radiation versus surgery in possible "oligometastatic" disease - 1267341

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ocean
radiation versus surgery in possible "oligometastatic" disease - 1267341

Hi,

I realise that I have already sort of asked this in a previous thread, but just wanted to get a bit more information. My dad has a small lesion in his lung, with a single met in the brain. He has recently had gamma knife treatment on the brain lesion (surgery would not have been possible due to the location anyway). The drs are now trying to decide how to treat the lung lesion. If not for the brain met, he would have been staged at 1A. It seems to be coming down to surgery vs radiation - both with additional, though varied treatment (chemo?). He has been talked through both options (and had lung function tests) - but apparently not many patients are seen where he is at in this situation - and so he is now being referred elsewhere. It is obviously good that his lead dr (I think a respirologist, but also linked with oncology) wants to get him the best possible advice/treatment (he is in the UK, so is on the NHS). Anyway, he has an appt with another specialist next week (what with being dx abroad and various slow referrals and now this, there seem to have been a lot of delays...) - and I was just wondering if there is anything in particular that my dad should think about or ask during this appt?

I think I may have read somewhere on this website that a potential problem may be if another lesion appears during recovery from surgery - making it harder to treat. I'm not sure if there is anything else that should be considered??

Thank you.

Dr West
Previously, surgery was the

Previously, surgery was the only way such patients were treated if it was felt that cure might be feasible. That's still the approach that has the greater history, but in the past few years, there has been a lot more research showing the feasibility of treating a solitary lung lesion, particularly a small one (<2-3 cm or so), with focal radiation. Surgery tends to perform a little bit better in comparable patient populations (really a rather slight difference), but it's hard to tell, because many patients who don't pursue surgery have other medical problems that are as likely to limit the survival of these patients as the lung cancer does.

However, this work has all been in patients with early stage disease, not "precocious metastatic" or "oligometastatic" disease, which is likely to be affected more by risk of distant disease and less by local disease control. In this situation, good radiation may be every bit as good as surgery at treating the local area sufficiently, with potentially fewer adverse effects.

This means that there's no clear answer and that either approach may do the job effectively.

Good luck.

-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Medical Oncologist
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

Dr West
Previously, surgery was the

Previously, surgery was the only way such patients were treated if it was felt that cure might be feasible. That's still the approach that has the greater history, but in the past few years, there has been a lot more research showing the feasibility of treating a solitary lung lesion, particularly a small one (<2-3 cm or so), with focal radiation. Surgery tends to perform a little bit better in comparable patient populations (really a rather slight difference), but it's hard to tell, because many patients who don't pursue surgery have other medical problems that are as likely to limit the survival of these patients as the lung cancer does.

However, this work has all been in patients with early stage disease, not "precocious metastatic" or "oligometastatic" disease, which is likely to be affected more by risk of distant disease and less by local disease control. In this situation, good radiation may be every bit as good as surgery at treating the local area sufficiently, with potentially fewer adverse effects.

This means that there's no clear answer and that either approach may do the job effectively.

Good luck.

-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Medical Oncologist
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

ocean
Hi Dr West,

Hi Dr West,

Thank you so much for your reply, particularly over Thanksgiving! It takes some of the pressure out of the decision to know that either option may be effective. I will pass your comments on to my dad.

Another related question (sorry, I should have thought of this before) - is the role of chemotherapy in conjunction with either radiotherapy or surgery in this type of situation. Would it be similar to that of an early stage patient - or would it be more sensible to try and save options in case of future metastatic disease? (sorry if this is a silly question)

Thanks again, your advice is really appreciated!

Dr West
It's not a silly question --

It's not a silly question -- it's an open question, and still a somewhat controversial one, because there's really no "evidence" to inform the issue. However, I consider oligometastatic disease/precocious metastatic disease to be a situation that is really akin to a very high risk early stage NSCLC. Adjuvant therapy is really given to reduce the risk of recurrence by attempting to kill any stray cancer cells that may be circulating after surgery. We see that the higher the risk of recurrence, the greater the benefit of adjuvant chemotherapy. Therefore, I personally advocate for chemotherapy in this setting.

It's reasonable to do it prior to surgery or radiation rather than after, since this also gives time for the cancer to "declare itself" if it is actually destined to progress over the first few months. Though that's never welcome, it's better to learn this before a patient undergoes a challenging treatment that may prove to be futile if it's destined to spread more extensively.

Good luck.

-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Medical Oncologist
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

ocean
Thank you again for your

Thank you again for your reply.

The original dr(s) plan was to include chemotherapy with either surgery or radiation (more with the radiation I think). My dad is leaning towards surgery at this point, though this may change after his appt with the new dr tomorrow. If this is the treatment option, the idea is to get him into surgery asap at any of 3 nearby hopsitals, whichever can fit him in first.

My dad was originally taken to hospital in the beginning of September (symptoms from brain lesion) - and has had no treatment except for medication for the brain lesion and now the gamma knife on it. So I suppose that there has proabably been enough time for the cancer to "declare itself" (there was a bit of a gap between the scans in Spain and re-scanning in the UK, though not sure if they are planning to update anything at this stage). I think both of the lesions were considered to be fairly inactive - though I'm not sure if that is from scans and/or the lung biopsy (or how relevant that is).

