wife adenocarcinoma with BAC feature, Stage IV operation? - 1269519

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jem825
wife adenocarcinoma with BAC feature, Stage IV operation? - 1269519

Hi: Was told Dr. West is here who is a BAC specialist. I know I cannot substute website answer from Dr. visit, but want his/other Dr. opinion none the less. Will help firm my opinion for follow up care.

Background: Wife had been diagnosed (6 weeks ago) with Stage IV adenocarcinoma with BAC feature. RUL 5.5X2.5 cm mass biopsy confirmed adenocarcinoma. RML: 4mm nodule with GGO to 1cm no biopsy. LUL: 4mm nodule with GGO and biopsy showed atypical, suspect malignancy. EGFR possitive with exon 19. PET scan show no mets to other organ and brain MRI clear. RUL shadow had been there for many years on X-ray, all were judged to be scar/pneumonia/prior TB exposure etc. Start to have chest pain on the right side.

Dr. want to start tarceva, but I read that for bilateral stage IV, surgery still could give good result if no mets outside of both lungs. We want to have this operation while still can and save the Tarceva path for later. She need all the weapon possible. We have found a second Onc/thoracic surgeon who agree that we can have this window for surgery. First will be in days, RUL lobectomy and at the same time RML wedge. Second operation in 4 to 6 weeks, LUL wedge.

My dilima: I still believe strongly to go through the first operation. The mass is big and pain had started. Also want to get this source of cancer out so it does not emit cancer cells all over. I start to have doubt on weather second is necessary. Here's why. If she go through both operation, will she be on adjuvant Chemo or Adjuvant Tarceva? Dr. said and I have read that BAC is not responsive to Chemo, If she is on adjuvant tarceva, would the second operatoin be wasted? Thanks for reading and your wisdom is appreciated.

Dr West
I think there several key

I think there several key points to make here:

First, there is a difference between being able to undergo surgery and it being a good idea. The fact is that many patients who undergo surgery for multifocal BAC can do well for years after that, but I think in most cases that is despite rather than because of the surgery. All too often, if patients have multifocal BAC and then undergo surgery, particularly to many different sites, they will end up with recurring lesions months or years later, then have much of what should have been their functional lung reserve surgically resected for what was a futile intervention.

The link to the post clearly describes my recommendations on how best to manage multifocal BAC, including the possibility of surgery in some cases. It can be very reasonable, particularly if there is only a solitary area growing, and background lesions are stable or very slowly growing. In that case, however, I would consider it inadvisable to do surgery on the other lesions.

http://cancergrace.org/lung/2013/01/20/mf-bac-algorithm/

In the event that more than one or certainly 2 lesions are growing at a clinically perceptible pace, there is simply no good evidence that resected cancer just to remove a possible source of future spread is an effective approach, and I say above, it may be detrimental both in terms of upfront risk of a surgery that will not be curative and significant risk of sacrificing needed functional lung tissue when the cancer progresses within the lungs. I strongly favor focusing only on the areas of disease that are growing at a clinically significant rate, and observing rather than reflexively treating other areas that are merely detectable on a CT scan but not growing significantly.

As for systemic therapy, it is a common myth that chemotherapy is ineffective for BAC. I would refer you to my post on the subject:

http://cancergrace.org/lung/2011/11/29/bac-today/

to be continued.

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

Founder & President
Global Resource for Advancing
Cancer Education

Dr West
The evidence clearly

The evidence clearly demonstrates the patients with an activating EGFR mutation are best served by receiving an oral EGFR inhibitor such as Tarceva (erlotinib) or Gilotrif (afatinib) as a priority over chemotherapy; on the other hand, patients who do not have one of these activating EGFR mutations are better served by pursuing chemotherapy, which absolutely has activity against BAC. The issue largely stems from BAC lesions tending to be difficult to measure, and oncologists generally grading their work by tumor shrinkage. If you can't measure it, you can't define shrinkage. However, careful assessment shows the patients with BAC respond to chemotherapy similarly to other patients with lung cancer. Alimta (pemetrexed) may have particular activity against BAC, which is a subtype of lung adenocarcinoma, which also often responds very well to Alimta.

This is not a situation of adjuvant therapy if there is multifocal disease. It is appropriate to think about it in an individualized way, but the concept of adjuvant therapy applies to early-stage disease only.

Unfortunately, online and even in discussions with many medical personnel, this information is more common than accurate information about BAC. I would be very wary about accepting recommendations from anybody who is not a lung cancer expert, and unfortunately I would consider many surgeons to be as likely to perpetuate misinformation as accurate information about BAC. Know your source and place value accordingly.

Good luck.
-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

jem825
Hi Dr. West:

Hi Dr. West:

Thank you very much for your detailed reply. Really appreciated. Your point is well taken and in fact,
we will pursue the systemic approach in this case ( multifocal BAC). Will be on Tarceva and hope it works.
Finger crossed.

JEM