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Lung Cancer

This is a true clinical story. For obvious privacy reasons, the names of the patients, the doctors and their titles and the institutes have been omitted.

 

The Patient’s Story

I’d been coughing for a bit but otherwise feeling fine so it took a couple of months before I decided to go and see my doctor. He sent me for an X-ray which showed something on the right lung. I was a bit surprised when he wanted to admit me to hospital to for investigations but went along with it anyway.

In the hospital they took a sample from the right lung. I wasn’t really worried as I’d never smoked in my life, so when they told me I had lung cancer I was completely stunned. As far as I was concerned I just had a slight cough and was otherwise feeling completely fine.

I went through all sorts of other scans which ended up showing cancer all over my body... all over my lungs , my liver , my back, my bones... I cannot begin explain to you the feeling of shock when I was told I had to have chemotherapy... I felt fine!!

The chemo wasn’t pleasant, having initially felt well I went through the next six months gradually feeling more awful. In addition to the chemo I’d been put on some new drug called Bevacizumab which was meant to reduce the blood supply to the cancer so it would grow more slowly. It seemed to pay off as the repeated scans showed the cancer wasn’t growing. However, six months later it had to be stopped after as one of the scans showed a blood clot in my lungs which would have worsened if I’d continued the treatment.

My oncologist sent me home and told me to continue on with my life in as normal a fashion as I could. The first check up scan I had was fine, but the second showed that the main cancer in my right lung was getting bigger and starting to damage the area around it. Some special tests were done on the cancer samples to see what the best treatment would be and then my oncologist started me on a new drug called Tarceva.

I was still feeling fine and couldn’t quite comprehend what had been going on. I realised there were three things I wanted to know; had I been getting the right treatment, what other treatments are available and , most importantly, how long did I have to live?

I started doing some research on the internet and came across the Second Opinions website. As I saw it , I had nothing to lose so I decided to get them involved. My oncologist was happy to give me all my files and I simply sent them off to Second Opinions. They quickly got back to me with answers to all my questions from one of their experts on lung cancer.

When I got his report I was relieved to find out that I had been getting the right treatment.This was particularly important as my family had spent a lot of money on the medications. He also suggested other options such as radiotherapy and drugs to reduce the damage the cancer was causing to my bones. These were things my oncologist hadn’t suggested. He went on to suggest further options if my current treatment wasn’t successful. My doctor at home was happy to discuss these possibilities and in the end we decided to go with the radiotherapy.

The report didn’t ignore the most difficult question. It was one I had been scared to ask my doctor and it was clear to me he didn’t really want to address the issue. Now I have an idea of how long I may live for and have been able to plan appropriately. Its difficult to say thank you for such a terrifying thing but at least now I know I’ve been getting the right treatment, know what the options are and feel I understand what is going on.


The following documents are the case history that the patient provided and the experts opinion in response.

Clinical information

A 58 year old non smoker presented with a three month history of cough with no constitutional symptoms. His past medical history was unremarkable apart from a TURP for prostatic hypertrophy in 2002. He was taking no medications and had no allergies.

A chest x-ray that showed a right parahilar opacity and was therefore admitted to hospital to for further investigations.

Bronchoscopy was performed showing slight bulking and obstruction of downstream branches from the right main bronchus. A biopsy was taken and the histology showed adenocarcinoma.

Total body CT scan was peformed. In the right superior lobe of the lung there was a 10.5x3.5 cm lesion spreading to the hilum with involvement of the right anonymous vein, the right and left main bronchus, the right pulmonary artery, the anterior segmentary bronchus of the right superior lobar bronchus with consensual atelectasis. In addition, there were signs of subcarenal and paratracheal adenopathies, an osteodense area in the sixth lumbar spine as well as a hepatic lesion of 28 mm maximum diameter. There were no cerebral metastasis.

A bone scan showed increased uptake in the left scapula, in the the first rib, in the sternal body, in the right seventh rib and at in L4, indicating bony metastasis.

The patient was diagnosed with was Stage IV Pulmonary Adenocarcinoma (right lung + mediastinic lymph nodes + liver + bone).

A Cardiology consultation, blood and urine tests showed no contraindications to chemotherapy.

Chemotherapy was started with a regime of Cisplatin, Gemcitabine and Bevacizumab/Placebo (Avail protocol) for 6 cycles. A CT scan after the sixth cycle showed an asymptomatic pulmonary embolism so Bevacizumab maintenance could not be given.

The therapy was well tolerated by the patient despite a thrombocytopenia which responded to dose reduction. There were signs of partial response after the third and sixth cycles.

Five months after the completion of the chemotherapy a follow-up CT scan showed that the condition had stabilized, with no pulmonary embolism. Therefore, the patient continued follow-up with no further treatment.

A subsequent CT scan showed an increase in the size of the original right pulmonary parenchymal lesion with the onset of post-stenotic collapse, superior lobe volume reduction with an associated pleural effusion. The hepatic lesion had also increased in size. The lymph nodes and bone lesions were unchanged.

Currently the patient is in relatively good health and is essentially asymptomatic.

