NSCLC Bone Metastasis only? - 1294827

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gofella2009
NSCLC Bone Metastasis only? - 1294827

My 79 yo uncle was just diagnosed with NSCLC Adenocarcinoma. Waiting for an oncologist appointment set for July 19th, in the meantime here is his PET/CT and biopsy. Any help would be appreciated, specifically:

- What is the significance/likelihood that he indeed has mets in his posterior acebatum while nothing else lights up and he has no pain? All things being equal, does it really reduces chances of his survival?
- What should we look for/discuss with the oncologist in terms of treatment - he lost a lot of weight - 20-30 lb recently, has heart condition and diabetes. I know surgery is not an option. Any help/advise would be hugely appreciated.

LUNGS: FDG avid (SUV 13.7, image 75) approximately 9.0 x 8.0 cm irregular
centrally necrotic right upper lobe perihilar mass invading the
mediastinum, including superior vena cava, innominate and subclavian
vessels. Low-grade FDG avid patchy airspace opacities in surrounding right
upper lobe and superior segment right lower lobe, probably
infectious/inflammatory; new since CT dated April 27, 2018.

THORACIC NODES: FDG avid right mediastinal and hilar adenopathy. For
example, 2.0 x 2.0 cm right anterior mediastinal node (SUV 5.6, image 93).

BONES/SOFT TISSUES: Focal FDG avidity (SUV 2.6, image 234) in right
posterior acetabulum without CT correlate, possibly marrow metastasis.

He had transbroncheal needle biopsy and they did not get any malignant cells in the lymph nodes.
The subsequent CT needle biopsy of the tumor showed the following: histologic and immunohistochemical findings support a diagnosis of primary adenocarcinoma of lung.
Immunohistochemical stains (Block A1):
POSITIVE: TTF-1, napsin, cytokeratin 7.
NEGATIVE: Cytokeratin 20 (rare single cell positivity), p40,
chromogranin and synaptophysin.
Histology subtype/Predominant growth pattern: Acinar and solid
Anatomic location of biopsy: Right upper

Sorry for long post, we are a bit desperate and want to be prepared.

Thanks!

onthemark
Hi gofella2009,

Hi gofella2009,

Welcome to GRACE. Some additional questions you might ask your oncologist about would be

1. Are there any actionable mutations that could be treated with TKI or ALK inhibitors?
2. What is his PD-L1 and possibly tumour mutation burden?
3. What is the main area that is likely to cause symptoms and would he benefit from palliative radiation if he is stage IV?
4. It's possible that the presence or absence of marrow metastases would change his stage from 3 to 4. What is his stage?
5. If he is stage III is he strong enough for definitive chemoradiation followed by durvalumab consolidation therapy?

Mostly I would try to get his stage nailed down at this point.

gofella2009
Thanks a million! Also

Thanks a million! Also curious about histology subtype/predominant growth pattern - it shows acinar and solid.
If anyone can shed some light as found info about these as discrete entities but not together?

Alex

catdander
Hi Alex and welcome to Grace.

Hi Alex and welcome to Grace. I'm so sorry your uncle is going through this. onthemark's comments are right on point or should I say on the mark.
acinar is a subtype of adeno and refers to the cell patterns found in the biopsy. It's a grade 2 tumor so falls somewhere in the lower and middle end of aggressiveness in lung cancers. And acinar lung cancer cells create solid tumors as are all lung cancers except certain BAC subtypes.

The info you get from knowing acinar isn't really very useful to the individual. For the pathologist it points to adenocarcinoma. Aggressiveness varies along a wide spectrum so one can not make too many expectations about how aggressive or indolent their cancer will be.

Keep us posted and the best of luck,
Janine

JimC
Hi Alex,

Hi Alex,

I'll add my welcome to GRACE, as well as a few comments. Typically the staging of a cancer determines the appropriate treatment options (chemoradiation for inoperable stage III disease, systemic therapy (chemotherapy, targeted therapy or immunotherapy) for stage IV metastatic disease). But there are exceptions. Although only a biopsy would definitively determine whether there is a bone metastasis, if that is the only metastasis some oncologists favor treating the disease locally. In your uncle's case, that could mean chemoradiation plus radiation to the bone metastasis. Dr. West discusses this concept here: http://cancergrace.org/lung/2010/09/07/local-therap-for-metastatic-disease/

That course of action might be worth exploring when he meets with the oncologist.

JimC
Forum moderator

<p>I began visiting GRACE in July, 2008 when my wife Liz was diagnosed with lung cancer, and became a forum moderator in January, 2010. My beloved wife of 30 years passed away Nov. 4, 2011 after battling stage IV lung cancer for 3 years and 4 months</p>

onthemark
Jim is right to point out

Jim is right to point out options on how some stage IV patients can be treated. What he refers to is called oligometastatic disease. In that case, patients with Stage IV can be treated as patients with Stage III with the addition of local treatment to one or a few metastatic sites. In short, they can offered what is called definitive treatment rather than palliative treatment and consolidation vs. maintenance.

The 2018 NCCN [National Comprehensive Cancer Network Clinical Practise Guidelines in Oncology] recommend this type of treatment for selected oligometastatic Stage IV lung cancer patients based, in part, on a Phase 2 study. I am not able to copy and paste from the NCCN pdf document, for some reason, but i have placed screenshots of part of the recommendations. In some cases radiation is an option or even surgery. (I hope this works!)

