Residual disease after chemoRT for stage IIIB lung cancer - 1252921

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Residual disease after chemoRT for stage IIIB lung cancer - 1252921

I have another tough case and I would like to get some help from the experts here.

I have a 65 year-old patient who recently completed carbo/taxol & RT for his stage IIIB lung adeno(KRAS+). He had a rough time with treatment, his PET/CT 2 months after treatment suggested possible residual disease. He was given 2 cycles of maintenance pemetrexed after completion of standard treatment given his high risk of recurrence. Unfortunately his PET/CT after 2 cycles of pemetrexed showed increased FDG activity of a mediastinal lymph node. The lymph node was present at diagnosis & it did respond to treatment but not completely. His primary disease site is otherwise stable. I am concerned that additional chemotherapy may not help him, I am debating between switching to combinational chemotherapy and gamma knife boost to that area with the hope that his disease may still be curable.

Your expert opinions are appreciated.

Dr West
Reply To: Residual disease after chemoRT for stage IIIB lung

No best answer here. This is a situation in which we'd probably be focused on considering additional local therapy, whether stereotactic radiosurgery or even consideration of surgery (our thoracic surgeons will do surgery after definitive radiation and chemo in the right situation). I think that the availability of stereotactic radiosurgery is definitely a strong option to consider if the radiation oncologist is in agreement that it's likely to be safe and feasible. We don't do concurrent chemo with hypofractionated radiation. Hard to know how much it might add at this point.

-Dr. West

Dr. Howard (Jack) West
Associate Clinical Professor
Medical Oncology
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

I don't know to what extent

I don't know to what extent testing for immunotherapy markets like PD-L1 or Tumor Mutation Burden (TMB) or others enters the clinical picture now for a small town oncologist.

Here's a 2017 paper "Emerging Therapies for Stage III Non-Small Cell Lung Cancer: Stereotactic Body Radiation Therapy and Immunotherapy" at:

"By building on the proven concept of conventional chemoradiation for patients with locally advanced NSCLC with a subsequent radiation dose intensification to residual disease with SBRT concurrent with immunotherapy, we hope address the issues of metastatic and local failures. This “quadmodality” approach is still in its infancy but appears to be a safe and rational approach to the improving the outcome of NSCLC therapy.