Hello,
How does one handle very slight progression in the primary tumor in the absence of other visible disease.
If the primary tumor is hard to access and possibly partially semi- dead from Tarceva, and only a small fraction of the tumor shows possible progression on CT scan, How does one get a tissue sample for a next generation therapy like AZD9291 ??
The size of the tumor is about 2.4 cm in diameter and is sitting towards the back of the right lung.
Would attempting a biopsy risk spread into the pleura?
No visible lymph nodes, and 3 last visible brain mets where just treated with Stereotactic radiation surgery one month ago.
Would a liquid biopsy be advisable under these circumstances ?
But I heard that trials require tissue sample testing.
What is the general advice ?
Thank so much
Kempten
Reply # - November 8, 2015, 07:34 AM
Hi Kempten,
Hi Kempten,
When there is slow progression on a targeted therapy such as Tarceva it is usually recommended that a patient continue the therapy and get the maximum benefit from it. If the tumor is only 2.4 cm and only a small part of it appears to be progressing, it might be difficult to obtain a biopsy of the cells which may have developed a resistant mutation.
Needle track seeding from a biopsy is a possible but small risk. You are correct that trials will usually require a tissue biopsy.
JimC
Forum moderator
Reply # - November 8, 2015, 09:15 AM
Thank you Jim,
Thank you Jim,
That does make sense.
I hate the idea of letting the tumor just sit there , get bigger and possibly start seeding resistant cancer cells into the periphery though.
What other options does one have?
Could I try to tackle it with Radiation Therapy, depending on location and other adjacent vital tissues?
Thanks again
Kempten
Reply # - November 9, 2015, 07:58 AM
Hi Kempten,
Hi Kempten,
With stage IV lung cancer, local treatment such as radiation is not usually recommended, unless the purpose is to alleviate pain or treat a tumor pressing on a vital structure. The assumption is that there are cancer cells which have entered the bloodstream, which is how they reached the brain. Radiation will only treat one visible cancer site while causing side effects and not addressing the systemic disease.
Although it's tough to watch a tumor grow, the slow rate of growth indicates that the current therapy is having an effect and as Dr. West says "bad brakes are better than no brakes."
JimC
Forum moderator
Reply # - November 9, 2015, 09:58 AM
Thank you Jim,
Thank you Jim,
Part of me accepts this waiting approach and the other part is wondering :
If this is so, than why are we now getting away from WBRT and are substituting SRS in the brain for singular lesions ?
Would not the same theory apply to brain mets?
We are doing in the brain exactly what we are ( not jet ) doing in the rest of the body.
Treating one lesion at a time ( while taking advantage of Tarceva's " breakes " .
Why the different approaches for the different body parts.
Sorry I don't mean to be a pain, there might be a totally legitimate reason for this, that I'm ignorant about.
Kempten
Reply # - November 9, 2015, 04:25 PM
The brain is an exception to
The brain is an exception to the rule, otherwise: With stage IV nsclc the focus is on keeping the disease under control. It's not possible to eradicate all the cells so systemic drugs like tarceva and chemo are used to keep progression down throughout the entire body (except the brain). This blog post explains it well, http://cancergrace.org/cancer-101/2011/01/01/cancer-101-faq-i-have-meta…
As for tarceva, if there's an egfr mutation as in your case, tarceva can shrink or otherwise keep the cancer under control for long periods of time. But after a while, sometimes 1or 2 years an "acquired resistance" happens usually in the form of acquiring a T790m mutation but often that mutation happens in just one or two places at first and can be treated focally if there's a need. The idea here is to continue one treatment as long as possible before moving to another; there are only so many treatments available hence the metaphor, each treatment is a marathon (as long as possible) not a sprint (as soon as you see a little progression make a treatment change). There lots of info on this here, http://cancergrace.org/lung/acquired-resistance-patient-forum-2014-vide…
As for brain mets, there is a phenomenon called the blood brain barrier (bbb) that keeps systemic drugs like tarceva from entering the brain at effective doses (there are some exceptions but nothing that can be counted on) so as long as the systemic drug is working in the rest of the body, radiation is given in the brain for brain mets. As for why srs instead of wbr, srs can be given when there are just 1 or very few mets. srs causes less damage in the brain and many fewer side effects whereas wbr can cause cognitive issues and quite a few other side effects.
Treating stage IV nsclc is like a puzzle, there are many moving parts that have to be consider that's why many people call oncology an art form.
