Advanced Stage ROS1-driven NSCLC with massive pleural effusion - 1262651

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Advanced Stage ROS1-driven NSCLC with massive pleural effusion - 1262651


My dad was diagnosed with a stage IV NSCLC adenocarcinoma around 4 weeks ago. He experienced a shortness of breath and difficulty in breathing prior to being hospitalized. Any simple exercise such as walking would tire him easily. His thorax photo showed a massive pleural effusion on the left side of the lung spreading toward the right side. The pleural fluid has since been drained using a small chest tube. My dad went through the pleurodesis procedure twice using a 30 mg bleomycin sclerosing agent each time. However, the procedure failed both times as the pleural fluid continues to come out at a rate of 300 ml per day. The color of the fluid is yellow.

He was tested EGFR and ALK negative but ROS1 positive. He plans on taking Xalkori (Crizotinib) after the pleurodesis succeeds. He has not undergone any chemotherapy.

Listed below are some of my questions that I need your help with:

1. Should an alternative pleurodesis sclerosing agent such as TALC be considered since bleomycin has failed both times? Or should the bleomycin dosage be increased? The TALC procedure would involve a bigger chest tube being inserted.
2. My dad's pleural effusion is not as massive as it once was (300 ml/day now vs 1000 ml in early February), his thorax image also showed his left lung's no longer covered with fluids, but why is he still unable to muster enough energy to walk? His eating appetite is still good.
3. Aside from the pleural effusion, his body tends to become rigid and numb occasionally, does this mean that the cancer might have spread to his nerve system?
4. Can he take Xalkori now or does he have to wait until the pleurodesis succeeds first?

Your kind assistance would be highly appreciated. Thank you very much.

Reply To: Advanced Stage ROS1-driven NSCLC with massive pleural


Welcome to GRACE. I'm very sorry to hear about your dad's diagnosis and symptoms. Much of what you ask requires the full knowledge of your dad's situation, which only his local doctors possess. But here are a few thoughts on your questions:

1. In his thorough discussion of the management of pleural effusions, Dr. West said:

"These procedures can use talc, or some antibiotic medications that cause inflammation (previously
tetracycline before it was taken off the market in 1992, now commonly doxycycline), or some
types of chemotherapy (bleomycin is commonly used but very expensive compared to equally
effective approaches), or a few other agents. There are no significant differences among the
agents and approaches in wide use..."
- (This is a pdf file).

2. It's not unusual for a lung cancer patient to be fatigued, but it is certainly something to discuss with his doctors to see if further workup is advisable.

3. Again, the cause of his rigidity and numbness is something to discuss with his doctors, but it seems that if his cancer had reached the central nervous system he would be having a wider range of neurological symptoms.

4. Systemic therapy such as Xalkori can treat his cancer wherever it appears, including in the pleutal space, so starting treatment may help. The main question would be whether his doctors feel he is well enough to tolerate it at this point. My wife's pleural effusion was drained once, then chemo cleared up the remainder and it didn't recur.

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>

Dr West
Reply To: Advanced Stage ROS1-driven NSCLC with massive pleural

Yes, alternate agents for pleurodesis are likely to be a lateral move, as there isn't one that is superior to another.

As Jim noted, there are many causes of fatigue, so it isn't as simple as being a product of the effusion alone. His doctors may have more insights.

I would have concern about his numbness and think it makes sense to check for involvement within the brain, though I wouldn't presume that to be the case.

It is absolutely feasible to start Xalkori (crizotinib) before definitively managing the pleural effusion, and in fact I would say that it is the intervention most likely to be effective in someone with an ALK or ROS1 rearrangement.

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

Reply To: Advanced Stage ROS1-driven NSCLC with massive pleural

Generally, repeating a pleurodyesis a third time seems unlikely to be successful. Often if a pleurodyesis fails, it is because the cancer is causing the lung to stick in place, preventing it from re-expanding fully - so-called 'trapped lung'. It seems reasonable in this type of setting to start systemic treatment with Xalkori or chemotherapy first, and leave a pigtail catheter in place. Ideally the effusions can be expected to dry up with systemic treatment. Hope this helps.

Reply To: Advanced Stage ROS1-driven NSCLC with massive pleural

Thank you very much for the helpful replies. After discussing things with my family, my father will start taking Xalkori soon without the pleurodesis. I will keep everyone posted.