Best options to treat multiple bone mets & into soft tissue from NSCLC - 1254346

safille
Posts:5

Dear Drs. West and all,

I have benefited much from your guidance in the past and would appreciate some insight on the best course at present.

My dad, 73, with NSCLC (BAC/mixed adeno), history below, has been on herceptin/Taxol in his home in France since spring of 2012, after discovering a HER2 mutation thanks to the wonderful Dr. Ross Camidge. His latest scans show that bone mets we knew about in spine (vertebroplasty/rad. in Feb2012) have also spread extensively, in adddition to T9, to the pelvic area (right iliac wing, into the joint,, cortical rupture of external r. iliac wing, some into the r. glutei and psoac muscle, S4-S5, sacro-cocyx junction, endo-canalar extensions into ischio-rectal fossae & left iliopubic branch). Pain has also increased a lot.

I have read/listened to the cancergrace info, and have a few questions. None of the new areas have been radiated previously:

*would one reasonably radiate all these areas? (is SBRT preferable?). Are there other options to shore up weight-bearing bones (pelvis)?
*would you still lean generally toward XGeva vs. Zometa if obtainable?
*does radiation cover/help soft tissues? (the muscle, the joint)
*would you consider returning to afatinib given prior success (and potential for renewed response?)

Thank you so much for any thoughts you might have.

Case:
2005-06 after surgery, Cisplatin plus vinorelbine
2006 mets to other lobes: Tarceva (progressed), Avastin
2007-2009 Alimta, Avastin
2009 Surgery at Mayo for large bone met at L1-L2
2009-2010 Gemcitabine; progressed
2010-2011 LUX;LUNG--15% response with Afatanib, eventually progressed in 2012
2012 feb. vertebroplasty
2012 spring-now Herceptin/Taxol

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Reply # - March 1, 2013, 02:05 PM

mpinder
Posts: 42

Dear safille,

I'm sorry to hear that your Dad has progressed. We typically would radiate only those areas that were causing pain or were in danger of causing a fracture or impingement on the spinal cord. A radiation oncologist would need to evaluate previous areas of radiation to determine whether it would be possible/advisable to treat a site of disease if it was causing symptoms. When many areas of the bone are radiated, the patient can experience significant decreases in the bone marrow function (since the a large part of bone marrow/blood cell production occurs in the pelvis), which can make it more difficult to treat with chemotherapy or to qualify for clinical trials. If an area that has previously been radiated progresses, I am usually not too enthusiastic about radiating again. Radiation can treat both the bone and any soft tissue component of the metastasis. The determination of whether to use conventional radiation or stereotactic radiation depends on many factors and has to be made by a radiation oncologist after evaluating the individual patient. An orthopedic surgeon can be involved to determine whether any areas of bone weakening should be considered for surgical stabilization.

I typically continue Zometa or Xgeva for patients with bony metastases.

For patients with multiple areas of bony metastases that are causing pain, one option I consider is samarium. This is discussed in a post by Dr. West:

http://cancergrace.org/radiation/2007/02/20/radiopharmaceuticals-for-bo…

In patients with limited options, I definitely consider going back to previously effective therapies, particularly if side effects were limited and the patient had a prolonged response.

Kind regards,
Dr. Pinder

Reply # - March 1, 2013, 02:56 PM

safille
Posts: 5

Thank you so much, Dr. Pinder, that is tremendously helpful. I had not found the samarium info before, but once I checked the abstract referenced by Dr. West in the link you sent, I also found a recent Johns Hopkins study that is free full-length on PubMed that addresses that in combination with radiotherapy, and we will definitely look into that. (link below)

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3090537/

thank you again SO much for such a prompt and thorough response.

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