The Non-Small-Cell Lung Cancer 2018 NCCN Guidelines are freely available at https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf, after registering, which was easy to do.

It all depends on the precise staging (i.e. M1A etc.) and the clinical judgement of the doctor about what is best for the patient. There is more that is written in this document about options for treating Stage IV. This is only a small piece.

onthemark
Jim rightly points options

Jim rightly points options for treating Stage IV, when the spread is limited to one or a few metastatic sites. This is called oligometastatic disease.

The 2018 NCCN guidelines [National Comprehensive Cancer Network] spell out detailed options for treating selected stage IV patients with definitive therapy rather than palliative therapy and consolidation rather than maintenance. In short, as Jim indicated, these selected patients are treated aggressively as Stage III patients with the addition of local therapy for the oligometastatic sites. Local treatment can be radiation or even sometimes surgery.

I am not able to copy and paste from this document, which is freely available at
https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf

But a search of the term 'oligomet' gave about a dozen results: two of which are included below as images. (I hope this works!)

It all depends on the detailed staging {i.e. MIA etc.} and the clinical judgement of the doctor about what is in the best interest of your father.

This is just a small piece of what the guidelines have to say about Stage IV disease, if that is what it is.

onthemark
Jim rightly points options

Jim rightly points options for treating Stage IV, when the spread is limited to one or a few metastatic sites. This is called oligometastatic disease.

The 2018 NCCN guidelines [National Comprehensive Cancer Network] spell out options for treating selected stage IV patients with definitive therapy rather than palliative therapy and consolidation rather than maintenance. In short they are treated aggressively as Stage III patients with the addition of local therapy for the oligometastatic sites. Local treatment can be radiation or even sometimes surgery.

I am not able to copy and paste from this document, which is freely available at
https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf

But a search of the term 'oligomet' gave about a dozen results: two of which are included below as images.

It all depends on the detailed staging {i.e. MIA etc.} and the clinical judgement of the doctor about what is in the best interest of your father.

This is just a small piece of what the guidelines have to say about Stage IV disease, if that is what it is.

onthemark
Jim rightly points options

Jim rightly points options for treating Stage IV, when the spread is limited to one or a few metastatic sites. This is called oligometastatic disease.

The 2018 NCCN guidelines [National Comprehensive Cancer Network] spell out options for treating selected stage IV patients with definitive therapy rather than palliative therapy and consolidation rather than maintenance. In short they are treated aggressively as Stage III patients with the addition of local therapy for the oligometastatic sites. Local treatment can be radiation or even sometimes surgery.

I am not able to copy and paste from this document, which is freely available at
https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf

But a search of the term 'oligomet' gave about a dozen results: two of which are included below as images.

It all depends on the detailed staging {i.e. MIA etc.} and the clinical judgement of the doctor about what is in the best interest of your father.

This is just a small piece of what the guidelines have to say about Stage IV disease, if that is what it is.

onthemark
Jim rightly points options

Jim rightly points options for treating Stage IV, when the spread is limited to one or a few metastatic sites. This is called oligometastatic disease.

The 2018 NCCN guidelines [National Comprehensive Cancer Network] spell out options for treating selected stage IV patients with definitive therapy rather than palliative therapy and consolidation rather than maintenance. In short they are treated aggressively as Stage III patients with the addition of local therapy for the oligometastatic sites. Local treatment can be radiation or even sometimes surgery.

I am not able to copy and paste from this document, which is freely available at
https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf

But a search of the term 'oligomet' gave about a dozen results: two of which are included below as images.

It all depends on the detailed staging {[i.e. M1a etc.] and the clinical judgement of the doctor about what is in the best interest of your father.

This is just a small piece of what the guidelines have to say about Stage IV disease, if that is what it is.

onthemark
Jim rightly points options

Jim rightly points options for treating Stage IV, when the spread is limited to one or a few metastatic sites. This situation is called oligometastatic disease.

The 2018 NCCN guidelines spell out options for treating selected stage IV patients with definitive therapy rather than palliative therapy and consolidation rather than maintenance. They are treated aggressively as Stage III patients with the addition of local therapy for the oligometastatic sites, even though they are still Stage IV patients. Local treatment can be radiation or even sometimes surgery.

This document is freely available after registering at
https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf

Here is a small piece of what is written about treatment in that situation

Advanced/Metastatic NSCLC (Stage IV)
• RT is recommended for local palliation or prevention of symptoms (such as pain, bleeding, or obstruction).
• Definitive local therapy to isolated or limited metastatic sites (oligometastases) (including but not limited to brain, lung, and adrenal gland)
achieves prolonged survival in a small proportion of well-selected patients with good performance status who have also received radical therapy to the intrathoracic disease. Definitive RT to oligometastases, particularly SABR, is an appropriate option in such cases if it can
be delivered safely to the involved sites.40,41 A randomized phase II trial of local consolidative therapy (RT or surgery) to oligometastatic lesions versus maintenance systemic therapy or observation for patients not progressing on systemic therapy found significantly improved progression-free survival for local consolidative therapy.42
• See the NCCN Guidelines for Central Nervous System Cancers regarding RT for brain metastases.

In the end it comes down to a precise staging (i.e. M1a or M1b etc.) and full taking into account of your father's overall performance status together with the clinical judgement of your doctor.