More chemo after a solitary lung met?

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skb
Posts: 41
Joined: Tue Mar 28, 2017 2:00 pm

More chemo after a solitary lung met?

Postby skb » Mon Oct 28, 2019 11:27 am

Hi,
I am posting this question as a new topic because my search in existing topics did not yield answers. My signature tells my story. After a solitary lung met and its removal by VATS, is adjuvant chemotherapy recommended?

NCCN guidelines for 2018 does not give clear recommendations. All it says is 'some experts say more chemotherapy is not recommended if chemotherapy was already delivered as part of original treatment'. I received recommendation from Mayo to get more chemo. No strong push for it from my oncologist at University of Minnesota but he may have been influenced by my reluctance to get more chemo. Given that Folfox treatment was already done (6 rounds) and it could not prevent this recurrence, I do not know how helpful it would be if I did the same treatment again.

-Is there any experience from anyone here on this topic?
- What does MD Anderson recommend?
- What does MSK recommend?

Thanks,
skb
3/21/17: Dx T3N0M0- distal rectal cancer, 4.5cm tumor, 2.5 cm from anal verge
4/18 to 5/22/17: chemoradiation - Xeloda 1800mg twice a day for 25 days, 200 Cgy/day
6/28/17: biopsy shows no invasive adenocarcinoma
8/09/17: MRI - no primary tumor left, starts wait and watch
8/17/17 to 12/1/17: mop-up chemo with Folfox and oxaliplatin (IV infusion), every two weeks
5/19 expanding right lung nodule, 8mm
8/19 VATS wedge resection
9/19 Clean PET, NED, no detected alterations of BRAF, KRAS,NRAS, PIK3CA, PTEN

boxhill
Posts: 392
Joined: Fri Apr 06, 2018 11:40 am

Re: More chemo after a solitary lung met?

Postby boxhill » Mon Oct 28, 2019 11:34 am

I have no idea what various institutions recommend, but I do know that FOLFOX is unlikely to work for some of us, depending on tumor genetics. So the questions might be 1) is adjuvant chemo desirable in your situation, and 2) if so, what should that chemo be?

Do you have information about your tumor genetics to add to your sig?
F, 64 at DX CRC Stage IV
3/17/18 blockage, r hemi
11 of 25 nodes,5 mesentery nodes
5mm liver met out
pT3 pN2b pM1
BRAF wild, KRAS G12D
dMMR, MSI-H
5/4/18 FOLFOX
Neulasta 6/28
7/9/18 CT NED
11/20/18 CT NED. Enlarged spleen.
12/20/18 Liver MRI 5mm liver met? and 2 lymph nodes in porta hepatis
12/31/18 Keytruda
6/5/19 Triphasic CT LN and spleen normal, Liver node stable
6/28/19 Pause Keytruda, predisone for joint pain
7/31/19 Restart Keytruda
9/10/19 CT stable

skb
Posts: 41
Joined: Tue Mar 28, 2017 2:00 pm

Re: More chemo after a solitary lung met?

Postby skb » Mon Oct 28, 2019 11:41 am

Thank you boxhill for the prompt response.

1) CEA: My CEA has never been elevated.

2) Gene sequencing information-
Detected Alterations of Known or Potential Pathogenicity: None
Detected Alterations of Uncertain Significance: None
Genes with No Detected Alterations of the Amino Acid Sequence: BRAF, KRAS,
NRAS, PIK3CA, PTEN

3) Lymph node spread: Never detected
Nearby lymph nodes were also removed during VATS surgery and were negative
3/21/17: Dx T3N0M0- distal rectal cancer, 4.5cm tumor, 2.5 cm from anal verge
4/18 to 5/22/17: chemoradiation - Xeloda 1800mg twice a day for 25 days, 200 Cgy/day
6/28/17: biopsy shows no invasive adenocarcinoma
8/09/17: MRI - no primary tumor left, starts wait and watch
8/17/17 to 12/1/17: mop-up chemo with Folfox and oxaliplatin (IV infusion), every two weeks
5/19 expanding right lung nodule, 8mm
8/19 VATS wedge resection
9/19 Clean PET, NED, no detected alterations of BRAF, KRAS,NRAS, PIK3CA, PTEN

User avatar
betsydoglover
Posts: 973
Joined: Mon Aug 14, 2006 2:31 pm
Facebook Username: Betsy Lindh Williams
Location: Maryland - outside DC

Re: More chemo after a solitary lung met?

