Ascites in Lung Cancer - 1247664

Tue, 09/04/2012 - 11:20

Hello everyone,

I wish I had more cheerful news to post, but except for the fact that my husband underwent a bone biopsy yesterday and 700 ml of pleural effusion was tapped from his right lung (the good lung because the primary is in the left Lung) I have very little to add. I never thought I would be happy about a biopsy or that a pleural effusion had been tapped which could finally give us more information about the Lung Cancer.

The saddest part is that the pet ct scan showed that there is mild ascites. I discussed this with his onc but he says it is nothing to worry about. But I am sure that this 'mild ascites' was the cause of the stomach distension, feeling of fullness, loss of appetite he was suffering from until he was managed by HAPPI-D, Sucrafil O Gel and Drontin. However he was not fully well except the symptoms subsided a bit.

Now the onc says there is nothing to worry about regarding this ascites. He even refuses to prescribe diuretics for it. But I have Fruselac, a diuretic which was prescribed by a cardiologist for his foot swelling some months back so tonight I gave him half of that along with a new anti flatulent that the onc had prescribed.

He is now feeling more comfortable, with the pleural fluid drained. I was studying on ascites on the net and the archives of Cancer Grace. Cancer Grace archives seem to have very little discussion on this. There was a post in which Dr. Ramachandran had suggested a clot in the liver as a possible cause if the ascites was not malignant. I think this is an interesting suggestion and I will take it up with another onc. This one thinks I am studying to become a doctor now :)

Please give me more information on Ascites in Lung Cancer and any successful cases you have treated.

If this is mild ascites, what can we do now to prevent it from becoming advanced and severe.

Right now my husband is on a treatment break for a few days as his biopsy and mutation test results are awaited. Thank you.

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Dr West

Apra,

There just isn't a lot to say about ascites in lung cancer. It's usually just another potential manifestation of metastatic disease in some patients, but that's usually a minority of patients, so it's not really a common issue for lung cancer management. At the same time, there's just not that much to do specifically for it. Diuretics can be at least a little useful, but not usually especially so. If the amount of fluid is very significant, such that the abdomen is protruberant and a person looks pregnant, it's possible to stick a needle in and remove fluid in essentially the same kind of procedure as a thoracentesis for pleural fluid -- it's just a needle going into a different fluid-filled cavity, and the fluid then gets sucked into vacuum-filled bottles.

The most effective thing is to treat the underlying problem, which is usually the cancer. The problem is that this is usually easier said than done.

Good luck.

-Dr. West

apra

Thank you Janine, I had also come across this article as I googled about Ascites. The first point is worrying, it says, "if cancer cells have spread to the lining of the abdomen they can irritate it and cause fluid to build up.". This seems to be the case.

Dr. West,

Thank you for your prompt reply. I wonder why my husband is he one getting all these rare complications. At least I am very happy that he slept so well after the fluid tapping. When there was fluid in his right lung he was having breathing problems and slept fitfully.

I wonder whether thie sudden increase of Alimta to 900mg was also a contributing factor as I believe Alimta can also cause water retention in the abdomen.

As his performance status is still good, we are thinking of starting Tarceva next week though the results of he mutation tests will not be available yet. The onc has prescribed just 100 mg.

Thank you for listening.

Dr West

I don't know if the Alimta is being given at a total dose of 900 mg for your husband, which would be the right dose for a small to average-sized adult, or 900 mg per meter squared, which is nearly double the normal dose of 500 mg per meter squared. There is no evidence at all that giving a dose higher than the normally prescribed amount provides any clinical benefit at all. I have never given nor recommended a higher than normal dose, nor have I ever heard of an expert favoring this approach.

As for the complications, different people can just have cancers that behave in unique ways. Many people have unusual to rare features in their cancer's behavior. It's why we favor a careful individualized assessment of a patient's situation.

-Dr. West

apra

My husband is 80kgs and 5'7". The dose was worked out on this premise.

Now this onc is afraid to give the full dose of 150mg of Tarceva for my husband as he became weak on the 900 mg of Alimta. But the weakness can be prescribed to the progression and cumulutive effects of 16 doses of Alimta.

I asked this question already but as I just saw this reply, I would like to ask the question here. The first onc, has prescribed 150mg but the second onc, who is seeing him now wants him to start with 100mg.

Is there any possibility that the medication will not be effective if given at a lower dose? Also perhaps resistance could be acquired early at a lower dose? If he was tolerating 900 mg of Alimta is Tarceva more difficult than Alimta that he would not be able to tolerate the full dose?

