Here is the last of three interesting cases I discussed with Drs. Alex Farivar, thoracic surgeon at Swedish Cancer Institute here in Seattle, and Anne Tsao, medical oncologist at MD Anderson Cancer Center in Houston. This particular case is a man I saw a few years ago, with a solitary brain lesion and what otherwise appeared to be a very isolated lung cancer in the right upper lobe. His case brings up issues of the feasibility of treating someone with a solitary lesion with curative intent.

One of the issues that we've commonly discussed and debated here is the question of when a local approach like surgery and/or radaition may be appropriate for I recently saw a patient of mine who I first met more than four years ago. At that time, he was only 37 years old and had just been diagnosed with stage IIIA NSCLC with several N2 nodes involved, after having quit smoking a couple of years earlier. He had actually initiated treatment with another local oncologist, a plan of chest radiation along with concurrent weekly carbo and taxol.

In prior posts I've described the special circumstance of a Pancoast tumor, which is a tumor at the top of the lung that tends to grow into the spine, ribs, and sometimes the nerves going to the arm. These cases are a major challenge because surgery is often something to consider, because they often grow locally more than speading to the rest of the body, but surgery can be a special challenge because the vertebrae are generally not considered to be resectable.

In my last post I outlined the typical clinical scenario for pneumonic bronchioloalveolar carcinoma (BAC), which is typically the mucinous subtype of this unusual disease. In fact, we are still actively learning a great deal about BAC, enough for the lung cancer experts to begin to develop a more sophisticated view that the mucinous and non-mucinous subtypes have different behaviors and respond differently to treatments.

Let's return to what happened with Anne S., who I introduced in the last post. The highlights are that I met this woman in September of 2005, when she was 79, slowing down from many medical issues unrelated to cancer, wary about chemo, and with a cancer that was metastatic but that had progressed only minimally in the months between the initial detection of her cancer and when I first saw her. We agreed that attentive follow-up made sense.

In addition to the presentations about the evidence, I thought it might be helpful to highlight some of my own clinic cases that can illustrate how I use the principles in practice. These cases should highlight that many if not most people don't exactly follow the "classic" example, and that if we were to open the case files from most oncologists, we'd find that it's very common (and appropriate) to bend the guidelines, to individualize based on the particular issues of a specific person. And I think it may also be helpful to see the range of what's possible.