Dear GRACE Team,
Firstly I would like to sincerely thank the GRACE Team for the fantastic service that you provide patients and their families globally. The information that you provide is extremely helpful for clinicians as well as patients as the information is reliable and is evidence based. Oncology is a vast field and the updates on the podcasts /reviews are very helpful for generalists like myself.
My father is over 1 year post operative from a right pneumonectomy for lung adenocarcinoma (NSCLC).
(Never smoked)
Unfortunately, contrary to imaging work up pre-operatively, post operative staging was T2a N2 M1a
He underwent 4 x chemotherapy (Carbo/Pemetrexed) + successful gamma knife x2
Currently: Imaging shows the brain is under control no new lesions. Thorax and intra-abdominal no evidence of disease!
However CT staging revealed progression in the bone:
T8 vertebral body- lytic disease and loss of height. Plain film of right humerus tiny lucencies -report states 'possible lytic' areas? Now awaits a bone scan.
Unfortunately previous primary tumour testing for eGFR & ALK mutation was negative. I am aware from forums that non smokers are often mutation +ve and therefore targeted therapies can be more effective.
Fortunately the pain is being well managed with analgesia and my father remains independent with active daily living and continues to pursue his hobbies within limitations.
Overall he remains stable and was very fit and well before the lung adenocarcinoma.
Also out of curiosity this adenocarcinoma seems to have an affinity for brain and bone and is sparing other organ systems, is this a pattern in subtypes of NSCLC?
I wanted to ask you that at this stage what treatment options are available to help control the disease ?
Many thanks once again and I look forward to your helpful suggestions and guidance.
Reply # - May 19, 2014, 04:29 PM
Reply To: Stage 4 Lung Adenocarcinoma
Hi ishy,
Welcome to GRACE. I am sorry to hear of your father's diagnosis but I hope we will be able to assist you and your father.
After first-line treatment, there are a number of other chemo drugs and targeted therapies. In the U.S. for example, the three drugs which are FDA approved for second line treatment are Alimta (pemetrexed), Tarceva (erlotinib) and Taxotere (docetaxel). Although not as effective as it is for patients with an EGFR mutation, Tarceva can provide a lesser benefit for patients without such mutations.
In addition to those drugs, other drugs which are not as well studied in the second line setting but which are approved for first line and effective against NSCLC include, Paclitaxel (taxol), Gemzar (gemcitabine), Abraxane and Navelbine (vinorelbine). There are also many clinical trials of new drugs being studied.
NSCLC commonly metastasizes to the brain, bones, liver and adrenal glands; spread to other locations is less common but possible. For patients with EGFR mutations and ALK rearrangements, the brain is often the first locus of progression.
As far as bone metastasizes, they are commonly treated only if they are causing pain and/or threatening to cause a fracture, especially of a load-bearing bone. Drugs called bisphosphonates are also used in an effort to slow progression in the bones.
You may want to read Dr. Weiss' thorough Introduction to Lung Cancer: http://cancergrace.org/lung/2010/04/05/an-introduction-to-lung-cancer/ as well as these posts:
FAQ on second line treatment: http://cancergrace.org/lung/2010/10/04/lung-cancer-faq-2nd-line-nsclc-o…
Benefit of EGFR inhibitors for patients without a mutation: http://cancergrace.org/lung/2010/09/21/benefit-from-egfr-tki-if-egfr-wt/
Bone metastases: introduction: http://cancergrace.org/lung/2007/02/17/bone-metastases-in-lung-cancer-a…
Please let us know if you have further questions.
JimC
Forum moderator
Reply # - May 19, 2014, 06:11 PM
Reply To: Stage 4 Lung Adenocarcinoma
Yes, different individuals just happen to have different patterns of spread: some spread primarily to liver, or adrenal glands, or bone, or brain, or some combination with one area dominant. Our understanding today is that there isn't a clear biological correlation of any specific subtype and its pattern of spread, though I suspect we may well learn more about this in coming years.
There are a couple of trials, one called TAILOR and coming out of Italy, the other called DELTA and coming from Japan, that suggest a modestly better result in EGFR mutation negative patients who receive second line chemo compared with Tarceva (erlotinib). In those studies, it was Taxotere (docetaxel) as the second line treatment, but Alimta (pemetrexed) would likely be a favored approach in someone with a progressing/recurrent lung adenocarcinoma who had already received Taxotere. It would be reasonable to consider going back to Taxotere, since he didn't actually progress while on it, but I think more people would favor Alimta, or possibly Tarceva. I have had a few patients over the years who tested negative for an EGFR mutation but then responded in a way that is very much what you'd expect from somone with an EGFR mutation.
And yes, we often add either Zometa (zoledronic acid) or XGEVA (denosumab) to reduce the risk of future skeletal complications in patients who have a solid tumor metastatic to bone.