Postby betsydoglover » Mon Oct 28, 2019 4:14 pm

I had a solitary lung met removed via VATS in 2009. I decided to do Xeloda and Avastin. I decided that if I had a recurrence and hadn't done some chemo to stave it off, then I couldn't live with myself. It's a personal decision, but I'm glad I made the decision I did, My 2 cents.

Take care,
Betsy
diag. Stage IV, 5/05, liver met
lap sigmoid colectomy, 6/05
6 cycles Xeloda/oxaliplatin/Avastin (NED after 2)
11/08 9x13mm right lower lobe lung nodule; removed via VATS 4/09
NED
6 cycles Xeloda + Avastin
Avastin only 10/09-5/11
Still NED 06/18

kiwiinoz
Posts: 1130
Joined: Thu Jan 03, 2013 11:44 pm

Re: More chemo after a solitary lung met?

Postby kiwiinoz » Mon Oct 28, 2019 5:06 pm

I think the question is more why did you have a recurrence? If it is due to some cancer cells that seeded in your and started a slow growing lung met then chemo is probably not going to assist a lot as the VATS would have dealt with the cancer. Are they any more cancer cells floating that could also be active? Who knows.

That is what Betsydoglover is referring to when she says she could not live with herself if she didn't do it. I too, had no idea. I'd hate to be proven wrong by not having chemo and then having more recurrences so in my situation, just like Betsy, I asked my oncologist what he would be in my position (he said he'd take chemo) so I went for 12 rounds of FOLFOX. Not fun, but did the trick in her case, and in mine.
Stage IV Rectal Cancer (39 Year old male at dx)
pT3N0M1 (wish that was M0)
Diagnosed 05 Dec 2012
LAR 05 Jan 2013
VATS 27 Feb 2013
FOLOFX April 2013 - Sep 2013
Clear Scan 03 Dec 2013 - 22 May 2019
Port Out 26 March 2015

Tdubz
Posts: 149
Joined: Sun May 07, 2017 11:01 am

Re: More chemo after a solitary lung met?

Postby Tdubz » Mon Oct 28, 2019 10:39 pm

I could be wrong but if you have already done folfox, they would likely give you a different chemo regime.

WarriorSpouse
Posts: 204
Joined: Tue Aug 16, 2016 9:02 pm

Re: More chemo after a solitary lung met?

Postby WarriorSpouse » Mon Oct 28, 2019 11:52 pm

My wife has gone back to her original treatment after a few years of maintenance chemo, and it has appeared to work in some regard. She has also used SBRT to attack two specific para-aortic nodes. We will know more if the SBRT has worked after the holidays and her next PET scan.
Everyone is different, but by staying proactive, you do keep new growth suppressed. Maintenance chemo and six month scans have kept my wife's quality of life as manageable for over 5 years now. All the best in your decisions moving forward.
WS
D/H 47 years old, 10/2014, Stage IV M/CRC, nodes 12/15, para-aortic, 5 cm sigmoid resection, positive Virchow. KRAS mut, MSS, Highly Differentiated, Lynch Neg, 5FU/LV and Avastin 1 YR (Oxi for 5 months), Zeloda/Bev since 01/2016. 02/2019 recurrence para-nodes, back to 5FU/LV Oxy/Bev. It is working again. "...Perseverance is not a long race; it is many short races one after the other."-Walter Elliot

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CRguy
Posts: 10021
Joined: Sun Feb 10, 2008 6:00 pm

Re: More chemo after a solitary lung met?