Anyway, thank you so much for the information. I will talk to my dad before his appt tomorrow.

ocean
Hi again,

Hi again,

Since I last posted my dad has had surgery on the lesion in his lung (he said keyhole and that 1/8 of his lung was removed - so VATS wedge resection?). He is doing well and will be off most of the medication within the next 2 weeks (steroids, anit-seizure, etc for the brain lesion that was treated with gamma knife - as well as painkillers, etc from surgery). The decision has been made to not do chemo (the drs don't seem to think it is needed) - which my dad said was because the lesion in the lung was "not very active". I know from the replies above - that this (possible oligometastatic) may be a high risk situation. - and as my dad has said that the drs have not had much experience with this (there was a lot of back-and-forth with what to do) - I am a bit worried about this decision.

So I guess my question is: if the lung lesion is considered "not very active" - could this situation be considered not high risk enough to not give chemo? (My dad still mentions that the drs were not sure whether the two (brain and lung) lesions were related - and I am not sure how seriously this was meant - when I asked why, my dad said that the drs kept saying "evidence based" and something about "stage and development" (I think the brain lesion was about 2.5cm and the lung about 3cm). )

Sorry for jumping back-and-forth and being a bit repetitive from old posts. I just want to make sure that I talk to my dad about chemo if that is a much more reasonable path to take. (Just a bit worried whether the decision for no chemo sounds warranted.)

Thank you again for your help.

JimC
Hi ocean,

Hi ocean,

I think the question of whether this is a "high risk" situation has less to do with whether the lung lesion was active and more to do with the probability that the lung cancer has entered the bloodstream, as evidenced by the existence of the brain lesion. I'm not sure what his doctors mean if they are saying they're not sure if the brain and lung lesions are connected, except that without surgically removing the brain lesion there is no opportunity for pathology on that lesion to prove the relationship. But in any event that is normally not done; it is usually presumed that in the setting of a diagnosed lung cancer, a brain lesion represents a metastasis from that cancer.

Viewing it in that way, it would still be a high risk situation and as Dr. West stated earlier in this thread, he would usually advocate for adjuvant chemotherapy in an effort to eradicate any other cancer cells present in the bloodstream.

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>

ocean
Hi Jim,

Hi Jim,

Thank you for the reply. I thought that was probably the case,but I just wanted to feel like I am doing the right thing before suggesting this again. Before the surgery/radiation decision I passed on Dr West's comments, including those about chemotherapy in what appeared to be a very high risk type situation - and I was really hoping that the post-surgery chemo decision was going to be pro-chemo... I will talk to my dad about this again, as I am worried he does not have a realistic view of the risk.

Thanks again.

Dr West
I wouldn't want to be too

I wouldn't want to be too heavy-handed in my comments, since it's fair to say that there is no good evidence to speak to this issue. It is really based on extrapolation of the evidence we do have.

As Jim suggested, my thoughts on the matter are informed by the presence of a metastasis. In my mind, it's hard to wave off a primary tumor as "not very active" and not threatening enough to warrant adjuvant chemo based on it being small -- if it were truly not that active, there wouldn't be a brain metastasis. Moreover, this situation isn't the same as a small chest tumor and no metastases -- this is technically stage IV, not stage I disease, so I wouldn't approach this focused too much on the evidence in patients with stage I resected lung cancer.

That said, I do think it is very appropriate to consider the individual features of any case, there is definitely room for debate here, and I don't have all of the details as if he were one of my patients, so I wouldn't want to force the issue by my more general considerations. I think that no further treatment is certainly a defensible recommendation.

Good luck.

-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Medical Oncologist
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

ocean
Thank you Dr West. I realise

Thank you Dr West. I realise that all of your comments have to be fairly general - and also that all of my info is second hand...

I have said about my concerns, but will have a proper talk next week probably, as Dad is still feeling a bit forgetful from all the medication (and procedures/stress/etc/?). Hopefully he can discuss this with his dr - and either get some better (clearer?) reasons as to why the decision was made - or change that decision.

Is there some kind of optimum time limit that chemo should ideally be given in? He was first dx early Sept. (i.e. admitted to hospital with brain lesion symptoms).

Thanks again for all of your help. It is just a bit scary thinking of the possible implications of each decision...

ocean
Also...

Also...

Hi Janine,

I had a notification email, but then the post didn't seem to be here... Thanks for your reply. Dad is actually generally feeling pretty good, just a little bit dozy from the medication and has a bit of weakness in his lower leg from the brain lesion. Hopefully, that should get a bit better with exercises...

Thanks again.

Dr West
The studies that have proven

The studies that have proven a value for post-operative chemotherapy gave it within 5-7 weeks after surgery, so we generally feel that the opportunity to mop up any stray cancer cells before they "take hold" and become an incurable focus of visible disease on scans. There's nothing magical about a time point of 7 weeks, and I think most oncologists would be fine with starting chemo 8 or maybe even 9-10 weeks after surgery. Beyond 10-12 weeks, however, there's a real risk that the window of opportunity will be missed, at least based on the theoretical reason for why we recommend adjuvant/post-operative therapy.

-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Medical Oncologist
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

ocean
Thanks for that. Surgery was

Thanks for that. Surgery was only just over a week ago, so there is some leeway time-wise to think about this, which is good to know. Thanks again for all of your help.