is 1.9 cm adenocarcinoma N0M0 with 'satellite' 2mm carcinoma in situ T3:stage 2? - 1273619

Hi onthemark,

Welcome to GRACE. I think the first thing to be said is that your situation is not at all simple or typical, and that makes remote interpretation quite difficult for anyone not directly involved in your care and not having access to your full medical records.

Even if all of your cancer is considered to be lepidic in nature, Dr. West has often commented on the varied aggressiveness of multifocal BAC, now know as lepidic predominant adenocarcinoma (although the old name remains in widespread use). As he has written:

"There is incredible variability in the appearance and clinical behavior of what is called advanced BAC in the clinical world — some of it is aggressive and imminently threatening, and much of it is very slow growing and among the least threatening cases ever labeled as lung cancer.

...People with a very slow growth rate are likely to do very, very well no matter what treatments they get, as much despite as because of those treatments. In many cases, interventions are pursued on patients who are destined to do very well, and then when their short term survival is good, the people who did that intervention write a paper saying how their approach is feasible and attractive because the patients did well — not recognizing, or at least glossing over the idea, that they were going to do very well anyway.

I would say that in no other area of lung cancer care is it more important to distinguish between what can be done and what should be done. And the real experts know when to not intervene." - http://cancergrace.org/lung/tag/lepidic-predominant-adenocarcinoma/

Later in that post, Dr. West sets forth an algorithm for treatment of such cancers, and a vital factor in treatment decisions is knowledge about the pace of the disease. In the absence of scans establishing that pace, one must choose between watchful waiting and treatment based on an assumption of progressive disease.

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The staging system is a guideline for determining the optimal treatment of a given patient's cancer, but those guidelines don't obviate the need for judgment calls in complex cases. Regardless of whether you call it stage I or II, it appears that your doctors are concerned enough that your cancer may be progressing at a pace which suggests that chemotherapy is prudent. Perhaps you can have a conversation with your medical team about the factors they have taken into account in making that determination.

I think it's also reasonable to consider how well you are tolerating treatment when deciding what to do.

Even if you elect to complete the full course of recommended chemotherapy, the possible indolent nature of your cancer may also be considered in deciding what further steps to take once the regimen has been completed. For example, you may want to reject the idea of maintenance therapy in favor of relatively short-interval follow-up scans, in order to determine the pace of disease.

JimC
Forum moderator

As Dr. West has stated:

"It is common for there to be some elements of invasive disease along with some non-invasive/pre-invasive adenocarcinoma, which is what BAC is, and why it is now sometimes referred to as “adenocarcinoma in situ”, or AIS." - http://cancergrace.org/topic/lung-biopsy-language#post-1263422 This statement was made in his response to a patient whose biopsy report described a 1.3 mm lesion as "“well-differentiated adenocarcinoma with acinar and lepidic growth, invasive...adenocarcinoma shows predominantly an acinar growth pattern."

Given the description of your main tumor as having a "relatively predominant lepidic pattern on the periphery", the presence of a satellite nodule described as "adenocarcinoma in situ" and the other tiny nodules, it sounded like there is at least a BAC component to your situation. If that is wrong, it illustrates the difficulty of trying to interpret a complex set of circumstances based on limited information.

I can't tell you why your doctors staged you as T3. Visceral pleura invasion with a small primary would tend to stage you as IB, but such tumors can be staged as T3 for "having additional high risk features (invasion of chest wall, diaphgram, phrenic nerve, mediastinal pleural, parietal pericardium and several others)", according to Dr. Weiss. http://cancergrace.org/lung/2010/04/05/an-introduction-to-lung-cancer/ Perhaps your local medical team can explain to you their reasoning for the T3 choice.

JimC
Forum moderator

I believe it is incorrect to "upstage" a cancer based on the presence of a non-invasive component like AAH or carcinoma in situ. I'm not a pathologist, but I agree with your interpretation over those of the pathologists. Only invasive components should contribute to a higher T stage, in my interpretation.

Frankly, I think the value of adjuvant chemotherapy in this setting is debatable, but that the level of risk of recurrence of your disease may be too low to justify the risk of treatment or anticipate significant benefit from the chemotherapy (basically, higher risk of recurrence corresponds with higher proportional benefit of chemo).

