Dr West and Dr Weiss, your opinions please on a NSCLC "anomaly" - 1250649

katiejolove
Posts:6

Hello doctors,
I hope you wouldn't mind taking a moment to read and give feedback on what is happening with my Dad's case. Let me briefly review his case:
58 year old male non-smoker diagnosed November 2009 with 3 brain mets, unable to locate primary. Brain tissue confirms NSCLC adeno. Brain resection, WBR, radiosurgery to 2 remaining mets. No treatment again until August 2010when primary located on left lingula. 4 cycles cisplatin/etoposide concurrent with 37 chest radiation treatments. No treatment again until May 2011, one single brain met treated with SRS. No treatment again until February 2012, 5 small brain mets again treated with SRS. No treatment until MRI yesterday reveals 3 tiny brain mets, SRS planned for next Monday. (That makes 4 SRS treatments to a total of 12 mets over the course of 3 years)
Because his chest/thoracic CT's have shown no evidence of disease since treatment ended in October of 2010, his CT scans are now every 6 months. MRI’s every 3 months. No systemic therapy at all in over 2 years.
Now my questions/concerns
Where the heck are these mets coming from? Is it possible that in the time between WBR and systemic definitive therapy in 2010 (7 months) that they seeded in the brain and have taken this long to show themselves, slowly, averaging an appearance every 10 months?
The SRS doctor says, that with this history and the fact that his performance status is EXCELLENT, he will always continue to treat a handful of mets assuming they continue with this low frequency. My concern is, what if one day he presents with 20 brain mets. Where do we go from there? He will be 3 years out from WBR this January 2013. Would WBR be repeated with that much of a distance between the first course?
Would one consider using Alimta if such a scenario presented in hopes that it could cross the BBB?
And, have you ever personally seen such a patient with metastatic disease go for so long in between treatments that are only localized?

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Reply # - November 27, 2012, 11:01 AM

catdander
Posts:

Hi katiejolove, what an unusual course your dad's cancer has taken. I'm particularly impressed and happy to hear that he has remained as treatment free as he has.

If you don't mind I'd like to contact another doctor, a radiation onc, to answer your questions. You'll hear back in a matter of hours.

Good luck to your dad,
Janine

Reply # - November 27, 2012, 03:59 PM

dr loiselle
Posts: 37

Hi -

Sorry to hear that your Dad keeps having these recurrences, but they do seem to have been controlled with repeated radiosurgery, which is great.

The short answer to where the mets are coming from: we don't know. They could have seeded long ago, or he could have a subradiographic lung lesion, or lesions elsewhere which are too small to pickup with CT that are generating the metastases.

One can repeat whole brain radiation therapy, but I would prefer not too so lung as radiosurgery is a reasonable option. As well, I would favor radiosurgery over a systemic agent such as Alimta - radiosurgery is more likely to continue to be more effective with less in terms of a side effect profile.

I hope that helps. I have seen patients like your Dad...

-Dr Loiselle

Reply # - November 27, 2012, 09:07 PM

Dr West
Posts: 4735

I really agree with Dr. Loiselle. We don't have answers for the behavior of everyone's cancer, and there is no clear right answer to how to deal with his unusual case.

As for what I've seen, I've seen many cases that have very unusual features to them, including flavors like what you describe. It's not common, but it does happen.

-Dr. West

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