Lung Recurrence Treatment Plan

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nova17
Posts: 8
Joined: Sat Apr 17, 2021 3:22 pm

Re: Lung Recurrence Treatment Plan

Postby nova17 » Sat Jul 17, 2021 10:36 pm

roadrunner wrote:I am not certain there are definitive and/or comprehensive answers here. There are such things as transient pulmonary nodules, and they can grow or shrink and disappear on their own. I’m also not sure that growth (or reduction) was ever definitively established or well-quantified in some/all of these, at least from what you posted. (The one that showed 4mm growth may be an exception. I don’t think you said if it, or one of the smaller ones, is the “stable” one now.) The differences you mention—for example, 1mm growth (and you don’t give all the growth/reduction values, so it’s hard to judge)—are very small, and in micro-nodules at that. I believe 1mm “growth” would be generally regarded as “stable” in a person without known cancer. (If I remember right, 2mm is the threshold in that context.) Things are different where there is a history of cancer, but this still tells you something.

There are many vagaries when it comes to pulmonary nodules of this size. For example, inter-observer variability is +\- 1.72mm I believe (one study). Also the “slices” used for the CT, respiration at the moment of scan, contrast/no contrast (a significant factor), even electronic caliper factors and software variability can have effects (significant in this size range) that mimic growth or reduction in size. The challenge is that most of the nodules in this case are really small, so the relative impact of those factors may be increased. I wonder if the oncologist was “hedging” this when Xeloda was chosen for that reason. (Though you would presumably have been told that.) I must admit that I’m not sure what the PET results mean in this context, but the oncologist didn’t seem to regard that as definitive either.

All of this may explain (or be behind) the most recent radiologist’s impression, but the situation seems uncertain and potentially complex. Figuring that out would require (at least) a deep dive with your father’s team, and possibly a discussion with a (the?) radiologist. I’d certainly be interested in whether there is another potential etiology, e.g., an infection or prior smoking, especially if such a candidate fell into the period when these first definitively appeared. (You do say they “may” have appeared on prior scans, but the meaning of that is unclear.)

From reading your posts, it’s definitely possible that one or more of these are metastases, but I don’t think that’s certain. Your father’s oncologist thought it was concerning enough to do something, but they chose not to operate (even on the 1cm nodule (which you say would’ve been “easy,” and would likely have yielded enough material to test)). It may be that the treatment was just a conservative approach to observation.

That’s my reaction to your questions, anyway. Hope it helps in some way. But the bottomline appears to be that things are going in a good direction, which is awesome!


Thanks a lot for such a comprehensive response, I’ll add some direct information from the last ct report to give more information about the size reduction:

Image 14 of series 4 left upper lung nodule measures 7mm, prior study 6mm (**the last PET scan 3 months ago had this one at 7 so oncologist says this is a stable reading)

Image 28 there is a 3mm nodule right lower lung, prior study 5mm

On image 43 right medial lower lung nodule measures 5mm, previous study 10mm

On image 44, 2mm nodule right lower lung on prior study 5mm

So as you can see it was the largest nodule that grew the most from 6 to 10mm (that sounded the alarm for recurrence last time) that shrunk significantly on this last scan. The interval growth on the other nodules were all 1 or 2mm, but I assume this finding across all nodules was further suggestive of malignancy for the oncologist. The biopsy on that larger nodule wasn’t performed previously because I assume the interval growth was convincing enough for the oncologist to be certain that it was malignant. Even given that, the findings of that ct simply said “interval growth of nodules” and made no suggestion of metastasis or recurrence.

My dad was never a smoker and I can’t really think of any infectious history, although he does get pretty bad seasonal allergies. CEA isn’t a good marker for him and was always low throughout his initial treatment. The PET SUV uptake as you can see are all well below numbers suggesting malignancy, but the literature i’ve read says that these readings aren’t really useful for nodules that small.

I guess the conservative, attentive approach that his oncologist is using is akin to a ‘better safe than sorry’ attitude, even if there are some inconsistencies as you have pointed out. Regardless, I am grateful that whatever is going on is controlled at the moment.

roadrunner
Posts: 131
Joined: Sun Jan 12, 2020 8:46 pm

Re: Lung Recurrence Treatment Plan

Postby roadrunner » Sun Jul 18, 2021 12:13 am

I think you are correct that the nodules are likely below the PET size/sensitivity threshold (at least the smaller ones). It also sounds like the “moves” may be too big to be explained just by scanning “noise,” even at this small size, but I don’t think that’s 100% clear. (By the way, were all the CTs the same in terms of contrast/non?) Finally, while it’s suggestive that the nodules appeared to grow off chemo and then appeared to shrink when it was used, it still seems possible that some or all of them are benign. Especially if your father’s allergies are enough to cause significant inflammation. Not trying to suggest false hope, but while the growth/reduction seem correlated with the absence/presence of chemo, that could still be a coincidence I think. (Also see my last question below—if Xeloda works, why did FOLFOX bounce off?)

