We got the terrible news in Jan 2016. She felt pain in lower abdomen. Chest X-ray led to CT then PET.
Mom is mid-70s, smoker most of her life. in decent health, active, was able to take care of herself just fine.
Timeline:
Jan 2016: Dx: right inferior hilar mass 1.7cm x 1.6cm, homogeneously intense on PET. Right adrenal met hot on PET, 2.6 x 1.3 cm. right pleural effusion. Mutations negative. Poorly differentiated. No other mets.
Feb 2016: started 4-cycle doublet (carbo/pac I think).
Mar 2016: follow up CT after 2nd cycle showed lung tumor increased to 2.0 x 2.0 cm, however now shows central necrosis. Report said that although it has grown, the change from homogenously intense to central necrosis may be a sign of successful treatment. The adrenal met decreased to 1.8 x 1.3 cm. pleural effusion is gone.
Talking with the doctors has been nearly impossible due to their limited availability.
My questions:
1. Is it common to describe a tumor that increased in size, but has changed to centrally necrotic as possibly successful treatment response?
2. Since this is oligomet/adrenal case, is surgery in the future a possibility? Targeted radiation?
3. Could the adrenal met have started by transfer of cancer cells from lung tumor via lymph system? (Thus not from blood)? If so, does this technically mean it's not stage 4?
4. Is immunotherapy for second line a possibility?
Any other advice, observations would be greatly appreciated.
Reply # - April 2, 2016, 07:45 PM
Hi larryb,
Hi larryb,
Welcome to GRACE. I'm sorry to hear of your Mom's diagnosis, All of us here at GRACE know exactly how difficult a time this is for you and your family.
It's not unheard of for a tumor to increase slightly in size as a result of effective treatment, and the presence of central necrosis, as well as the smaller size of the adrenal met, makes that a reasonable interpretation.
I'll combine my answers to your next two questions: It's not likely that the adrenal met is the result of cancer cells traveling through the lymph system. Both that met and the pleural effusion indicate that cancer cells have entered the bloodstream. As Dr. West explained:
"Lymph nodes are like regional filters, and the lymphatic system is kind of like the gutters after a rainfall. You can have some movement within the same area that aggregates to particular areas, but it's still usually in the same area (on the same property).
Cancer in the bloodstream is like movement along the roads. Once cancer cells are out in the bloodstream, they can travel pretty much anywhere. You can't get from New York to Boston without taking a road (even to the train station or airport -- I'm working with what I've wrought), and you can't get from the lung to the brain without going to the bloodstream.
The problem is also that it is almost always the case that if cancer cells got from point A to point B via the bloodstream, they weren't traveling alone. Even when you can't see any other areas of metastatic spread on scans, if a lung cancer was metastatic, there are almost always micrometastases traveling in the bloodstream beyond what can be seen on scans." - http://cancergrace.org/forums/index.php?topic=4928.msg30072#msg30072
With the presence of cancer cells in the pleural space, as well as in the bloodstream, local treatment to the adrenal met is probably not an attractive option.
And yes, immunotherapy may be an option as second line therapy.
JimC
Forum moderator
Reply # - April 3, 2016, 10:03 PM
Thank you very much for your
Thank you very much for your explanations... Very helpful.
Regarding the central necrosis, I did a quick search of posts with the phrase and found this from dr. West:
" The necrosis can be because of the effect of the treatment (killing the center of the tumor), but I wouldn't expect to see growth of the tumor dimensions with that. Another reason we sometimes see tumor necrosis is that the cancer is growing and outstripping its blood supply, so the inside of the tumor dies because it's not getting enough nutrients and waste material isn't being removed. So we sometimes see this in the setting of a progressing cancer."
I am concerned because this seems like a less optimistic interpretation of the treatment effectiveness.
Another question:
The chemo side effects seem to be lengthening with each cycle, now they are to the point where she doesn't seem to get a much needed "break". It is mainly mainly nausea, tiredness, and feeling exhausted. Reading the side effects lists for chemo and lung cancer itself, it hard to tell which is causing her discomfort. Is it a concern that her side effects seem to last longer with each treatment? Is it possible that this is coming from the cancer itself?
Thanks
Reply # - April 4, 2016, 12:21 PM
Hi larryb,
Hi larryb,
I should amend my choice of words and provide some explanation which may help. I should have said that the tumor might appear slightly larger than on the previous scan, even if treatment was effective. First, there is an interval between the first scan and not only the beginning of treatment, but the point at which it begins to be effective. In that interval, the tumor may continue to grow a bit, so the baseline size of the tumor prior to treatment may be a bit larger than the measurements from the initial scan.
In addition, the increase is size is pretty small in each dimension, and there can a differences between the CT scanners, the precise angle captured in the images, and the spots chosen for measurement by the radiologist (since tumors don't tend to be perfectly round or rectangular, the radiologist must choose where to measure to obtain the maximum height and width of the tumor). As a result, a small increase in size is not necessarily evidence of progression, especially in light of the other favorable results revealed by the follow-up scan.
At worst, you might be looking at a "mixed response", in which some areas shrink and others grow. Regardless of whether that is the case, the fact that there may be doubt about whether the lung tumor is responding, together with the small increase in size, may very well suggest that continuing the current treatment and re-scanning after a couple more cycles would be a reasonable course of action.
JimC
Forum moderator
Reply # - April 4, 2016, 09:15 PM
Thank you JimC for the quick
Thank you JimC for the quick response. I hadn't thought about the stub period at the beginning between the initial scan and the treatment taking effect. Also the measurement variability from scan to scan.
I will post here with any updates.
Reply # - May 7, 2016, 09:43 PM
Update: had follow up ct scan
Update: had follow up ct scan after 4 cycles of chemo. Doc said he wasn't seeing the effect he had hoped for and wants to change course for treatment. The primary tumor was about the same size and so was the adrenal met. They also saw possible new nodes in the same lobe as the primary tumor. The doctor said he still wants to treat with curative intent. So the plan is to see if she is a candidate for surgical resection of the primary tumor. The first step is a PET next week, if that is negative for new disease then the next step is surgical medianastinoscopy. If that is negative, then surgical resection of the tumor along with cyber knife on the adrenal met. If however, she is found not to be a surgical candidate, the plan is opdivo with palliative intent. My question is this: I have read that stage 4 is not curable. Is there a significant risk that she will go through this traumatic surgery only to have it come back? I know it is impossible to say for sure, but from what I have read, surgery in this case is not always recommended. Any guidance you may have is greatly appreciated.
Reply # - May 8, 2016, 10:00 AM
Hi Larry,
Hi Larry,
Everything you have said about the proposed treatment plan is true. With stage IV lung cancer, treatment is not typically pursued with curative intent, because cancer cells have entered the bloodstream and will eventually show up somewhere else in the body. If a patient is still recovering from a difficult surgery, it may not be possible to initiate the type of systemic therapy needed at that point.
There are cases, however, when there is just one distant metastasis, and local treatment of this "oligometastasis" is pursued. The typical situation in which this is pursued is when the primary tumor is under control with prior therapy. In your Mom's case, this may not be true if there are new lung nodules. In any event, it is typically the metastasis that is radiated or surgically removed, since that is usually a somewhat less taxing a procedure for the patient, and if the cancer continues to grow or spread the initiation of systemic therapy is not significantly delayed.
You will find plenty of posts on oligometastases on this site; the most recent podcast on the subject can be seen here.
Good luck with whatever treatment course is chosen.
JimC
Forum moderator