clinical significance of plueral effusion increase - 1263043

dongsheng
Posts:21

My dad was being treated the 2nd time with Alimta for NSCLC IV with pleural effusion.

Before his 5th infusion, he had a CT scan that showed the pleural effusion increased significantly in size. ( roughly from 400-500 ml to 1000 ml ) compared to a CT scan 7 weeks ago. however, the scan says the lung mass did not change much in size compared to the CT scan 7 weeks ago and 13 weeks ago.

In addtion to CT, he also had MRI ( negative ) and Bone scan ( which showed multiple bone mets, however, his last bone scan was Feb 2013, so not sure if the bone mets were formed before this series of chemo, or during this series of chemo )

Because my dad has EGFR mutation, we ( our Onc and us ) are thinking about changing to Tarceva. But I want to check with your opinion - do you consider these being enough evidence of progression ?

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Reply # - April 2, 2014, 06:43 AM

Dr West
Posts: 4735

Size changes in a pleural effusion, in the absence of additional findings suggestive of progression, are generally not considered to represent a clinically significant, compelling finding of progression. It's a soft call, overall.

That said, the decision of when to change treatments in the setting of some degree of progression depend on several factors, including the tolerability of treatment and the appeal and anticipated value of the next treatment. In other words, when the drug waiting in the wings is an EGFR inhibitor in someone with an activating EGFR mutation, we might have a very low threshold to change therapies, while in someone who has exhausted just about all treatments, we would be much more charitable about seeing the potential benefits of continuing the same treatment, including considering whether very slow, mild progression is better than faster progression off of that treatment.

If you do switch, this is a situation in which I'd make a mental note that it isn't really in the face of striking progression of the cancer, with the significance being that it might be reasonable to return to Alimta (pemetrexed) later.

Good luck.

-Dr. West

Reply # - April 2, 2014, 03:40 PM

Dr West
Posts: 4735

No -- that's presuming it's a malignant pleural effusion. If it were known to be a non-malignant effusion, it would only make me less compelled to suggest a treatment chance, though our threshold still tends to be low for patients who have an identified driver mutation and a target for it.

-Dr. West

Reply # - April 2, 2014, 08:29 PM

catdander
Posts:

From what I've heard PE can be such a troubling problem moving ahead with tarceva would be a really good option. It's really possible tarceva will clear the PE and your dad will try it sooner or later. But there's always individual circumstance to be weighed and balanced when making treatment decisions. I hope your dad is doing better soon.

Janine

Reply # - April 5, 2014, 09:19 PM

dongsheng
Posts: 21

We have decided to move on to Tarceva next week. In the meanwhile, the fluild was drained and my dad had the 5th infusion of alimta last week, since the doc think the alimta was still partially effective.

Although we won't have alimta anymore, I am still bothered by some strange symptom my dad had after alimta.

Every time after the infusion (day 4-5), my dad will get mild fever up to 100.4 degree, and his c-reactive protein will spike up ( last time went up to ~50). then his fever will gradually go way over the next 4-5 days, and will pretty much go back to normal by day 15 or so. This is accompanied by cough, involuntary gasping ( like when you catch breath while crying ) and pain/disconfort around lower left rib cage (where left elbow touch body). These symptoms start shortly after the fever and last a bit longer, but pretty much cleared up by the next infusion. We brought these up with our doc but didn't get any answers. I have presumed these are alimta related since they all come in cycle with the alimta, but want to know if there is any serious concerns with these that we should push our doc to invetigate more.. Thanks

Reply # - April 6, 2014, 09:40 PM

dongsheng
Posts: 21

Thanks Dr.West.

I just called my mom, and I am so pissed at the radiologist who read my dad's CT last week.

My dad had a CT scan 12/26, which read that there is a soft tissue density mass at the left lung base of hilar, measuring 1.7x3.2 cm, it is well-marginated with heterogeneous attenuation. ( while a CT at end of Sep 2013 showed nothing, I have posted before regarding the growth rate of the mass on grace ).

Then after 2 alimta infusion, my dad had another CT scan 2/11, basically nothing changed from 12/16 scan.