I guess my questions would be the following.

Are they sure or fairly certain these (or at least some of these) are mets?

If they are, is there any risk attendant to using comparatively weaker chemo (5-FU only), without enhancements like Oxaliplatin or Irinotecan (or Avastin)? (This is a corollary to Green Tea’s earlier point, I think. It seems odd to use 5-FU only if these are mets and your father is healthy enough for the big guns, which usually work far better.)

Is there a 5-FU “window,” after which any cancer might no longer be as sensitive to it, such that “the time is now” to hit it with everything they have? (That, by the way, is not based on any review of literature or knowledge on my part, just a speculative question I would want answered for peace of mind.)

Next, what is the oncologist’s endgame? Does he think oral 5-FU alone can wipe these out?

Also, if they are sure these are mets, why aren’t they operating? You seemed to think they would operate when sure, but it doesn’t seem they are doing that. You are likely aware that resection is SOC for resectable pulmonary mets without disease elsewhere. Admittedly, these are now very small, might be hard to find, not enough to test, etc., but that wasn’t true before (at least not for the largest one).

Finally, is it odd that Xeloda would be so effective if FOLFOX, which is enhanced 5-FU (5-FU + Oxaliplatin and leucovorin) did not eradicate these mets (if they are mets) when they were much smaller?

Of course, none of this is meant to question your father’s oncologist’s approach. These are just questions I would want answered if it were me. There may be very good answers, I just can’t see them based on the information you provided.
7/19: Rectal cancer: Initially staged as IIIA, T2N1M0
Initially approx 4.25 cm, low/mid rectum, mod. well diff. adenocarcinoma
8/22 -10/14 4 rounds FOLFOX neoadjuvant, 3 w/Oxiplatin (lots of side effects/reduced size est. 70-75%)
neoadjuvant chemorad 11/19
4 rounds of FOLFOX July-August 2020
ncCR found 10/20; multiple biopsies negative
TAE 11/20, small amount of tumor removed, lung nodules orig id’d 6/20 stable Nov 2020
Chest CT 3/30/21 small growth in 2 nodules (3 and 5mm)
Stable in 6/28 scan.

roadrunner
Posts: 131
Joined: Sun Jan 12, 2020 8:46 pm

Re: Lung Recurrence Treatment Plan

Postby roadrunner » Sun Jul 18, 2021 12:28 am

Sorry, 2 more things:

You say your father’s oncologist said he wanted to use Xeloda “because it worked well on the primary.” But that was in the context of chemoradiation, no? How does he know the Xeloda caused any reduction, and not the radiation?

Second, how many cycles of adjuvant FOLFOX were used?
7/19: Rectal cancer: Initially staged as IIIA, T2N1M0
Initially approx 4.25 cm, low/mid rectum, mod. well diff. adenocarcinoma
8/22 -10/14 4 rounds FOLFOX neoadjuvant, 3 w/Oxiplatin (lots of side effects/reduced size est. 70-75%)
neoadjuvant chemorad 11/19
4 rounds of FOLFOX July-August 2020
ncCR found 10/20; multiple biopsies negative
TAE 11/20, small amount of tumor removed, lung nodules orig id’d 6/20 stable Nov 2020
Chest CT 3/30/21 small growth in 2 nodules (3 and 5mm)
Stable in 6/28 scan.

nova17
Posts: 8
Joined: Sat Apr 17, 2021 3:22 pm

Re: Lung Recurrence Treatment Plan

Postby nova17 » Sun Jul 18, 2021 10:00 am

roadrunner wrote:Sorry, 2 more things:

You say your father’s oncologist said he wanted to use Xeloda “because it worked well on the primary.” But that was in the context of chemoradiation, no? How does he know the Xeloda caused any reduction, and not the radiation?

Second, how many cycles of adjuvant FOLFOX were used?


I’ll try and answer the questions you present to the best of my understanding, but the oncologist is the one who would have a fuller understanding of these decisions.

1.) Are they sure or fairly certain these (or at least some of these) are mets? Yes, especially now that they’ve shrunk after 3 months of Xeloda.


2.) Risk associated with weaker chemo? My impression is that if these last scans showed more interval growth then Avastin would be added. I truthfully don’t really know why it wasn’t used to begin with, but I think the decision comes from the oncologist’s experience with oral 5-FU being observed as effective for his patients. Also, my dad has some residual neuropathy (particularly in his feet) from his post-ileostomy FOLFOX so there is probably limited use for that in the future. I have heard of FOLFIRI and am not sure why that hasn’t been considered yet. His oncologist describes this as a “chess game” and wants everything in the arsenal available going forward. I guess maybe that means starting small and seeing what happens before throwing in the big guns. I think quality of life is also partly a consideration he’s taking into account due to the minimal side effects my dad has with oral 5FU. I too share your concern with there being a “window” for treatment to be effective, so I’ll bring this up with my parents to ask about at the next appointment.

