Surgical lung biopsy? pros and cons - 1252491

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Surgical lung biopsy? pros and cons - 1252491

My mother, 68yrs, no history of smoking or second hand smoke, diagnosed with NSCLC. 50% of tumor is sarcomatoid and 50% is adenocarsinoma. The original biopsy did not have enough material to do mutation testing. She has already had 20 radiation treatments and was told that tumor could not be re-biopsied. The doctor said the only way to get new biopsy was through surgery to remove tissue from one of the two new small tumors just recently found in her lung. The only other tumors found were in her brain. There were 2 very small tumors that have been radiated and are presumed gone.
My mom starts general chemo, carboplatin/taxol, next Thursday.

We are weighing the pros and cons of surgery to biopsy the new tumor for mutations. Her doctor is not sure if it will matter given her type of cancer. What are the pros and cons of doing the surgery? Can it make a difference in her prognosis? Should we consider the surgery/biopsy?

Dr West
Reply To: Surgical lung biopsy? pros and cons

It's pretty unlikely that she would have a mutation that would lead to a new treatment option. The main value of molecular testing today (early 2013) is that it provides an opportunity to test for an EGFR mutation or ALK rearrangement, which would lead to a recommendation for an EGFR tyrosine kinase inhibitor like Tarceva (erlotinib) or an ALK inhibitor like XALKORI (crizotinib), respectively. However, it's still possible to receive Tarceva commercially even without a mutation, most often as a second or third line therapy, and there's no real evidence that they do worse getting an EGFR inhibitor after first line, even if they have an EGFR mutation. So it's possible to get the benefit of an EGFR inhibitor regardless of the results of the test.

The only practical way to get XALKORI or another ALK inhibitor, outside of a clinical trial, is to have a patient's tumor tissue test positive for an ALK rearrangement (or even more rare, a ROS1 rearrangement). But these are seen in about 4-5% of patients (together, not each), the vast majority of whom would have an adenocarcinoma. It would be exceptionally rare to see one in someone with a sarcomatoid tumor.

So while it wouldn't be in the category of impossible, the likelihood of a tangible benefit from seeking more tissue and doing molecular testing would be quite small, and that needs to be weighed against the potential costs, small risks, and side effects of undergoing a surgery just for that purpose.

-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