Then it's the CT scan last week. The radiologist basically copied the CT scan report from 2/11, didn't even change a word, lead me to thinking that the mass has not changed in size, which in fact, has significantly increased in size. ( my mom went back to him, and asked him to rewrite the report ). This time, it increased to 3.9x5.5 cm

I am just stunned by how fast this mass is growing.. it basically grew from 1.7x3.2 cm to 3.9x5.5 cm in 7 weeks. I am not sure how to accurately calculate the VDT, but at the surface, this seems like it is doubling in sizes every 10-15 days.

I have read from your previous post that well-marginated is a good sign except for metastasis, and I know metastasis lesion grows faster than orinigal tumor. But is this type of growth rate what you would expect of a metastaic tumor ?

Also to add some background, my dad was diagnosed Feb 2013 with poorly/undifferentiated adeno (which I know also tends to grow fast) with EGFR Exon 21 mutation. At the time of diagnosis, one pathologist think it was large cell, but three other pathologist at bigger cancer center think it was poorly/undifferentiated adeno. So we went with cisplatin/alimta and he responded well.

Although we are moving on to Tarceva next week, I just can't understand.. how can the mass grow so fast ? could it be that it mutated to SCLC ? should we do a biospy ? I'd appreciate feedbacks.. Thanks !

Reply # - April 7, 2014, 05:57 AM

JimC
Posts: 2753

dongsheng,

Using a VDT calculator at http://www.chestx-ray.com/index.php/calculators/doubling-time I calculated the doubling time at roughly 24 days, which is fast but certainly possible for cancer.

As Dr. Weiss and Dr. West said in one of your previous threads, it is impossible for the faculty here to determine whether this is cancer, but if your doctors feel confident that it is then as both GRACE doctors commented previously, a biopsy is usually not necessary.

For patients with an activating EGFR mutation, Tarceva can often be effective fairly rapidly so a quick change to Tarceva, as recommended by your dad's doctors, seems to make good sense. In any event it is one of the approved second-line treatments, even for patients without such a mutation.

Good luck with the new treatment.

JimC
Forum moderator

Reply # - April 7, 2014, 08:58 AM

dongsheng
Posts: 21

Thanks Jim ! I played around with the calculator, and it seems if I use "volume" (length * width ), it gives 24 days, and if I use "diameter" ( avg of length and width), it gives 17 days. My mom is going to buy Tarceva today, so I hope it will work.

Reply # - April 7, 2014, 05:44 PM

Dr West
Posts: 4735

I'm sorry to hear of that significant growth in a short time. It's possible that there's some inflammation or infection around this. My first thought was that this could be transformation to small cell lung cancer, but that's more expected in someone who has demonstrated acquired resistance on an EGFR inhibitor like Tarceva (erlotinib), not before starting an EGFR inhibitor.

A biopsy is certainly possible, but it would probably be a matter of at least a couple of weeks between obtaining it, reviewing pathology results, and then acting on new results. On the other hand, starting on Tarceva is most likely to be the optimal option based on what you know now, and there's a chance her cancer could be responding dramatically by the time you interpret the results on a repeat biopsy.

On the other hand, if Tarceva is ineffective and the cancer is growing, I think this would be a situation in which a repeat biopsy could be helpful in defining an appropriate way to proceed after that.

Good luck!

-Dr. West

Reply # - April 7, 2014, 06:02 PM

dongsheng
Posts: 21

Thanks for your feedback Dr. West ! seems like starting Tarceva is the most optimal option at this point.
As I mentioned in my previous question, my dad's c-reactive protein spiked every time after the alimta shot, and he would have a mild fever. Each time after the first 3 alimta shots, my dad received anti-inflammation injection for a couple of days because of his fever and elevated CRP. However, for the 4th Alimta shot, although he had fever, he did not get the anti-inflammation injection, and the fever just gradually subdued over the course of 5-8 days. I sure hope this is at play in regards to the growth of the mass, but he then had increased pleural effusion ( reddish, which I think is suggestive of malignancy ) and additional bone mets on bone scan. May be he has inflammation on top of cancer progression, I am not sure we'll never figure out exactly what is going on..
Anyway, thanks so much for sharing your thoughts, and I called my dad a hour ago and he felt assured that I am bouncing ideas/treatment plans off experts in U.S. ( my dad is in China). I can't say enough thank you for all the input I received. I'll update once my dad started taking Tarceva.

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