3.) What’s the oncologist’s endgame, does he think oral 5FU can wipe these out? No, he does not think a complete response is likely and is not hinging this Xeloda treatment on that assumption. The oncologist, the surgeon, and the radiologist all think systemic therapy should be used before going in with removing multiple nodules. From their perspective, multiple nodules popping up almost two years after removal of the primary make them think they are looking at just the tip of the iceberg. My dad could certainly demand surgery or ablation now, but everyone we’ve spoken to say long term NED status from that would be unlikely. They’ve also said with nodules so small, the operations would be doing more harm than good by taking out healthy lung tissue, thus comprising the ability to operate in the future. As with chemo, there is only so much surgery a person can undertake. Ideally, the oncologist would want to remove nodules if some of the spots go away/nothing pops up elsewhere.

4.) Why didn’t FOLFOX eradicate them when they were smaller? I don’t have a good answer for this, and it’s been frustrating to think about ever since these nodules popped up because my assumption was that FOLFOX DID clear everything out. Their growth now rather than sooner may be because the adjuvant FOLFOX was suppressing them for a while.

5.) How do we know Xeloda caused the reduction and not the radiation? I don’t think we do know that for certain. This is a point I have brought up in the past as well. No good answer for this one, besides that Xeloda seems to be working now at least.

6.) How many adjuvant FOLFOX cycles? 8 I believe. No complications besides some remaining neuropathy. We recently went on vacation to Glacier National Park and while hiking he says that it feels like his feet have 90% sensitivity. Also before I forget, the staging after surgery was T2N0M0

Thanks again for thinking so thoroughly about a complete stranger’s treatment strategy. I can’t emphasize enough how informative and helpful this community is.

roadrunner
Posts: 131
Joined: Sun Jan 12, 2020 8:46 pm

Re: Lung Recurrence Treatment Plan

Postby roadrunner » Sun Jul 18, 2021 1:17 pm

I’m not sure that I’m adding much value at this point, so I will be brief.

I think:

(1) You seem super engaged and astute. I wonder if you could get into the actual meetings? Of course, I understand that patients themselves make this call, and parents are often protective and don’t feel comfortable with their kids having too much input.

(2) I remain unclear on the desired endgame. It seems that there is concern about more disease appearing, and that’s the reason surgery is delayed. But there isn’t expectation of cure with Xeloda alone, so why not use Avastin or FOLFIRI (neither of which would add to neuropathy)? If they shrink further, the assumption is that they will come back, so will they just wait until they are big enough to resect/test? Note that it is unknown whether pulmonary metastases of colorectal cancer can themselves metastasize. Traditionally, this was thought to be impossible, but animal studies are inconclusive.

(3) I recognize that complete response even with additional chemo agents is unlikely, but it does happen sometimes, and I think if the Xeloda is being used to limit recurrence and/or eliminate some nodules, why not use all available tools?

(4) I still wonder if the Xeloda is causing the changes. FOLFOX is just a more powerful version of Xeloda (for the most part). Perhaps there’s something special about Xeloda for pulmonary mets, but I haven’t seen that anywhere.

A personal note: As you can see from my signature, I had two (resectable) micro-nodules that appeared, were stable, then appeared to grow, then were stable again on the most recent scan. I was offered surgery or observation (no chemo) when they appeared to grow. It was a close call, but I chose observation. Perhaps the choice of “chemo lite” in your father’s case is due to the higher number of nodules, but it does potentially make diagnosis harder in my view, and the future path murkier. If more appear now or later, and they go to heavier chemo, wouldn’t it have been better to use that now? If more do not appear, and surgery is ultimately performed, wouldn’t you feel more secure knowing everything was done to reduce disease as much as possible first (with the heavier chemo)?

Ok, I’ll stand down. I don’t want to raise questions that just confuse things or potentially cause upset, so I hope these didn’t do that. Some areas really are judgment calls. I wish you and your father the best.
7/19: Rectal cancer: Initially staged as IIIA, T2N1M0
Initially approx 4.25 cm, low/mid rectum, mod. well diff. adenocarcinoma
8/22 -10/14 4 rounds FOLFOX neoadjuvant, 3 w/Oxiplatin (lots of side effects/reduced size est. 70-75%)
neoadjuvant chemorad 11/19
4 rounds of FOLFOX July-August 2020
ncCR found 10/20; multiple biopsies negative
TAE 11/20, small amount of tumor removed, lung nodules orig id’d 6/20 stable Nov 2020
Chest CT 3/30/21 small growth in 2 nodules (3 and 5mm)
Stable in 6/28 scan.


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