Thanks again for your answers to my question about N3 nodes. I have another question about radiation. My father was diagnosed with stage IIIA squamous cell lung cancer. He had surgery to remove the 8cm tumor from his RML and RLL. Margins were clear. Multiple lymph node stations were dissected and biopsied. The pathologist found cancer cells in one node from station 7 (1 of several but numbers cannot be determined because nodes were fragmented),1 hilar node within the lung, and 1 node from station 13. From the mediastinal area, he also biopsied nodes from station 4R and 9R (as I've posted previously, he did not get nodes from the left side). None of these nodes lit up during the PET/CT scan. Lymph nodes were also determined to be normal size (non-bulky). His tumor was also determined to be well-differentiated G1.
He will begin chemo (carboplatin/gemzar) in a few weeks. The oncologist recommended he start with 4 rounds and we can reassess after we see how he does. We will also discuss radiation at that time but he doesn't think it would really yield any added benefit.
My dad had had radiation before to his laryngeal area to treat a former case of laryngeal carcinoma. He also has copd and a mitral valve prolapse. He's lost about 20 pounds over the course of the last few months (and though still considered normal BMI, is bordering on underweight). He's 71 years old.
I know you cannot comment on specific cases but given my dad's health and the nonbulky, microscopic activity in one mediastinal area, how would you weight the costs/benefits of radiation? Or the more general question might be, would you use radiation for occult n2 disease? who would you consider healthy enough for radiation? has there been proven benefit for these patients? (I know there's been alot of discussion on this forum about the heterogeneity of IIIA so I'm wondering about this specific subset of patients that might be bordering more on 2B).
Thanks in advance for your help!
Reply # - September 13, 2014, 04:30 PM
Hi ameslee,
Hi ameslee,
Dr. West posted a thorough discussion of the treatment of occult N2 disease here: http://cancergrace.org/lung/2008/03/24/occult-n2/
JimC
Forum moderator
Reply # - September 13, 2014, 06:27 PM
Your question is one without
Your question is one without an answer because there is no good evidence from a meaningful comparison of chemo vs. chemo/radiation. It is an unusual patient who can get through chemo and radiation after surgery, and risk may well exceed benefit. We will probably never have a big trial to answer the question, so it will be left to individual judgment. My own judgment is that patients with higher risk disease AND with a performance status that is very good should be considered for chemo/radiation, while those with lower risk disease and/or any reason to question their ability to get through the treatment program safely may be better served by proritizing pos-operative chemo (which has a proven survival benefit for N2 disease), over post-operative radiation (which does not have a proven survival benefit).
In real life, what I often do is start with chemotherapy for at least 3, urually 4 cycles, and then see if they are still doing so well that we might consider radiation after that. That way, we get through the proven treatment before worrying about radiation, which may or may not be the icing on the cake. On the other hand, if a remarkably fit younger patient has surgery and is found to have N2 disease and is eager for the most aggressive treatment possible, we'll start with concurrent chemo/radiation after surgery. But as I say, that's not the approach we pursue in most patients (if there is such a thing as "most" patients, when such cases are uncommon and always treated on an individualized basis).
I don't know if that was illuminating or confusing.
Good luck.
-Dr. West
Reply # - September 14, 2014, 04:35 PM
Thanks so much for your
Thanks so much for your responses! You have clarified the dilemma well. I know now that there's some controversy in this area and no clear-cut way of making a decision.