Hi everyone.
I need some advice. Unfortunately, my 65 year old mother was just diagnosed with stage 3A Nonsmall cell lung cancer with evidence of mostly adenocarcinoma and less than ten percent of possibility of squamous cells. Her tumor is 6cm in diameter and beginning to invade the main pulmonary artery. She tested negative for mutations.
The surgeon claims the tumor is potentially respectable if we can shrink it. So we were given two neoadjuvant therapy choices:
Option one: The oncologist offered us the standard of care which is a chemo cocktail of cisplatin and alimata for three months and then reevaluation to move on to surgical resection.
OR
Option Two: to participate in a clinical trial using Opdivo for two infusions over a 28 day period for the first time in patients that are not yet stage IV. Then reevaluation for surgery.
We don't know what to do? Can fellow members weigh in on knowledge and personal experiences on side effects and effectiveness for both the cisplatin and alimata vs Opdivo.
Is Opdivo too much of a gamble for a potentially respectable tumor? Likelihood of cancer progression in four weeks (add another two for routine tests).
Which is "safer" route to go? How proven is chemo to work on tumor shrinkage prior to resection?
We were not given as much feedback and reassurance as we would have liked on either option and feeling very afraid and frustrated in what already was a high stress situation with the new diagnosis.
Thank you to all!!!!!!!
Reply # - May 2, 2016, 10:36 AM
Number one priority, get a
Number one priority, get a second opinion from a unbiased thoracic surgeon at a high volume center. It is impossible know from a written description whether a tumor is really resectable or not. The images tell the story.
Based on a description of main pulmonary artery invasion, the resectability seems rather doubtful.
In practice, it is extremely rare for a lung cancer to be converted from unresectable to resectable with the addition of neoadjuvant chemotherapy. Even if the tumor shrinks, it generally remains adhered to the vital structures (pulmonary artery, aorta, etc) which made it inoperable to begin with.
Assuming the tumor is not currently resectable (need second opinion), then the guidelines generally recommend using radiation with concurrent chemotherapy, for Stage IIIA disease. That is usually the preferred approach.
It may be a shame to waste time tinkering around with an unresectable tumor, if it ends up delaying potentially curative chemoradiation.
Reply # - May 2, 2016, 11:31 AM
Hi Dr.!
Hi Dr.!
Thank you sooooooo much for the very sppedy reply.
On Friday, we went to Memorial Sloan Kettering. A surgeon there told us that my mother's tumor is resectable. They did a PET scan, MRI, CT scan, biopsy and pulmonary function test. Is it even possible to resect a tumor attached to an artery? Can they peel tumor off?
According to Sloan, their protocol is to use some sort of neoadjuvant systemic therapy first, prior to the planned surgery.
That is when the referred oncologist gave us a choice of chemotherapy OR the clinical trial with Opdivo as a first line treatment. The choice left us very confused.
Should I still get a second opinion from another thoracic surgeon? Thoughts so far???
Reply # - May 2, 2016, 11:34 AM
Hi Greekgirl,
Hi Greekgirl,
Welcome to Grace. I know how difficult it is to be thrown into a cancer diagnosis for someone you love and not knowing the first thing about current cancer care. Cancer treatment is changing it seems like daily and sometimes actually is. So I'm glad you've found us. Grace can make you feel less stress in knowing you or your loved one is getting the best treatment. We have an excellent library of information our faculty oncologist and web tech Mark provide almost daily.
We have an excellent post on all the good reasons 2nd opinions are important. http://cancergrace.org/cancer-101/2011/11/13/an-insider%E2%80%99s-guide…
Please let us know how things progress. My signature, shown below my posts provide a short history of my husband's journey. We don't know if he was ever really stage IV but maybe was at most III. Whatever the diagnosis he appears to be cured, no treatment in 3 1/2 years and no growth. His tumor was quite invasive and was treated with radiation and chemo only. Stay hopeful.
BTW, I took down your 2nd thread. We see and respond to all threads and I didn't want it to get confusing. Too I took the first part of your title off. Our founder's pet peeve since we all feel that way, "A style point pet peeve with a notable exception: Please refrain from posting in ALL CAPS and with multiple exclamation points" http://cancergrace.org/grace-discussion-forums#guidelines
I look forward to hearing the best about your mother.
Best hopes,
Janine
Reply # - May 2, 2016, 02:45 PM
Hi Janine!
Hi Janine!
Thank you so much for editing my post according to forum guidelines, I welcome it. I also thank you, as well for your speedy reply.
First, I will seek a second opinion this week so not as to waste more time.
My primary concern is if the tumor is indeed respectable as the surgeon evaluated it was, what net benefit would my mother gain using nivolumab as a first line treatment.
Sloan unfortunately does not offer chemoradiation together as a first line treatment, so my option would be just a standard chemotherapy cocktail OR the two dose infusion of nivolumab. Is choosing nivolumab a risk worth taking with a potentially respectable tumor?
May your husband always continue to be blessed with NED. How wonderful that you are his advocate.
Thanks a million for the responses.
Reply # - May 2, 2016, 04:49 PM
In general, if a tumor is
In general, if a tumor is resectable that is the best option, with follow-up chemoradiation in many cases. The value of nivolumab in this context is unproven. I'm not sure why chemoradiation would not be offered, unless there is something about the location of this particular tumor which makes radiation infeasible. Certainly a question to ask, and a reason to obtain a second opinion.
JimC
Forum moderator
Reply # - May 2, 2016, 05:46 PM
Hi Jim!
Hi Jim!
I hope you're having a wonderful night.
The surgeon said she will not resect it without a neoadjuvant therapy. I'm assuming she wants the tumor to shrink a bit to make the surgery less invasive?
In my moms case, Sloan offers chemotherapy or Opdivo first. Resection next. Radiation and/or chemo following resection. Thoughts on this? Does prognosis following this regimen sound feasible?
Second opinion tomorrow.
Reply # - May 3, 2016, 06:34 AM
Hi greekgirl,
Hi greekgirl,
That does make more sense; I knew MSKCC must offer adjuvant chemorads. Using Opdivo first would be in the nature of a trial therapy (even if not officially in a trial context), since its role is not established in that setting. Otherwise, neoadjuvant chemo, surgery and adjuvant therapy is certainly a reasonable course of action, with at least as good a prognosis as other treatment plans.
JimC
Forum moderator
Reply # - May 3, 2016, 07:23 AM
Hi JimC,
Hi JimC,
The oncologist also mentioned this regime:
-2 Opdivo infusions
-Resection
-Chemotherapy or Radiation
Any thoughts on that regimen?
Reply # - May 3, 2016, 10:55 AM
Hi greekgirl,
Hi greekgirl,
Essentially, any regimen that starts with immunotherapy is experimentsl at this point. Also, immunotherapy tends to take several weeks to show results.
JimC
Forum moderator