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Thread: To Remove Lung Metastasis or Not

  1. #1
    Moderator Top User ddessert's Avatar
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    To Remove Lung Metastasis or Not

    Pulmonary Resection for Isolated Pancreatic Adenocarcinoma Metastasis: An Analysis of Outcomes and Survival
    Abstract
    Full Text

    This 2011 Johns Hopkins Paper compared the outcomes of stage I/II (at diagnosis) patients that had surgical resections and later lung metastasis:
    • 9 patients who had lung metastasis removed
    • 22 patients that kept their lung metastasis


    The resections did seem to increase the survival times much of the time, but did not demonstrate any curative effect (little/no 5-year OS difference). We have to also consider that the group able to have the lung metastasis removed was significantly more healthy than the others, so we'd expect this to contribute to their some survival advantage.

    60% of the resected lung metastasis were removed by lobectomy.


    The bottom line is that a lung resection can be done fairly safely. Patients whose lung metastasis was removed lived longer, but were not necessarily cured. The causes of death (like additional mets?) were not investigated, so we don't really know.

    In this paper (and others), the authors are very interested in using the patient's DPC4 gene status to determine which patients are more likely to benefit. They think DPC4 status might indicate how likely more metastases are to form, although they did not show data for better survival in this study.
    BRCA2 3398del5
    Dec 2010 - back/abd pain
    May 2011 - Unresectable stage III, 2.5cm tumor
    Jun-Aug 2011 - Gem/Cis, 9 rounds
    Oct-Nov 2011 - Radiation+Xeloda, 25 days in 5 weeks
    Oct 2011-Sep 2012 - shrinking tumor
    Feb 2012 - National Familial Pancreatic Study
    Aug 2012 - Downgraded to stage IIA, PGP
    Sep 2012 - Whipple, T3N0M0, 0.5cm tumor, 0/16 lymph nodes
    Dec 2012 - Quebec PanCan Study
    Sep 2012-Dec 2016 - NED
    Mar 2013-present - NCT01088789
    @pancanology

  2. #2
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    I think I can add a little to David's comments above. I have lung mets that are so far slow-growing and so took the time to research and get various opinions on how or even if to treat them. I have seen or spoken with (in addition to my oncologist at MSKCC) Dana Farber (onco), MDA Anderson (radiation onco), and U Florida (interventional radiologist). I learned alot, and would note that there is no right answer for this, and nobody agrees. Here is what I found out, in no particular order.

    1) there is very little data on lung-only mets, just a few articles.

    2) the field is just beginning to consider treating lung mets, mostly a result of having some success with SBRT for colon cancer lung mets, so maybe that translates for PDAC

    3) the common view out there, especially among oncologists is that there is no point because if there is one there are 3 if there are 3 there are 5 because by definition, you have to have micromets in order to have mets, and you cant radiate or surgically remove that which you cant see. As well, tumors <5mm tend not to show up on scans. Hence the onco's like to watch and wait until they know how many they are dealing with and/or the disease shows some stabilization.

    4) lung mets, particularlly those that arise out of the distal part of the pancreas (my situation), like the lung for some reason, are bloodborne and tend to be lazy and slow growing, adding to the watch and wait approach above.

    5) Nano knife guys WILL NOT even talk to you if you have mets, largely for the same reason. They say it's not going to help. So don't waste your time.

    6) You need to see a lung guy, a surgeon and or a radiologist. This is more of a lung issue than a PDAC issue and IMO the PDAC doctors are very nihilistic in general and afraid to go outside of standard of care. To paraphrase David D., they like to treat you like the median, so you become the median.

    7) The best advice I got was from Dr. Joe Herman at MDA, who basically said I should bomb the lungs with FOLFIRINOX to "sterilize" the pleura, THEN go in and either ablate it with RFA, or do SBRT. This makes complete sense to me and that's what I am going to do.

    Interestingly, the UF guy - Dr. Justin Rineer - who took two hours with and went throught the scan online, explained everything - thinks that surgery might be a good option. This obviously depends on a lot of things, but it's pretty easy to surgically remove mets on the pleura, which supposedly is where they usually show up.

    9) Luckily, my oncologist is flexible and tries to tailor treatments to her patients' personaliy and general health. She would for me to watch and wait, but she knows I won't. So I presented all of this to her and she agreed it was a decent strategy.

    10) HAVING SAID ALL THAT, she wants me to look into a clinical trial at NIH which I want to let people know about because it seems very cutting edge and being led by a very prestigious guy Dr. Stephen Rosenberg. You must be able to withstand surgery for him to get a sample, and then he "grows" it over four months and injects you with it. I cannot explain these things, maybe David can! Here is the trial:

    https://clinicaltrials.gov/ct2/show/NCT01174121

    Hope this helps. Remember, when armed, you know what's right for you. Also, you need to speak to the right people! If you want chemo ask an oncologist, if you want surgery, go a surgeon. Chris
    9/25/16 - Distal pancreatonomy to remove growing "cyst" on tail of pancreas
    9/30/16 - Path confirms PDAC, 0/16 lymph nodes, clear margins, categorized 2A
    11/06 - start Chemo - Gemcitabine/Xeloda
    5/15/17 - Scan show growth in previously unidentified lung nodules. 1 in each lung
    5/30/17- Lung biopsy confirms PDAC in lungs
    7/17 - awaiting to be placed in immunotherapy trial at MSKCC
    7/17 - began Clinical Trial of KO-947, an ERK inhibitor
    9/19/17 Taken off trial, not doing anything
    9/21/17 considering FOLFIRINOX followed by some local treatment for lungs. CA-19 21
    9/21/17 also considering clinical trial at NIH

  3. #3
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    Great information right here, thank you both for sharing!

 

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