Due to the patient being a non-smoker with adenocarcinoma, epidermal growth factor receptor characterization was carried out. This showed amplification of the EGFR (FISH + (5 copies)) with no gene mutations ((exons 18-21): wild-type).

Given the progression shown on the recent CT scan the patient’s oncologist proposed starting second-line treatment according to the clinical and biological characteristics. He has since started therapy with Tarceva.

Questions:

  1. Can you clarify the effectiveness of the new treatment (Tarceva)?
  2. Are there any alternative therapies?
  3. What is the prognosis

The expert’s opinion

Prof. ---------
Senior Oncologist and Consultant in Oncology
Oncology Unit
Medical Center
Affiliated to JDS Faculty of Medicine

Thank you for the referral and the copy of the medical records. I had the opportunity to review his documents and to write the following second opinion, at the request of Medical Opinion Ltd.
Reconstruction of the case history
The patient is a 58 years old non-smoker. Three years ago he was diagnosed Stage IV Adenocarcinoma of the lung following a several month history of cough which was not accompanied by weight loss.

His chest CAT scan revealed a lesion in the right superior lobe, reaching the homolateral hilum and measuring 10.5x3.5 cm. This involved the right anonymous vein, the right and left main bronchus, the right pulmonary artery, the anterior segmentary bronchus of the right superior lobar bronchus and induced a corresponding atelectasis. In addition, there was subcarinal and paratracheal lymphadenopathy, and an osteoblastic metastasis in D6, and a hepatic metastasis measuring 28 mm diameter.

The patient underwent bronchoscopy which detected disease in the right bronchial hemi-system, explaining the atelectasis of his right superior lobe. A bone scan was consistent with wide spread bone metastases.

The first line of treatment consisted of Chemotherapy with six cycles of Cisplatin and Gemcitabine combined with Bevacizumab. He demonstrated partial response by the end of the third and sixth cycles.

By this time his CAT scan showed a pulmonary embolism, and although this had been asymptomatic it was decided to discontinue both the chemotherapy and the Bevacizimab.

A subsequent CAT scan revealed that there was disease re-growth. A second line of systemic treatment was initiated at that point, consisting on Tarceva (Erlotinib).
Questions and answers
1. Can you clarify the effectiveness of the treatments he has received?
The main aim of treatment in this case is to preserve his quality of life and to prolong survival. Various combination therapies are in use as first line treatment and Cisplatin with Gemcitabine is certainly one of them. It is good to see that the patient has had the opportunity to be treated with Bevacizumab, which has increasingly been found to improve both rate and extension of response to chemotherapy, including that of lung cancer.

Considering the situation (stage IV adenocarcinoma of lung) the intensity of treatment has to be moderate. Hence, following six consecutive cycles of chemotherapy with partial response, I agree with allowing the patient a rest period so that he can enjoy his life, without burning out his haematological reserves.

I concur with his oncologist and would have also have prescribed further treatment with Erlotinib. This has been found to improve survival of patients with NSCLC, especially for non-smokers with adenocarcinoma. The amplification of EGFR [(FISH + (5 copies)] supports this treatment, despite the absence of EGFR gene mutations [(exons 18-21): wild-type]. We will have to wait to see the clinical outcome.

2. Are there any alternative therapies?

Currently I would continue with Erlotinib as long as there is a positive response, or at least stabilization. Possible modifications of the current treatment could include its supplementation with concurrent administration of bisphosphonates (either Pamidronate or Zolendronate), aimed at reducing the risk of skeletal complications from bony disease.

In addition, in view of the lung condition shown by the CAT scan in October, namely the "increase of the original right pulmonary parenchymal lesion with onset of poststenotic disventilatory pneumopathy and superior lobe volume reduction", I would consider the option of palliative radiotherapy, aimed at preventing deterioration of lung function and general condition. If the primary disease represents the patients limiting factor, irradiation could be an effective treatment option for controlling this problem. Its administration combined with Erlotinib seems attractive, since this drug is both non-myeloablative and possibly radio-sensitizing.

However, the timing for such intervention, if at all, should be chosen through an interdisciplinary discussion involving the patient’s attending oncologist with a pneumonologist and a radiotherapist, weighing the risks and the benefits of irradiation at that specific time. They may also consider combined endobronchial radiotherapy for preservation of open airways.

In the future, if and when there is clear tumour progression, there is still the option of second line chemotherapy. There is good experience with Docetaxel (75 mg/m2/ q 3 weeks) and Pemetrexed (500 mg/m2/ q 3 weeks) with the latter needing supplementation with both Vit.B12 and Folic acid. If available, I would give Pemetrexed due to its preferable toxicity profile.

3. What is the prognosis?

If we base our prediction solely on the effect of "second line chemotherapy" (either by Pemetrexed or Docetaxel) the median survival time is around 8 months, with about 30% one-year survival. However, in this case this may be improved by the contribution of Erlotinib. If the patient develops any type of "skin rash" under Erlotinib treatment, it can already be expected that objective and possibly long lasting response will develop, with significant improvement of his prognosis.

If I can be of any further help to you, please contact me through Medical Opinion Ltd.

Yours sincerely,
Wishing the patient all the best,

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