Metastatic lung Cancer

Metastatic non small cell lung Cancer
Short Summary

67 year old male, previously a heavy smoker, suffering for 2 months from weakness, diminished appetite and weight loss. Tests showed a mass in right arm, possibly attached to muscle, and tenderness in right ribs. Chest CT showed a mass in LLL, lung foci, suspected secondary spread and masses in upper abdomen. CT guided biopsy from right lung mass was consistent with non small cell carcinoma with extensive necrosis. SPECT bone scan showed many focal findings in the vertebrae L,D2,7, most of the ribs bilaterally and in the limbs- suspected for secondary pathology. The advisory oncologist recommended chemotherapy treatment and didn't recommend biological treatment.

Patient's Questions

1. Is this course of action the only option? Are there other realistic options?
2. Is there any available treatment or doctors abroad who is able to help?
3. Are there alternative or experimental treatments available and suitable?
 

Medical Background

67 years old male.
Background:
Chronic renal insufficiency, nephritic syndrome, under nephrological observation
Hypertension
Dyslipidemia
• Previously a heavy smoker. For 3 years, has been smoking 5 cigarettes per day.
• Previously obese. At his heaviest, the patient weighed 135 kg. Underwent gastric bypass operation in 1981.
Bipolar disorder, controlled with drugs.
Osteoporosis, under endocrinological observation. Treated with calcium and vitamin D.
• Has suffered fractures, including an open fracture in the left knee area, which is currently locally distorted.
Ischemic heart disease, coronary catheterization 3 years ago, following periods of shortness of breath under stress, and positive scans, found two coronary arteries diseased. Underwent intervention with stent coated with medication on the far end of the right artery.

Long term medications taken:
Micropirin Tab 100mg x1/day, Norvasc Tab 10mg x1/day, Disothiazide Tab 25mg x1/day, Pravastatin Tab 40mg x1/day, Lamictal Tab 50mg x2/day, Cipralex Tab 10mg x2/day, Clonex Tab 2mg x2/day, Calcium and vitamin D Tab x1/day, Vitamin D DRP 200IU 10 drops x1/day, Konsyl orange PWD 2 spoons x2/day.

Family history:
Brother died from lung cancer (smoker). Mother and daughter of the patient had breast cancer.

Current illness:
For two months, the patient has been feeling his general state of health worsening, suffering from weakness, diminished appetite and weight loss.
In addition, a mass has appeared in his left arm, growing over time. Due to complaints of pain in right chest, was sent for chest x-ray, and in light of results, for CT.

Physical examination upon admittance:
Blood Pressure- 121/56.
Pulse- 76, regular.
Temperature- 36.5 P.O.
Breaths- 14 breaths/minute.
Lymph nodes- small lymph glands felt in armpit.
Chest- no masses felt.
Heart Sounds- normal, no additional sounds or murmurs heard.
Lungs- good breath sounds bilaterally, no rhoncus or whistling.Tenderness of ribs on right.
Abdomen- soft belly, no tenderness, masses felt in upper abdomen.
Peripheral pulses- felt bilaterally in radialis artery, dorsalis pedis and tibialis posterior arteries.
Limbs: no edema, and no signs of DVT.

Chest CT:(Without contrast medium injection).
No enlarged lymph nodes demonstrated in the axilla and mediastinum.
Solid mass in left lower lobe, inseparable from the pleura, with defined edges- 4.8 x 7.3 cm.
Lung foci demonstrated on both lungs, diameter up to 8 mm.
Slight pleural discharge bilaterally.
Post operative state – metal pins in upper abdomen.
On the left, well defined mass demonstrated, undefined edges- 4.1 x 6.7 mm
Additional mass, inseparable from the diaphragm on the left, dimensions 4.1 x 4.9 cm.
Conclusions:
1. Space occupying lesion in LLL, biopsy advised.
2. Lung foci on both lungs, possibly secondary lesions.
3. Two masses in left upper abdomen, of an unclear nature. Clarify with CT, with contrast medium.

CT guided biopsy from right lung mass:

Consistent with non small cell carcinoma with extensive necrosis.
Immunostains were positive for TTF-1, CK7, and CK8/18, and negative for CK20 and P63.
Post biopsy process normal.

The patient was discharched with recomendations for:
1. Tab oxycontin X 2/day.
2. Ambulatory bone scan.

SPECT bone scan:
A Whole body scan and SPECT was carried out from spinal column, back, waist and pelvis, including imaging of the upper limbs and comparison with the previous scan (2 years ago).
In comparison with the previous scan, the current scan shows many focal findings in the vertebrae L,D2,7 and most of the ribs bilaterally (shown with SPECT), particularly ribs 8-9 anterior, on the right.
These findings increased our suspicion of pathology within the skeleton (possibly originating from the bone marrow), although pathology arising from a different source cannot be ruled out.
X-ray confirmation of these findings is recommended.
Status of the proximal left tibia and the right knee are without change.
On the other hand, very uneven absorption was seen in the limbs – tibias, femur, bilaterally, which also raises suspicions of secondary pathology.Otherwise, nothing to mention.

Treatment:
The advisory oncologist, recommended chemotherapy treatment as follows:
Carboplatin (without diaplatin) with Navelbine, or taxol, or ALIMTA (one of the three), at a rate of one or two doses per three weeks.
Currently, she does NOT recommend biological treatment – NOT Erbitux, and NOT Avastin.

Due to the patient deteriorated condition the treating oncologist has decided to start with Weekly Cycles of Vinorelbine for 2 weeks and stop on third week. Additional therapy will be considered according to clinical status.

Expert's Opinion

All opinions stated in the enclosed report are based solely on the records received by the physician without benefit of physical examination or contact with the patient.

Summary:
67 year old with multiple co morbities: heart, renal, vascular, hypertensive.
Left lower lobe lung mass that biopsy showed was a TTF-1 non small cell lung cancer- most likely an adenocarcinoma.
Multiple small nodules < than 1cm noted but etiology uncertain.
Also “masses” in the upper abdomen and left arm. Therapy recommended is single agent Vinorelbine.

 

 

Impression:
I am not certain there is enough evidence of stage IV metastatic disease. Unless the abdominal and bone lesions are confirmed to be neoplastic (Biopsy or PETCT), radiation therapy or even surgery would still be possible.

Treatment Alternatives:
If abdominal and bone lesions NOT malignant, surgery or irradiation.
If truly metastatic- Taxotere weekly 35mg/m2 would be a potentially more effective option.
If tissue available would be checked for EGFR mutation- if positive and if disease truly metastatic- Erlotinib.

Comments:
The key is finding out if the disease is really metastatic to the lung, arm and abdomen. If so palliative
chemotherapy with Taxotere, Vinorelbine, Tarceva the best bet. If NOT metastatic- explore surgical and radiation options.
This can all be carried out in Israel.

If I can be of any further help to the patient, please have the patient contact me through Philadelphia International Medicine.

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