Before turning back to brain metastases, I wanted to cover a topic that has generated some recent questions, and that is the issue of potential interactions of tarceva with food and other drugs. Just as an introduction, the standard dose of single-agent tarceva in lung cancer is 150 mg by mouth daily, and this is meant to be taken on an empty stomach, at least one-hour before or two hours after eating.

We'll break from brain metastases for a while to talk about another potential avenue of targeted therapy in lung cancer: the cyclo-oxygenase, or COX, pathway.

We'll cover the general management principles for the more typical situation of patients with multiple brain metastases from lung cancer soon, but today we’ll cover the special situation of the patient who has a brain metastasis identified as the ONLY area of metastatic disease (generally referring to NSCLC, since SCLC has such a high tendency to spread distantly early in its history). Recall that metastatic, or stage IV, lung cancer, is treated with a palliative approach, due to the inability to achieve prolonged survival except in very rare cases.

The notorious and always welcomed words after surgery are, "we got it all", providing great relief to the patients and families who hear the phrase. We know that surgeons can take out all identifiable disease that they see when they do surgery, and that there is no evidence of visible disease on CT scans or on newer imaging techniques like PET scans. But why do we see that approximately 30% of patients with stage I NSCLC or about 50% of patients with stage II NSCLC recur?

Most of the focus on predicting response to EGFR inhibitors has been on identifing molecular markers that are associated with major response to this kind of treatment. But we know that there is a group of patients who get no benefit from these expensive drugs, and in these patients, EGFR inhibitors would just lead to side effects and keep them from a potentially more effective therapy for them.

There is still plenty of active debate about whether patients with stage III NSCLC who have mediastinal lymph nodes, the ones in the middle of the chest between the lungs but on the same side as the main tumor, should receive surgery in some circumstances or not.

Historically, surgery for lung cancer has been through an open thoracotomy (thorax = chest; otomy = cutting/slicing), which involves a long incision around the side of the chest, removal of ribs, and spreading of the remaining ribs to get a good view of the area of the operation. Even with the most skilled surgeons, it's a procedure that is rigorous for a patient to get through and has a recovery period typically of weeks.

Adjuvant chemo has become increasingly established as having a survival advantage, at least for the general population of stage II and IIIA patients, and potentially for some with earlier stage disease (see adjuvant chemo post). However, post-operative radiation therapy, or PORT, does not have an established role.

I've discussed the trials that have led to a general recommendation in favor of chemotherapy after surgery for patients who have stage II and IIIA NSCLC, with some ongoing questions about the value in stage IB NSCLC. I haven't touched the issue of post-operative radiation therapy, but the question comes up from members who ask about the evidence for or against radiation, and how it might be given.

Several people have asked about the technique of radiofrequency ablation, or RFA, for lung tumors. RFA is a pretty specialized approach in which a needle probe is inserted through the skin, under visual guidance using a CT or ultrasound, to go directly into a tumor. The tip is then pushed out and splays into a shape like the frame of an umbrella, and then an electric current is turned on to superheat the tip of the probe. In some cases, the probe is moved around to cover a broader area and destroy a larger tumor, but the procedure works particularly well for smaller tumors.