator

mnyoshi, Hello and welcome to Grace. We're glad to have you though not the circumstances.

I'm sorry gefitinib isn't working as effectively as it has been (for those who don't know the term it's 'acquired resistance'). As long as there are no other vital structures in which your tumor has grown or is heading and you're not experiencing cancer symptoms it's worth taking your time on this decision. As a matter of fact "I think" everything you mentioned and more are options in a case like yours. People do very well for sometimes 4 years or so then start a slow progression, at this point stopping TKI can cause a quick growth of the cancer. People are starting to stay on the TKI such as gefitinib until the change is made. It's like having your old VW car slowing lose its breaks. Losing breaks is a bad thing but not nearing a dangerous as having no breaks. So

Slow growing tumors is a fast moving field. I'll not go into anymore here because there is so much written and said by our faculty, a group of oncologists and researchers heading the field have much more to offer than me trying to paraphrase.
As a matter of fact we there is an Acquired Resistance patient forum headed by our Dr. West with some of the best thinkers and practitioners in the field. It takes place Saturday Sept. 6 in Boston. It's being broadcast on a site you can find here, http://www.oncology.tv/Home/OncologyTVLiveWebcastPortal.aspx

Here are the latest in the field of acquired resistance, http://cancergrace.org/lung/category/lung-cancer/general-lung-cancer-is…

Jim and Janine provided a huge amount of information already, including my lack of enthusiasm for atatinib for a more compelling reason than its mere existence and availability. There is no good evidence to say it's even remotely likely to be significantly more effective than Iressa or Tarceva once the cancer begins to progress. Newer agents like AZD9291 and CO1686 show far more promise in acquired resistance, at least for the 60% of patients with acquired resistance to EGFR TKI therapy who have a T790M mutation detected on repeat biopsy of the progressing area of disease.

In a situation in which one lesion is growing and there are no other areas of progression, local therapy is certainly a reasonable idea to consider. However, I don't think there's a lot of reason to get too focused on the technique for treating the area of progression. If the cancer was advanced/metastatic, it really doesn't make sense to focus obsessively on any one spot. The overall disease issue is still likely to eventually be more diffuse, systemic spread, so I don't think there will ever be a study that shows that one modern radiation platform is significantly better in this setting than another. The most common approach in this situaiton, however, would be a hypofractionated approach (few treatments at high dose, like Cyber Knife).

Good luck.

-Dr. West

Hello,

I am sorry to hear that brain metastases have been discovered. Please understand that whole brain radiation (WBR) can successfully treat these lesions.

To start with, the terms "tumor" and "lesion" can be used interchangeably. For whatever reason, "lesion" is often preferred for small tumors in the brain. When there are just a few of them (usually no more than 3-4), targeted radiation may be used to treat just those lesions. However, when the number of lesions is greater WBR is the preferred treatment. Dr. West introduces a good primer on WBR by Dr. Jacob Scott here. At the end of that introduction, there are also other links to good information about WBR.

The survival times your doctor mentioned are estimates for a general population. Without treatment brain metastases can grow quickly with disastrous results, so there isn't much question whether they should be treated promptly. WBR can often keep brain metastases under control for an extended period of time, and your overall survival may depend more upon how the rest of your cancer is controlled.

Good luck with your radiation treatments.

JimC
Forum moderator

Yes, lesion is just a less descriptive term for nodule or mass (mass sometimes being considered a more appropriate term for a larger lesion, vs. nodule for a smaller lesion), but lesion itself is basically just a fancy medical word for "spot".

There is no middle hemisphere (hemi means half, so there's a right and left half of the brain, and there's a "midbrain" below it in the skull, if that's what you might be referring to).

Though a few brain lesions/masses/nodules can potentially be treated with stereotactic radiosurgery (essentially gamma knife or cyber knife), that is not always feasible with lesions in the most important brain structures such as the midbrain or pons because it may be more dangerous to radiate around these critical structures to a very high radiation level. WBR is sometimes recommended in these situations as a very thoughtful recommendation.

Good luck.

-Dr. West