I am a 51 year old female, never smoker. In June 2014, a biopsy from a painless lump in my neck indicated high grade metastatic carcinoma. A PET-CT scan revealed various tumours in the lymph nodes on both sides of the neck, but no primary tumour. Histology showed strongly positive TTF1 and p63; positive Napsin A; EGFR not mutated; ALK negative. Conclusion was "metastatic adenosquamous cell carcinoma of pulmonary origin with primary origin extinguished". Staged at T1N3M0; IIIB.
Treatment was 6 sessions of Taxol and Carboplatin, from July to October 2014, followed by 6 sessions of Cisplatin weekly till end of December concurrent with daily Radiotherapy to my neck area. All treatment was well tolerated and I have continued to feel well throughout.
PET-CT scans in September and November showed a very good tumour response with all tumours having disappeared.
I had a follow up PET-CT scan last week expecting to find nothing, but disappointingly the results showed that while the original tumours have gone, there are a number of new, albeit small, lesions round the left hand side of the mediastinum and also in the lung.
My oncologist is suggesting Gemcitabine although says that it only has a 10-20% success rate as a second line treatment. He is discounting Alimta for the meantime given the adeno and squamous cell components, as well as Docetaxel as in same group as Taxol which I have already had. Do you agree with the suggestion to try Gemcitabine?
Is there any other treatment regime that you suggest I can consider? He has also mentioned the immunotherapy drug Pembrol as a possible option in the future although on a named patient basis.
Any opinion on the way forward would be very much appreciated. I am still in shock as to how quickly and aggressively the cancer has returned after what seemed like such a postive response to treatment.
Thanks in advance and for your excellent site.
Reply # - April 7, 2015, 09:36 PM
Hi gillie,
Hi gillie,
I'm sorry to hear of your progression. "Success rates" for second line treatment usually represent "response rate" and are usually fairly low, because response rate is defined as tumor shrinkage of 50% or more. More often, such treatment results in lesser shrinkage or stable disease, either of which is a good result for second line treatment of advanced lung cancer.
The three drugs which have been FDA-approved as effective in the second-line setting are Docetaxel, Tarceva and Alimta. I can understand the reluctance to use Alimta, due to the squamous component of your cancer, although if that component is relatively small it could still be considered. Tarceva has been shown to provide some benefit as second line treatment, even for patients who do not have mutations. And Docetaxel has shown benefit even for patients who have used Taxol, despite also being a taxane.
Clinical trials, including those of the new immunotherapy drugs, would certainly be an option to consider, especially if traditional therapies are not found to be effective.
JimC
Forum moderator
Reply # - April 7, 2015, 10:25 PM
Hi Jim,
Hi Jim,
Thank you so much for your very quick reply. Tarceva has not been mentioned by my oncologist. What is your opinion on Gemcitabine in my situation as a second line treatment?
Thanks.
Reply # - April 8, 2015, 04:25 AM
Hi gillie,
Hi gillie,
Dr. West has said this about using agents such as gemcitabine in previously treated patients:
"Other agents, such as standard chemotherapy drugs like Gemzar (gemcitabine), Navelbine, or perhaps other chemo agents may have some activity in previously treated patients, but they haven’t been as well studied, don’t have an established clinical benefit, and consequently remain poorly studied non-standard options in previously treated patients." - http://cancergrace.org/lung/2010/10/04/lung-cancer-faq-2nd-line-nsclc-o…
Though gemcitabine hasn't been as thoroughly tested in this context as the approved treatments, it is used at times and some patients do benefit from it. There just isn't much clinical trial experience to point to for its efficacy.
As far as the clinical trial evidence of Tarceva's efficacy as a second-line treatment, in that same post Dr. West states:
"The benefit in survival was comparable in woman and men and for patients with squamous NSCLC compared with adenocarcinoma NSCLC, though there was clearly a narrower subset who achieve a more profound and prolonged benefit. Such patients most typically have an activating EGFR mutaiton, but many patients who don’t have an EGFR mutation receive a more modest but still meaningful improvement in survival with Tarceva."
JimC
Forum moderator
Reply # - April 8, 2015, 07:32 PM
Thanks again Jim.
Thanks again Jim.
Reply # - April 11, 2015, 03:49 AM
Someone has suggested a re
Someone has suggested a re-biopsy. Do you know roughly in how many cases does a re-biopsy (after 9 months in my case) show a change in mutation, and/or a switch in balance between Adeno and Squamous components?
Grateful for any advice before I decide if it's worth trying. Thanks.
Reply # - April 11, 2015, 06:51 PM
I don't think you can put
I don't think you can put specific percentages on the outcomes you're describing, but your EGFR and ALK negative status is unlikely to have changed unless it was somehow missed previously (since neither an EGFR mutation or ALK rearrangement appears to be a cause of your cancer), so the main reason for a biopsy would be to look for mutations which are the target of new drugs in clinical trials, It is possible that your previous treatment has been more effective against one of the components of your cancer and that has changed the percentage of each component, but it's good to remember that if a small amount of tissue is obtained in a new biopsy it may not be representative of the overall balance.
JimC
Forum moderator
Reply # - May 12, 2015, 01:54 PM
I'll chime in here......
I'll chime in here......
Teacher Wife showed no EGFR component in her initial biopsy, yet had a great response to Tarceva as a second line treatment. A later biopsy before clinical trials showed that she actually had the EGFR gene. A later mutation? Who knows, but I do know it kept her rocking for a full year.