Advice and update on lung mets

[wdt]

My husband had surgery last Thursday. The preoperative CT and PET showed a single nodule in the rt lower lobe and a hilar lymph node showed up on PET. THe plan was surgery - using VATS to go in and essentially wedge section the are of the nodule to send to pathology. If it showed malignancy, they would proceed with an open thoracotomy. Well, that is in fact what happened. The nodule was malignant (colorectal met) as well as the hilar node. However, while in there the surgeon palpated (felt around) the lung and found an additional nodule that had not shown up on either the CT or PET. Also, one of the mediastinal lymph nodes that was taken out showed cancer. This was worse than we first thought. So now what?

Those of you that have been treated for lung mets, please let me know what regimen you are on for chemo, etc. and what has worked for you.

What do I need to be considering at this point? I still think he needs to go to Mayo or Sloan.

Thank you!

[Kathyp]

I was treated for Stage III colon cancer last year (FOLFOX/erbitux) and was diagnosed six months later with mets to lung. I have seen numerous doctors, including one at MD Anderson, all have recommended FOLFIRI/Avastin, but that is because this occurred in very close timing to the previous treatment.
I hope this helps.
Kathy

[wdt]

Kathy, thank you so much for your reply. Did you have any surgery, or did you just go straight to the chemo you listed?

[justsing]

I had 5 mets and numerous thoracic and abdominal LN's show up last August and I've been on some flavor of FOLFIRI / Avastin since September.

I had a PET/CT last week and a surgical consult with the thoracic guy. All but one of the mets are too small to show up on the scan and none of them are lighting up. There is only one thoracic LN that is still enlarged and it's VERY faint on the PET and centrally necrotic.

Some of the abdominal LN's are still hot, but they are all significantly smaller.

So the surgeon basically said that there is nothing he would offer me at this point other than continued monitoring. If they do start to re-activate, we decided to go with the least invasive option which would be the RFA / Cyberknife combo pack: the surgeons go in and RFA the tumors and leave a fiducial marker there when they're in. Then they come back in a few weeks and Cyberknife the area for good measure.

[dianne052506]

wdt,

I had FOLFOX/Avastin before and after my liver resection. Eight months after finishing the chemo, scans showed multiple nodules on each lung (approx 20 in total). Because I had a history of good response to FOLFOX/Avastin, I started back on it in Feb 08, and am still on chemo. I switched to XELOX (oxi and Xeloda)/Avastin in December due to the leucovorin shortage and am still on it. It's pretty much a maintenance system for me, with treatment every six weeks. We will stay with XELOX/Avastin until it stops working or until I have side effects I can't live with.

I think that both FOLFOX and FOLFIRI are used for lung mets. I've read of people with excellent response to FOLFIRI; with my treatment, the nodules have shrunk significantly so that surgery is not needed at this time.The decision which to use may come more from your husband's history rather than the location of the mets. From what I understand, he did not have progression while on XELOX, so he could still be a candidate for it, unless the side effects were a significant problem for him. If he then had progression while on FOLFOX or XELOX, then he would still have the FOLFIRI available as the second line.

Good luck to you both.
Dianne

[SusanE]

I had VATS for lung mets and a hilar lymph node as well as mediastinal lymph nodes. My oncologist and surgeon recommended follow-up radiation. I went to USC Norris Cancer Center for a second opinion. They recommended chemo and NOT radiation. Since my lung mets appeared within a year of completing Folfox, they said that I "failed" Folfox. So In my case, they recommended Folfiri and Avastin. Depending on your husband's history, Folfox may be an option for him.

Has your husband's tumor been tested for KRAS? That is an important next step in deciding what chemo regimen he should be on. If he is positive for the KRAS mutation then he will not be eligible for Erbitux or Vectibux.

Hope this helps,
Susan

[John603]

Diane,

Is the maintenance chemo every six weeks your choice or did your oncologist suggest this?

[Terry]

I have two lung mets (very small), 2 nodes in the chest, 1 behind the diaphram and two in the sacrum. I'm on oxi, avastin and xeloda for one year (4 months off the oxi from months 5 to . I checked with 3 different surgeons and none will do surgery at this time. They said after the chemo, hopefully there isn't anything to talk about.

Good luck, God bless and good thoughts to you and your husband!

[EBMJ]

They found 3 lung mets on me last July, I was off chemo at the time. All 3 were about 1 cm in size. My onc got me right back on FOLFOX, we would rescan in another 12 weeks. Now 1 year later the lung mets are almost gone from chemo only, and no sign of anything new. They are actually too small for surgery at this point. So the plan is to continue to monitor and we always have surgery or Stereotatic radiation in our hip pocket if we need them. I also feel good that we are treating systemically for what the scan can't pick up. I guess I would wonder why they are so quick to rush your husband off to surgery, rather than resuming chemo.

Jim

[wdt]

EBMJ - in response to your question I believe the decision for surgery hinged more on the fact that the CT and PET only showed the one small 11mm nodule and the one hilar node. They found the other node and other nodule during surgery; both were too small to show up on either CT or PET. So, it looked like he was a good surgical candidate when they decided to operate. From what I have read, the gold standard for a single metastatic nodule is surgery to remove it. The treatment is different when multiple nodules are present, or for situations where nodules are present in both lungs. The decision to take the rest of the lung was made while he was on "the table". If they had known this on the front end, they most likely would have just offered chemo and not done the surgery. Hindsight is 20/20....always a risk. My husband had a nodule show up located in his thyroid on his staging PET and they removed it and the pathology ended up being benign. Lesson= CT's and PETs are not 100% accurate. Also, his CEA was only mildly evelvated (around 4) and had hovered there for months before any nodule showed up. Had it shot up, they probably would have initiated chemo earlier. Also, the nodule did not show up until he had been off chemo for about a year, so that always factors into the treatment decisions as well. Meaning, he did not "progress" while on chemo.

I found out that his onc has been in contact with someone at MD Anderson and asked them about the drug regimen that they would recommend. He was tested for the microsatelite instability prior to his adjuvant chemo, but I don't believe they tested for KRAS at that time because he was stage III and only on a two drug regimen - Xeloda and oxaliplantin - no EGFR's. I feel confident that our onc will send for the KRAS testing now before he proceeds with this next round of chemo because it will include Avastin this time, but I plan to ask him to confirm. He has to heal from the lung surgery and won't start chemo for about a month.

I am praying that going back on chemo will keep this disease at bay and prevent other mets from surfacing, since he cant afford to loose any more lung tissue! You are correct that RFA is always an option, however.

Thank you all for your responses and keep them coming. I need all the help I can get!

[vancouver eve]

I had the Vats surgery and I had two small mets to be removed as shown on the scan. When the surgery was preformed the Surgeon noticed a 2mm nodule outside the lung. The surgeon the had it tested and it was cancer so he burned all around the area. I am now on irinotecan avastin and xeloda. When I finish the next four treatments it will be only avastin and xeloda. This combination has worked for many people. I hope this helps you.

If you want to know anymore just p.m me or post.