Postby CRguy » Tue Oct 29, 2019 12:08 am

Given that our situations are nearly identical, albeit 10 years apart, I have replied into your prior quotes for reference.

skb wrote: After a solitary lung met and its removal by VATS, is adjuvant chemotherapy recommended?
NCCN guidelines for 2018 does not give clear recommendations.
In 2010 with my single VATS removed lung met, this was controversial and called "pseudo-adjuvant" chemo which I did take

Given that Folfox treatment was already done (6 rounds) and it could not prevent this recurrence, I do not know how helpful it would be if I did the same treatment again.
I had full resection and elected Xeloda for neoadjuvant chemoradiation and post surgery adjuvant chemo.
When I had the lung met recurrence 3 years later, I chose to do 12 cycles FOLFOX as I had not had it previously and was determined to throw the book at the cancer !

skb wrote:1) CEA: My CEA has never been elevated. ...SAME = never elevated anytime so far since 2007 diagnosis
2) Gene sequencing information- ...in 2007 not done routinely as it may be now, so no info
3) Lymph node spread: Never detected ...SAME = never detected with MRI, CT, PET, or in surgery pathology samples post resection

skb wrote:Is there any experience from anyone here on this topic?

We are the poster kids for "Watch and Wait" versus "Cut and Chemo"
Different protocols, 10 years apart... BUTT ... with a commonality of low rectal primary tumors,
a period of NED, then a single metachronous lung met.

You had cCR and I had pCR with regards to determining if the tumor was gone.
We both had neoadjuvant chemoradiation and an "adjuvant" chemo after primary tumor resolution.
We both got recurrent lung mets.
You did not have surgery for the primary, but had it for the met.
I had surgery for the primary and the met.

You are deciding at the post VATS stage, 2 months out.
I am giving some input 9 years out from last chemo for my lung met.

My take :
explore other chemo / immuno therapies which could be targeted based on your genetics testing, with my preference being to do SOMETHING

Enact an AGGRESSIVE monitoring program with as many modalities and experts as you can muster to the cause.

JMO my friend
BTDT and still here to talk about it

In Harmony on the Journey
CRguy
Caregiver x 4
Stage IV A rectal cancer/lung met
12 Year survivor
my life is an ongoing totally randomized UNcontrolled experiment with N=1 !
Review of my Journey so far

skb
Posts: 41
Joined: Tue Mar 28, 2017 2:00 pm

Re: More chemo after a solitary lung met?

Postby skb » Wed Nov 06, 2019 1:55 pm

I want to thank boxhill, betsydoglover, kiwiinoz, Tdubz, WarriorSpouse and CRguy for the responses.

CRGuy, you have been on a very similar journey and your detailed advice is very much appreciated.
3/21/17: Dx T3N0M0- distal rectal cancer, 4.5cm tumor, 2.5 cm from anal verge
4/18 to 5/22/17: chemoradiation - Xeloda 1800mg twice a day for 25 days, 200 Cgy/day
6/28/17: biopsy shows no invasive adenocarcinoma
8/09/17: MRI - no primary tumor left, starts wait and watch
8/17/17 to 12/1/17: mop-up chemo with Folfox and oxaliplatin (IV infusion), every two weeks
5/19 expanding right lung nodule, 8mm
8/19 VATS wedge resection
9/19 Clean PET, NED, no detected alterations of BRAF, KRAS,NRAS, PIK3CA, PTEN

User avatar
Atoq
Posts: 349
Joined: Wed Oct 25, 2017 9:31 am

Re: More chemo after a solitary lung met?

Postby Atoq » Wed Nov 06, 2019 2:25 pm

Hi! I also had VATS for a solitary lung metastasis and did not do any chemo after that. The oncologist said it is not the protocol anymore here and it would have been different if it was in the liver.
The metastasis was sincrone and detected at diagnosis.

All the best

Claudia
45 year old, mother of 2
Dx rectal cancer 10.2017
T3N2aMX (suspect metastasis to one lung 8 mm)
Lynch neg
CEA 1.8
Neoadjuvant chemoradiotherapy Xeloda + 25x2 Gy
05.12.17 laparotomic surgery for blockage, colostomy
25.01.18 laparotomic lar, hysterectomy, ileostomy
05.03.18 core needle biopsy of lung, stage IV
07.05.18 CAT scan, lung met 11 mm
04.06.18 ileo reversal
26.06.18 wedge VATS
24.08.18, 31.02.19 CAT scan
12.09.18, 06.02.19 scope, CEA 1.6
19.11.18 colonscopy
20.08.19 CAT, eco
13.09.19 scope, CEA 1.2


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