Thank you for your replies.

catdander

There different types of drugs, working differently in the system so can't really be compared like that. Full dose tarceva is often given to patients who can't tolerate typical IV chemo.
Your question, "is there any possibility that the medication will not be effective if given at a lower dose?". Yes like anyother drug dose matters. But in clinical trials they start with finding the highest dose a person can take without being too toxic and usually stick to that dose throughout the rest of the trial process and subsequent doctor prescriptions. You can be hopeful that a lower dose will work but the possibility is always there.

apra

Thank you Janine, what you said about the highest tolerable dose being given in clinical studies is quite relevant.

Our first onc is adamant that Tarceva will not work below 150 mg but the second onc who is younger and works under another senior onc who I am sure was not consulted in this matter, wants to tread slowly. He says let him build up tolerance then we will increase the dose. So we decided to go with the lesser experienced younger onc this time.

I went to Inspire and read a thread on dosages of Tarceva, where I found some people starting at 100 mg and tolerating it quite well and the medicine was also working to stabilise the cancer. So taking all these things into consideration, we decided to start off with the lower dose, get acclimatised and then go on the higher dose. Tonight he has taken the first dose. Hope this works :)

However, we want to go to the higher dose in a few days because we feel if the medicine is going to work then the full dose should be given and subsequently lowered if side effects become intolerable.

Doctors on this site too must have experimented with dosages. I believe they have had some patients start off on lower doses too?

catdander

There are tons of posts that speak to this very issue. Most docotors want to try the normal 150mg dose if they feel their patient can handle it then dose down if the side effects are shown to be too toxic instead of the other way around.

apra

I know Janine and we also wanted it to be the other way round, but that was not so.
Anyway my husband has other issues, like stomachache, fullest etc for which he needs antacids. For tonight I gave him the antacids one and half hour after the Tarceva. Then he also has to take Seloken 50 mg for his Herpertrophic Obtructive Cardio Myopathy (HOCM). Then he has to take the pain meds for bone pain and nerve pain like Gabapentin and Ultracet. So it's a big list of medications that goes into him along with the Tarceva. Although we are keeping the Tarceva apart and not taking an meds along with it.

We are keeping in abeyance the loos thinner as we believe Tarceva also has some blod thinning capacity.

Trying to read up on interaction of these drugs with Tarceva. Except for the antacids, have not understood others yet.

Thanks for your constant prowling on Grace to keep the likes of me updated :)

double trouble

Hi Apra. I'm sorry you're facing so many problems. I haven't seen you mention sodium restriction when talking about ascites. I'm wondering if your husband has limited his salt intake?Along with cancer, I have liver disease also so ascities is a concern, and that is the first thing my doctors told me to do, plus I take a mild potassium sparing diuretic.

I'm glad he has gotten some relief, and I hope you get a break too. You deserve it.
Debra

Dr West

As Janine indicated, I and most of the other doctors here start with the full dose of Tarceva (erlotinib) at 150 mg and then drop it as needed, if side effects are problematic. There are certainly some oncologists, including very thoughtful ones, who do start some patients at 100 mg daily, either because the patient is elderly and/or frail, and they are concerned about side effects, or because the patient has a known EGFR mutation, and many patients with an EGFR mutation can respond extremely well to a lower dose than the standard, full dose for either Tarceva or Iressa (gefitinib).

That said, I have many patients who respond very well and for a very long time on a lower dose than the standard starting one for an EGFR inhibitor. However, it is absolutely possible to under-dose the Tarceva, and that is a leading reason why most experts favor trying to treat a patient with the highest dose, up to 150 mg daily, that a patient can tolerate on a sustained basis.

-Dr. West

apra

Thank you so much Dr. West,

Yes, under dosing was my concern. As the onc has already prescribed 150 mg we are planning to give him 150 mg from tomorrow, Monday, as today is Sunday and we will not be able to get the tables. That means he will have had two 100m tabs before moving to the maximum dose.

Maybe the second onc is concerned as he has had mild ascites, continuing bone pain from the bone mets, and not up and about too much. Spends most of his time in bed though there is no loss of weight. Also he is a never smoker so more likely to have a mutation. The bone tissue and the cell block from the pleural effusion have been sent to Ques Lab in the States yesterday. Cue will have the results only after 10 days.

Glad the spam post was deleted.

apra

Thank you for your concern Debra. Last night I gave him a diuretic called Fruselac, half a able. Yes we ar trying to bring down the salt intake.