Much luck,
Janine
Reply # - November 9, 2015, 07:07 PM
Thank you Janine,
Thank you Janine,
The article you quoted actually makes my point, that in a case of very limited progression, with just a small fraction of cells becoming resistant and the majority of cells still responding to therapy, the case could be made, that targeting those few cells with local therapy might have a benefit.
I understand the futility of local therapy, when one has to expect vast spread of microscopic disease, and the microscopic cells in question are not " asleep " so to speak because of TKI therapy.
In my case the small amount of resistant cells is may be 2mm worth of new growth on the existing shriveled up tumor. All other v I s i b l e signs of disease have disappeared from the imaging.
Would it not be possible, that reducing the load of newly mutated cells, and trying to preempt seeding of those cells , might have an advantage over just letting the new growth expand?
I read articles right here on this site, that seemed to agree with my train of thought.
Thanks
Kempten
Reply # - November 10, 2015, 05:52 AM
Hi Kempten,
Hi Kempten,
There are times when the strategy of local treatment of a lone area of progression is successful, but in general it's not effective. When only one area of growth of known stage IV disease is visible, the assumption may be made that these are the only cells which have become resistant, but that is not usually true. The cancer cells already present in the bloodstream are just as likely to become resistant to Tarceva, but haven't yet formed visible metastases. In the typical situation, using local therapy to eradicate the only visible tumor or met really fits the "whack-a-mole" analogy...it's going to pop up somewhere regardless. That's not to say it can't be or isn't done, but as you point out there may be issues with radiation specific to the location of the tumor, so all the risks must be weighed against the possible benefit.
JimC
Forum moderator
Reply # - November 10, 2015, 08:14 AM
Thanks Jim
Thanks Jim
I will bring up the subject with my oncologist and educate myself about the position of the tumor, adjacent vital tissues
like spinal cord etcetera, and all the possible side effects of radiation to that area. I know from reading the posts of others, that some end up with terrible side effects, some of them permanent. Others seem to have little or no trouble.
I am on my path " whacking the mole " when it comes to my brain mets. I know as time goes by, more will pop up that will probably be treated one by one , as long as things don't start to get out of hand in the central nervous system.
For us patients , the thought of leaving a growing tumor to its own devices is very disconcerting.
It's a psychological thing.
The good news is, that there will be choices for systemic treatment, that I can take advantage of when the time is right.
Thank you Jim and Janine for responding to my questions,
Your answers put things in perspective for me.
Kempten
Reply # - November 10, 2015, 12:50 PM
You're very welcome Kempton.
You're very welcome Kempton. I am in complete agreement that I don't know what's it's like as someone with cancer. I wholeheartedly believe "you have to be there to understand" even more so having watched my husband go through...
I wish you times of peace of mind if that's possible. D talked about the jolt of remembering after moments of forgetting. Intellectual knowledge is one thing, keeping it in the forefront during decision making is a whole other level of work.
Certain Spring I think it was coined the term, "holding her nerve" that became an instant go to explanation.
Thanks for being here and advocating for yourself.
Janine
Reply # - November 10, 2015, 04:49 PM
Thank you Janine,
Thank you Janine,
I have to remind myself in those moments of total preoccupation , that others like yourself and Jim have been as close as it gets to these same situations, and I'm convinced it is even harder for the loved once.
I'm actually feeling less fear I think, than my partner or son.
Intellectualizing my disease is very helpful to me. It makes me think of it as a mental challenge and suppresses the fear, at least for now, as my symptoms are still few.
Excuse my debating style. I'm from Germany and we like to debate over there, but it is all because of curiosity
and fascination with the biology. If god had given me a brain, I would have gone into research.
Thanks for all your help,
you guys are so important to all of us.
Kempten
Reply # - November 11, 2015, 02:02 PM
I'm not surprised at your
I'm not surprised at your description of yourself. The sentence, "I'm from ...out of curiosity" sums me up pretty well. Though I'm not from Germany my grandparents are and there's still nothing better than a good debate with my 4 siblings :) So no excuses necessary, my pleasure to help.
Reply # - November 11, 2015, 04:00 PM
I am in similar boat. I
I am in similar boat. I requested blood biopsy from guardant360. Although cutting edge, it showed no "circulating" "shedding" cancer cells. Egfr or otherwise. Although my onc was against it, it gave me piece of mind.
Reply # - November 13, 2015, 12:27 PM
The blood test aren't quite
The blood test aren't quite there yet so none of the specialist are using it outside of research trials. If it's available and shows cells in the blood that's great and is a positive result but if it shows no mutation cells it doesn't mean the cancer is negative for that mutation.
It's getting close but not yet there.
Janine