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assessing a course of treatment

ken f.

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hello experienced ones!

i meet next week with my oncodoc about future course of treatment. he has set up a meeting for me in advancel with radiation oncologist and says he, radiation oncologist, and surgeon will review my situation jointly to get a plan. as you appreciate, i don't much like the thought of "melting" any of the remaining tissue in my lung unless it is really indicated and probably necessary and wonder whether you might be able to provide me an assessment or lines of inquiry to follow in my upcoming consults.

i haven't got a formal staging statement. i believe it would be either two independent stage 1b tumors of different sizes (seems unlikely to me) or stage 4. i'm not certain what difference the staging would make at this point after surgery but think it is probablya factor in determining treatment course.

my situation, generally, is that after finding evidence of two tumors on CT scan suggested by GP on no symptoms, i had PET scan, biopsy and, finally, surgery 11/24. path report from surgery notes:

1. wedge biopsy right lower lobe: adenocarcinoma, 1.1 cm. grade II/III, no angiolymphatic invasion identified. specimen received in somewhat disrupted state. evaluation of pleura and surgical margin or resection impossible. (operative report notes-wedge-shape incision on lateral aspect of lower lobe using the cautery. incision continued downward until the nodule could be grasped. continued to do dissection with cautery. artery and vein branches controlled bewteen medium hemoclips. no major bronchial structure divided. nodule excused with an adjacent margin of normal lung and submitted for frozen section examination. gross appearance of the mass was that of a metastasis with pushing margins rather than infiltrating margins. K7 strongly positive, K20 negative, TTF1 strongly positive

2. wedge biospy right upper lobe: adneocarcinoma 3.2 cm, grand II-III/III. extensive turmor cell necrosis leaving very little viable neoplasm. necrotic tumor generally surrounded by a fibrous capsule and neoplasm itself comes within .6 CM of the inked plural surfgace of the wedge biopsy specimen. no angioymphatic invasion identified and neoplasm is excised by the wedge biopsy specimen. K7 rare weak positivity, K20 negative, TTF1 negative.

3. 9 lymph nodes right level 4 and 6 lympth notes right level 7 show sinus hsitiocytosis and anthracosis but no evidence of maligancy.

imunohistochemistry conclusions were that stains for lower lobe nodule positively support primary pulmonary neoplasm. but right upper less definitive as only rare keratin 7 positive cells noted and TTF1 completely negative. whether secondary to extensive necrosis within the tumor unknown. but neiplasm is histologically nearly identical to that in the lowerlobe + metastatic colon carcinoma should be strongly CK20 positive and both tumors are completly CK20 negative against possibility of metastatic carcinoma of colonic primary site for either nodule.

subsequent immunohistochemical stains of samples of my colonic carcinoma of 1997 (resection of 1/2+ of upper colon with staging of 1b) were performed with overall findings favoring lung tumors as representing primary pulmonary neoplasms rather than metastases for colonic carcinoma with CK20 positive in proportion of tumor cells.

so...i suspect that all, save surgeon perhaps, will be concerned with margins and may want to "fry" the surrounding tissue with radiation. i also suspect some chemo course will be suggested. i have read that as i have a smoking history, iredessa (sp?) would not be indicated.

i would appreciate your thoughts and any suggested lines of inquiry or further fact gathering.

thanks so much.

love, ken

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Hi Ken, sorry I missed this earlier. This is a very hard case. If you believe the immunostains, I think you can definitely argue that these are separate primary lesions since the TTF-1 staining is different. TTF-1 is very useful when it is positive, very specific for lung cancer. When it is negative it is not so helpful as many lung cancers are negative. The only way you could call these tumors from the same primary would be if you either believe that the TTF-1 didn't "take" on the negative tumor or if you think this is a different clone from the same tumor. I would give you the benefit of the doubt and call these separate primaries.

If we assume that you basically have 2 synchronous primary lung cancers, then the question is what can you do to give you the best chance of cure? Your risks of recurrence are for both local and distant recurrence. The fact that you had wedge resections rather than a pneumonectomy or bilobectomy unfortunately does increase your risk local recurrence significantly. Radiation will reduce the risk but you'd be talking about radiating 2 lobes. I think it would probably be reasonable to consider depending on the condition of your lung function. Your risk of distant recurrence is also significant and I would feel more strongly that you should consider chemotherapy.

In terms of what other treatments would be options, you are unfortunately going to have a hard time qualifying for a lot of clinical trials because of the uncertainty as to whether you have 2 Stage 1 cancers or Stage 4 cancer. Off protocol, I don't know of any other treatments that would improve your risk of recurrence.

Good luck ken, sorry your case was so complicated but glad they didn't get any nasty surprises with your surgery.

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