After a prolong 6 1/2 years stage IV battle for survivor on Tarceva, my wife's last four CAT scans(in a period of one year) have shown a rapid increase in size of a solitary prevascular lympth node from 1cm to 2.6x3.2 cm. She is still asymtomatic but with a very mild cough and "frog in her throat" once or twice a day when she lay flat in bed.
CAT guided needle biopsy was aborted due to risk of major bleeding from artery by sternum area. Serum biopsy shown negative T790M. She has no cancer load anywhere else other than this new enlarged solitary node. However, she have had two prior brain surgeries to remove solitary brain met and necrosis on the same site within her right occipital lobe area. Most recent two brain MRI were clear of any sign of cancer.
What would be a reasonable choice? Localized radiation or out right excisional biopsy to remove the one and only enlarged node? Any targeted therapy for non-T790M suspected acquired resistance candidate?
Reply # - August 1, 2017, 10:54 AM
Hi Advocate,
Hi Advocate,
The leading course today would be to eliminate the one area of growth. The thinking is if this is the only area of progression it is probably the only area of resistance, leaving all else under the thumb of tarceva. Whether radiation or excision is up to the team involved to determine what is safest in your wife's case. If it's radiated you'll not have to chance to check for t790m but if it is taken out you'll have the whole nodule to test, which is a good thing since t790m can be found in one part of a nodule but not in tissue in the same nodule.
Keep us posted
Hoping for the best,
Janine
Reply # - August 1, 2017, 04:37 PM
How large of an acquired
How large of an acquired resistance mutation cell load does one required to have before a serum biopsy could be considered as reliable as the actual tissue biopsy?
Reply # - August 1, 2017, 10:49 PM
I'm not sure of the answer so
I'm not sure of the answer so will ask one of our oncologists or Jim to comment.
Reply # - August 2, 2017, 08:48 PM
There isn't any specific
There isn't any specific number or tumor size. In general, the more cancer visible on a patient's scans, the better the chance of a plasma (blood-based) test being able to detect sufficient circulating tumor DNA to have the test detect mutations that are actually present in the tumor. Lung cancer that is only seen in the chest has a lower success rate for detecting mutations on the blood test (about 50-60% success rate) than cancers that have spread outside of the chest (about 70-80% success rate in trials).
Good luck.
-Dr. West
Reply # - August 15, 2017, 09:31 AM
Thank you again Dr. West for
Thank you again Dr. West for responding.
Is it true that an enlarged lymph node can never be fully excised because it is usually attached to or entangled with all kinds of blood vessels?
My thinking is since the thoracic surgeon is going through all the trouble (cutting a rib, deflating the lung..etc, just to get to the mediastinum area) for the biopsy, why not completely remove the suspected cancerous node?
She is now experiencing more frequent coughing spells possibly due to the enlarged lymph pressing on a nerve somewhere.
Reply # - August 16, 2017, 06:08 AM
Hi,
Hi,
Enlarged lymph nodes can at times be resected, in a procedure known as lymphadenectomy, but as with any surgical procedure, the particular circumstances may dictate whether the procedure can be performed on a specific lymph node, and what risks may be involved. With that in mind, a conversation with the surgeon would be in order to discuss the advantages and disadvantages of resection in your case.
Good luck,
JimC
Forum moderator
Reply # - August 22, 2017, 06:36 PM
Thank you JimC for your
Thank you JimC for your attempt to explain and answer my question.
The docs now decided to schedule a mediastinotomy on the pre-vascular lymph node. They are still set to get to the bottom of the suspected "acquired resistance" to Tarceva.
Been reading a bit on the procedure. Very concern on the risk. The surgeon already mentioned that she has to cut a small section (about 1 inch) of my wife's rib bone in order to get to the spot where the enlarged lymph node is located, to get a good sample.
Fortunately and unfortunately that is the only point of cancer load or resistance, so there is no other place they can get to the cancer.
Just wondering if this is worth the risk as opposed to just go for chemo?
Reply # - August 23, 2017, 03:39 AM
I had a mediastinoscopy
I had a mediastinoscopy before my surgery in 2013. It's usually done on an outpatient basis. My only problem was the stiff neck after. They position you with your neck tilted all the way back. You're not awake during this procedure. The bone would likely be a rib bone and I'd think they could spread it instead of cut it, it's worth asking.They can also check other lymph nodes while they're in there. I've given you a link to lymph node locations that could be helpful for you. Wishing her all the best.
Take care, Judy
https://radiopaedia.org/articles/thoracic-lymph-node-stations
Reply # - August 23, 2017, 11:00 AM
Hi advocate,
Hi advocate,
I understand your concern for such an invasive procedure just to look for the mutation and not be hopeful of removing all the cancer. Have you talked to the surgeon about her thoughts on whether she feels she can excise all the cancer or is she looking to just get enough tissue to biopsy? The nodule appears to be in a very delicate position.
Like Judy suggested most mediastinoscopies are pretty routine in a lung cancer workup but the prevascular is in a hard to reach location and not taken during these procedures unless its in a trial. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4367702/
Another question I'd have is why do you think finding the t790m is important enough to preform such an invasive surgery. How many times have you accessed a prevascular node in these conditions and why, and why do you think it's important in this case. Certainly the risks bar is set higher if the surgeon believes she can get clear margins.
I forget if your wife is already being seen by a lung cancer expert who specializes in EGFR mutation. Talking to an expert in this type of mutation about the risk and benefit of either of these goals (to remove tissue but not all cancer and remove all cancer) will provide more understanding to add to your decision making. Knowledge is so much more powerful when there won't be a clear answer about what should be done.
It's important that the oncologists understand how you and/or your wife feels about these procedures. Oncologists often make decisions based on how the patients feel about more or fewer procedures that can effect quality of life when there are no guarantees longevity will change. This is especially true when there are no clear decisions. Like you mentioned chemo is also a clear option. What if she was able to reduce the size of the node with chemo, would shrinking make it easier to radiate or get clear margins?
Lots of thoughts and questions but unfortunately no answers.
All best,
Janine