I have a patient who was recently diagnosed with lung adenocarcinoma. His primary lesion is at right upper lobe, PET/CT showed increased FDG uptake in a right paratracheal lymph node and a small right axillary lymph node. No other sites of disease, MRI brain negative. Since it is a rare occurence, both the primary lung lesion and right axillary lymph node were biopsied, pathology from both sites were consistent with adenocarcinoma, lung primary. EGFR negative.
Axillary lymph node is not included in the 7th edition TNM staging, I think many oncologists would stage him as stage IV due to the presence of extrathoracic metastasis. I am hesitant to declare him stage IV and treat him with only chemotherapy at this time.What would you do in this setting?
Reply # - September 5, 2012, 09:03 PM
Reply To: axillary lymph node metastasis, treat as IIIB or IV?
As you indicated, this case is really one that falls between the cracks. I agree that technically this falls in the range of stage IV, but I can definitely understand the temptation to hope to treat with curative intent.
If this were a quite young, fit patient who I thought could readily accept concurrent chemo/radiation, I'd really consider that approach and just including all of the areas within the radiation field. However, I think the most prudent approach would be to treat with initial optimal systemic therapy (chemo +/- Avastin (bevacizumab) unless the person has an EGFR mutation or ALK rearrangement, in which case I'd definitely favor targeted therapy), then see what repeat imaging shows after 2-4 cycles. If the person is tolerating treatment very well and is responding well, adding radiation to do a concurrent or sequential approach might possibly be curative. On the other hand, if the cancer progresses after an initial 2-4 cycles, or the patient experiences prohibitive toxicity or other decline in performance status, then more aggressive therapy almost certainly wouldn't have been helpful, and you'd have spared the person the toxicity of over-treatment.
Good luck.
-Dr. West
Reply # - September 7, 2012, 04:48 PM
Reply To: axillary lymph node metastasis, treat as IIIB or IV?
Thank you vey much, this is very helpful.