New to Forum - Q on Maintenance vs. Radiation - 1271757

scohn
Posts:237

Hi everyone. This is my first posting - just joined.
My wife (60yo, never smoker) was dx with Stage IV NSCLC adenocarcinoma in April, out of the blue, after appearance of persistent cough and what was thought to be non-responding pneumonia. No brain mets, mets in a couple of chest lymph nodes and two bone spots (one on sternum, one on vertebral). One main tumor was in lung - ca. 5cm in middle right lung.
No markers on immunohistology, guardant blood test suggests HER2 exon 20 mutation.

She has had 6 rounds of carbo/alimta - good response, by CT about 50-60% reduction in tumor volume (much of it after first 2 rounds), all lymph nodes back to normal size, and re-calcification spot in area of sternum cancer suggesting positive chemo response. Since there was a lot of dead tissue in early biopsies of vertebral cancer spot and lung via bronchoscopy, Dr. thinks much of remaining lung appearance on CT scan is dead/scar tissue. Side effects were manageable, and she had neulasta shot with every round after 2nd round of chemo to reduce WBC drop.

She is currently on Alimta maintenance - every 3-4 weeks. Her RBCs are coming up and she does not seem to need the neulasta for WBC either so far. She is still on xgeva every 4 weeks.

My question relates to radiation. In our first meeting with the oncologist he suggested that if the chemo went well he would likely do some radiation down the line to further reduce any remaining cells at chest tumor and bone spots. His current plan is to remain on alimta maintenance until any sign of recurrence, and then do radiation. My question is basically just wondering what the current thinking is as to when one does preemptive radiation for oligometastatic spots versus waiting on the radiation and using alimta maintenance.

Thanks - and I hope question isn't too general. Love the site. Video on HER2 in NSCLC was very useful!

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kempten
Posts: 128

Hi,
I'm very much wondering about this also.
I will be checking out the answers with great interest.
Thanks for posting the question
Kempten

JimC
Posts: 2753

Hi scohn,

Welcome to GRACE. Congratulations to you and your wife on her excellent response to treatment.

It seems that you have done a bit of research and that you understand that in the stage IV setting, local treatment such as radiation or surgery is usually not recommended, although there are instances in which it is used to treat one or two lone spots of metastasis. The theory underlying local treatment of such oligometastases is that they may represent a kind of rogue group of cancer cells that spread outside the lung, but that it is the only place they have spread. Treating such a lone lesion may take care of the only metastatic cells.

In your wife's situation, her cancer had spread not only to lymph nodes but to two separate bone locations. Whether that qualifies as oligometastatic spread is debatable, and the side effects of radiation should not be taken likely in an instance in which other metastases may appear, requiring additional systemic treatment. A patient's ability to tolerate such necessary treatment can be compromised by those local treatment side effects.

This is certainly an issue to be fully discussed with her oncologist, and perhaps a "second set of eyes" via a second opinion.

JimC
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scohn
Posts: 237

Thanks Jim.

I really appreciate the nice welcome. Everyone here at GRACE seems really kind.

The original question, however is moot for the moment, Just shows how fast things can change…

The radiation was only going to be an option if there was stability for a long time with the Alimta maintenance.

Turns out that at the last CT scan this week two small liver tumors showed up. The oncologist now is switching to Opdivo. My wife has the first treatment today. Now comes the anxiety as the Dr. said the effects of Opdivo aren't really apparent for about 8-10 weeks, and that often, even if it is working, the CT scans can look a little worse at first as what looks like tumor enlargement can actually be immune reactions occurring at the site.

Thanks again for all your help!