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

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

Hi,

I am currently receiving adjuvant chemotherapy (16 weeks of cisplatin/vinorelbine) after a LUL lobectomy removing a 1.9cm peripheral adenocarcinoma that invaded the visceral pleura (PL1). The main tumour had a 'relatively predominant lepidic pattern on the periphery' with an invasive component that was acinar. The report doesn't state the relative proportions numerically.

The pathologist also found two other areas in the completion lobectomy. One was a 2mm area of aah and the other was a 2mm area of 'carcinoma in situ' that was labelled a satellite nodule although the report is negative for 'intrapulmonary metastases' it states that this additional area 'had a lepidic pattern that is suggestive of endobronchial spread'.

No cancer was found in lymph nodes. I also had a mediastinoscopy, ct and pet scans prior to surgery with no mets or lymph nodes found positive. However the ct scan found several tiny 2mm nodules that suggested to follow in other parts of my lung.

I have read a couple of papers that suggest that lepidic type cancers can present multifocal and carcinoma in situ should not be used to upstage cancers. However my report was staged at T3 because of the satellite nodule and therefore stage 2.

Do you think I should be T2 (because of vpi) and stage 1 instead?

There also was no LVI or necrosis or anything else of concern in the report.

I am wondering if I am wasting my time, health and energy getting chemo and would really appreciate another opinion. I can say that I live in Canada and my pathology report was reviewed and signed off on by 2 pathologists.

JimC
Hi onthemark,

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.

[continued in the next post]

<p>I began visiting GRACE in July, 2008 when my wife Liz was diagnosed with lung cancer, and became a forum moderator in January, 2010. My beloved wife of 30 years passed away Nov. 4, 2011 after battling stage IV lung cancer for 3 years and 4 months</p>

JimC
[continued from previous post

[continued from previous post]

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

<p>I began visiting GRACE in July, 2008 when my wife Liz was diagnosed with lung cancer, and became a forum moderator in January, 2010. My beloved wife of 30 years passed away Nov. 4, 2011 after battling stage IV lung cancer for 3 years and 4 months</p>

onthemark
As I wrote my main tumor had

As I wrote my main tumor had an invasive acinar component so this is not BAC.

onthemark
Also the recommendation for

Also the recommendation for chemo was based solely on staging as T3, not for any other reason.

JimC
As Dr. West has stated:

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

<p>I began visiting GRACE in July, 2008 when my wife Liz was diagnosed with lung cancer, and became a forum moderator in January, 2010. My beloved wife of 30 years passed away Nov. 4, 2011 after battling stage IV lung cancer for 3 years and 4 months</p>

onthemark
There were no additional

There were no additional features of concern. It was staged T3 because of this additional satellite nodule.

onthemark
Also my pathology report does

Also my pathology report does not refer to BAC. My understanding is that this is not an accepted medical term any more. I was hoping to get a medical opinion here from a doctor.

Dr West
I believe it is incorrect to

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

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Associate Clinical Professor
Medical Oncology
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

onthemark
Thank you very much Dr. West.

Thank you very much Dr. West. The situation with additional nodules is quite murky in the literature I've been able to find. I am halfway through chemo and need to decide what to do. I am wondering if those additional 2-3mm nodules that were not removed in surgery as they were in other parts of the lung are of any concern and if chemo helps if those are ais or something invasive. How would you estimate my risk of recurrence?

onthemark
I have tried to discuss these

I have tried to discuss these questions with my oncologist and surgeon but both were quite dismissive and said not to try to read too much into the pathology report (well that is all there is to go on beyond my general health which is good...) and were not up to speed on lepidic type multifocal tumours or what is in the literature.

I was told to either take chemo or leave it -- end of discussion. In Canada you don't get to pick your specialist in cancer care. You are triaged by a team and assigned to a doctor based on availability. You can complain and ask for a new doctor but that only will add months long delays in getting treatment.

I do wonder what features a pathologist sees in a carcinoma in situ to believe it came from aerogenous or endobronchial spread from a main tumor. Is that typical for tumors with a lepidic component -- that they spread aerogenously?

JimC
As far as the spread of

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

<p>I began visiting GRACE in July, 2008 when my wife Liz was diagnosed with lung cancer, and became a forum moderator in January, 2010. My beloved wife of 30 years passed away Nov. 4, 2011 after battling stage IV lung cancer for 3 years and 4 months</p>

onthemark
thank you for the information

thank you for the information. However it is not I believe relevant to my situation because I do not have BAC.

You can't say that BAC is ais (as written above) and also say (as was also written previously) that BAC can have an invasive component since by definition an in situ carcinoma has no invasive component. That was my point when I wrote that my tumor wasn't BAC because it had an invasive acinar component. My understanding is that this is why BAC was abandoned as standard medical terminology, because it is used in different ways that are mutually contradictory.

Please note that my main tumour was not AIS, not BAC, it was moderately differentiated invasive adenocarcinoma.

catdander
I hope I'm not jumping in to

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

Dr West
The distinction between BAC,

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

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Associate Clinical Professor
Medical Oncology
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

onthemark
Thanks to Dr. West, Janine,

Thanks to Dr. West, Janine, and Jim for taking the time to respond. I prefer to avoid the term BAC and stick with the modern classification. I note "The classification addresses both resection specimens, and small biopsies and cytology. The terms BAC and mixed subtype adenocarcinoma are no longer used." http://www.ncbi.nlm.nih.gov/pubmed/21252716

About the additional 2mm nodule of AIS, it was interpreted as a spread from the main tumour (by the airways), so the additional risk is not in the in situ carcinoma per se but in the supposition that it spread from the main tumour making that tumour more aggressive than it otherwise would be. The pathologist noted a lepidic pattern in the additional nodule that was suggestive of endobronchial spread. That is why I asked the question about what the pathologist would look for to arrive at this supposition.

Dr. West, I wish I had the size of the invasive acinar component in the main tumour but that was not provided. All it said was that the lepidic component was relatively predominant on the periphery.

Anyway I think it is great that you all make this public service for anyone who writes in to ask questions!

catdander
We look forward to good news

We look forward to good news moving forward!

onthemark
It looks like the new

It looks like the new classification system arriving later this year will replace my tumour staging of T3 with T1b(2) since the main tumour had a relatively prominent lepidic component and the in situ 'satellite' was purely lepidic. I am quoting from the abstract of an in press publication:

The IASLC Lung Cancer Staging Project: Summary of Proposals for Revisions of the Classification of Lung Cancers with Multiple Pulmonary Sites of Involvement in the Forthcoming Eighth Edition of the TNM Classification.

"Four patterns of disease are recognized; the clinical presentation, pathologic correlates and biologic behavior of these suggest specific applications of TNM classification rules. First, it is proposed that second primary lung cancers be designated with a T, N and M category for each tumor. Second, tumors with a separate tumor nodule of the same histologic type (either suspected or proven) should be classified according to the location of the separate nodule relative to the index tumor - T3 for a same-lobe, T4 for a same-side (different lobe), and M1a for an other-side location - with a single N and M category. Third, multiple tumors with prominent ground glass (imaging) or lepidic (histology) features should be designated by the T category of the highest T lesion, the number or "m" in parentheses (#/m) to indicate the multiplicity, and a collective N and M category for all..."

http://www.ncbi.nlm.nih.gov/pubmed/26940528

So this means instead of being stage 2 my disease will be reclassified as stage 1.