Good luck.

-Dr. West

As far as the spread of tumors with a lepidic component, Dr. West has written:

"It’s not known if the spread within the lungs of BAC is because of aerogenous spread or some other aspect of the biology. One other potential reason for the pattern of spread is that BAC may possibly sprout independently from many different parts of the lungs at the same time or over a period of years, perhaps because their lungs have a “field defect” — a predisposition to develop similar lesions independently from multiple places that all share some genetic feature(s) of high risk to develop a cancer.

We don’t have an exact answer. There isn’t overwhelming direct evidence for either theory." - http://cancergrace.org/topic/aerogenous-dissemination#post-1265029

Please note that although the newer term for this type of lung cancer is now adenocarcinoma in situ, Dr. West (one of the world's leading experts in that type) and many other oncologists often continue to use the term "BAC", most likely for convenience and from habit. You will find that in his recent posts (examples may be found here), he uses the terms somewhat interchangeably. Searching for the GRACE tag "adenocarcinoma in situ" produces plenty of posts on BAC.

JimC
Forum moderator

I hope I'm not jumping in to confuse the matter I really want you to be on the same page as us. It may just be me who is confused over the discussion. Wouldn't be the first time.

As you said in a prior post your onc and surgeon don't understand these components. So I hope you are reading the literature we have on BAC and ais. It's written by one of the foremost specialists in the area of lepidic adeno nsclc. The link Jim pasted as "here" above is very helpful in providing a lay understanding of the phenomenon.

When you speak about ais as only lipidic that is describing what is known as Pure BAC (that's what you wrote your path discovered under the microscope, all lipidic/scale like cells) however there often an invasive component to the otherwise predominant non invasive piece.

What is possible is that a BAC became invasive (the tumor that was removed) and a non invasive mass will stay as is, as long as it stays purely lipidic or ais.

It could be as Dr. West and Jim have said, "Frankly, I think the value of adjuvant chemotherapy in this setting is debatable, but that the level of risk of recurrence of your disease may be too low to justify the risk of treatment or anticipate significant benefit from the chemotherapy (basically, higher risk of recurrence corresponds with higher proportional benefit of chemo)."

Questions about lepidic component as you've asked about will get answers that center around BAC because lepidic is the predominant type of cell structure in BAC.
managing multi-focal bronchioloalveolar carcinoma, a clinical entity that is in the process of being re-labeled lepidic predominant adenocarcinoma (LPA) (lepidic meaning scale-like, which is the classic way that the cells are defined as spreading when looked at under a microscope)

I hope I've not confused the situation more, ;)
Janine

The distinction between BAC, AIS, and invasive cancer is a fallacy. There is incredible overlap, as the vast majority of BAC cancers have an invasive component. The pathologists changed the semantics, but that didn't change the reality that MANY, MANY, MANY adenocarcinomas have some areas that are invasive, some that are non-invasive BAC, and other areas that could be called AIS. The fact that pathologists don't have a good way to characterize this doesn't mean that people can't have this. They often do, and we need to make judgments about how to proceed with very imperfect information.

Many experts would be guided by how much of the disease is invasive. If a cancer is 4 cm but only 1 cm of the total diameter is invasive, the prognosis is based on that 1 cm of invasive disease. This is why I said that the recommendation to pursue chemotherapy is rather shaky if the only basis to vault the risk is based on a non-invasive nodule, then that shouldn't actually increase the risk enough to do so.

I would recommend believing nothing about the aerogenous vs. aerogenous spread. To my knowledge, there is no good evidence to support any mechanism. I can't tell you a right answer, but as a global expert in BAC, I know that nobody really knows better, and I know that a large fraction of what you read out there (except what I wrote) is stated with more certainty than is justified.

I cannot tell you your risk of recurrence. I can say that a 2-3 mm focus of AIS or any other non-invasive adenocarcinoma does not increase the risk of recurrence and death from cancer recurrence enough to significantly impact a decision in favor of adjuvant chemotherapy.

Good luck.

-Dr. West

We look forward to good news moving forward!