My fiance is on his fourth month of Tagrisso after 14 months on Afatnib. His most recent scans show improvement in his lungs and bones. There has been slight growth in his lymph nodes but it's more likely they're stable and the 1mm change was due to treatment effect and/or a recent illness. Regardless, he has two supraclavicular lymph nodes that are at 1.2cm and 1.7cm and causing pain and discomfort. Considering the Tagrisso seems to be working on the rest of his body, including his brain, it's too early to say he's not responding, correct? Due to the discomfort, we'd like to pursue additional treatment options. He's obviously nervous about standard radiation side effects since it's so close to his throat. What about radiofrequency ablation, alcohol ablation or cryoablation? Is SRS an option?
Additionally, is there a chance that these lymph nodes don't carry as much of the T790 mutation as the rest of his cancer? Could there be an additional mutation that we should test for like Met? Or could it just be carrying the original EGFR mutation and something like an afatnib pulse as a chaser could help? Just trying to think outside the box.
Reply # - July 6, 2017, 07:56 AM
Hi stage4gf,
Hi stage4gf,
Congratulations to you and your fiance on the tumor shrinkage. With second line therapy, we don't expect as dramatic a response to treatment as we hope for with first-line therapy, so shrinkage is a very good result. After four months of Tagrisso, we would usually expect that further treatment will result in stability, but it's certainly possible to see further shrinkage.
It's true that a 1 mm increase in a node is probably not significant; even the variance in angle and the way the images slices cut between two different scans (even if taken just hours apart) can produce such a small difference.
Although local treatments for stage IV lung cancer, such as surgery or radiation, are not typical, they may be used when specific areas of cancer are causing pain or other symptoms. Surgery and radiation are the best-tested and most often used modalities. In your fiance's case, the radiation oncologist would need to determine that SRS or other radiation technique would be feasible.
Drs. Sanborn and West discussed alcohol ablation in this thread, with Dr. West stating:
"As Dr. Sanborn notes, injecting alcohol is locally ablative--it kills any cells in the area of the injection. Sometimes local ablation is desirable. In local cancer (stage I for example) local ablation can cure--in this case, the best validated modality for local ablation is surgery, with stereotactic radiation giving surgery a run for its money. In stage III disease, we use radiation to locally ablate cancer. Occasionally, we use local ablation in stage IV disease. For example, we've spoken of metatectomy and SRS before here. However, alcohol injection has not found a place in the local ablation of lung cancer. Other modalities, principally focal radiation methods such as cyberknife have found a more established role. Some institutions do RFA (radiofrequency ablation) as well. Alcohol simply hasn't shown any advantage over any of these [other] modalities."
Continued
Reply # - July 6, 2017, 08:15 AM
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[Continued from previous post]
Dr. West also discussed radiofrequency ablation, in the context of lung tumors, in this post.In another thread, Dr. Weiss stated "RFA tends to work best on small lung lesions. I've never heard of it being used for mediastinal lymph nodes." - http://cancergrace.org/forums/index.php?topic=10937.msg89189#msg89189
The take away point from these discussions is that SRS, if feasible, would be preferred over the other modalities mentioned.
As far as the presence of T790M in the nodes, it's possible that the mutation is not present there. Testing for the mutation would require a biopsy of the nodes, or surgical removal. A biopsy which provides only a small amount of tissue from one or both nodes might not answer the question, since the cells captured might not be representative of all of the cancer cells in the nodes. If the nodes were enlarged at the time your fiance switched to Tagrisso, then I don't see that using Afatinib would be likely to help.
JimC
Forum moderator