Finally, it may be a bit ambiguous from Jim's commentary, but these systemic therapies are a treatment for the bone metastases along with treating disease in lung, liver, adrenal glands, etc. Adding radiation or surgery is generally only done to treat pain or a risk of a pathologic fracture (caused by structural instability from the cancer compromising the integrity of a weight-bearing bone).
Good luck.
-Dr. West
Reply # - May 20, 2014, 05:53 AM
Reply To: Stage 4 Lung Adenocarcinoma
Thank you very much Jim C and Dr West for providing me with prompt advice that I can discuss with my father and his oncologist.
In terms of the next step, my fathers case has been discussed at the MDT & a clinical oncologist is due to see him with a view to radiotherapy to the T8 spine.
My father had 4 cycles of carboplatin+ pemetrexed a few weeks after a pneumonectomy.
I must say it was tough, but he managed the side effects well and I am yet to inform him about chemo as an 2nd line Rx option.
One positive treatment that I could share is that out of all the antiemetics post chemo, he found olanzapine 5mg pre and post chemo for a few days, for delayed nausea most effective (unlicensed indication of an antipsychotic).
From a previous post, Dr West you were absolutely spot on that the chemotherapy that my father received (1st line) significantly reduced the size of the brain met. This made the gamma knife much more targeted and effective. I also read on your website that after stereotactic radiotherapy to the brain, the chances of recurrence is sometimes lowered- perhaps immune mediated and this is the case with my father on serial brain imaging on monitoring.
I am pleased to hear about the trials for 2nd line treatment that Dr West has mentioned & I look forward to further trials and advancements in lung cancer care. I have personal experience of a friend with advanced lymphoma - who is now in complete remission &several patients with breast cancer who have survived > 5 years. One of my tutors from Sheffield UK was part of the team that discovered the BRCA1/2 genetic link in breast cancer. Clearly lung cancer is a leading cause of morbidity and mortality worldwide and I hope that the Pharmas would look into research in the same way they have for other cancers. I am going to put my money where my mouth is and donate here. I have great admiration for the work that Dr West and his team are doing and I hope you continue to go from strength to strength.
Regards
Ishy
Reply # - May 20, 2014, 07:34 PM
Reply To: Stage 4 Lung Adenocarcinoma
Thanks so much for both your kind works and your support!
-Dr. West
Reply # - July 3, 2014, 03:56 AM
Reply To: Stage 4 Lung Adenocarcinoma
Hi GRACE Team,
Further to the above post, my father underwent 10x radiotherapy to the T8 spine and this has provided good pain relief especially the radicular pains.
(Background stage 4 lung adenocarcinoma, radical Rx of pneumonectomy, gamma knife and chemo given as appeared to be oligometastatic- brain x1 & lung- now spinal disease and brain recurrence)
After having 2 separate treatments of gamma knife in 2013, for 2 separate different lesions, the brain was showing no evidence of new disease for over 7 months.
We attended a surveillance MRI scan yesterday and received unfortunate news that there are 6 new areas that are suspicious of brain metastases. The oncologist described these as very small in volume but gamma knife cannot be offered as there are possibly 2 areas around the surface of the brain. The largest metastasis measures approx 6-7mm. The others are much smaller.
The clinical oncologist has referred us back to the medical oncologist.
The clinical oncologist did say that the treatments that our medical oncologist may offer could be systemic chemotherapy +/-WBRT
In your opinion can WBRT control/shrink the current brain disease and do you recommend it?
A difficult question to answer but could WBRT extend his life in this setting ? (Currently chest/lung/abdomen shows no evidence of disease on staging scan- only disease is brain and T8 which has been irradiated). He is 56 years old, independent in active daily living and no other significant comorbidities)
Any other treatments old or new that can help in this setting?
Many thanks
Reply # - July 3, 2014, 08:28 AM
Reply To: Stage 4 Lung Adenocarcinoma
Hi ishy,
When there are more than two or three brain lesions, WBR is the treatment of choice, and it has a good likelihood of resolving those lesions and increasing survival. The fact that his disease is limited to the brain lesions and spine bodes well for his prognosis.It may help to review Dr. Goldberg's post on WBR here: http://cancergrace.org/radiation/2008/07/30/wbrt-review/
Good luck with the treatment.
JimC
Forum moderator
Reply # - July 3, 2014, 04:45 PM
Reply To: Stage 4 Lung Adenocarcinoma
I completely agree with Jim's summary. While not risk-free, WBR is the treatment of choice, is likely to be effective, and it is difficult to come up with anything that would have much chance of being a meaningful alternative. And the relatively modest risks from WBR are considerably less than the anticipated complications of progressing brain metastases.
Good luck!
-Dr. West
Reply # - July 5, 2014, 04:49 AM
Reply To: Stage 4 Lung Adenocarcinoma
Thank you very much Jim C and Dr West for your expert advice and support. I wish one day chemo agents or immunotherapy advances so that the blood brain barrier is overcome in cancers with brain metastases. I have read with great interest the articles on WBR on the grace website and the good outcomes that are observed. We will talk to his oncologist to look at this treatment soon.
Once again thank you.