Update: Surgical Resection Stage 3A

[Greekgirl3]

Good morning Members,

For some of you that have followed my last post or not, here is the background info.

My mom was diagnosed Stage 3A NSCLC. Her tumor is 6cm, 4.1x 3.8 x 5.8, located in the central upper left lobe and beginning to invade left main pulmonary artery.

I was told that resection is possible following neoadjuvant therapy. I was given a choice of standard chemotherapy for three months OR 2 infusions of nivolumab as a trial for 4 weeks. I contemplated which first line therapy choice I would use for the last five days.

However, I received a call and now was told that upon further review of the case, the team wants to move forward straight to surgery and do adjuvant chemotherapy afterwards due to fear of disease progression leaving my mom unresectable. I was not informed of what kind of resection is planned just yet.

I’d like to know the risks/recovery expected with a resection of this size and location.

How quickly must chemotherapy be initiated after a surgery?

Is there a strong chance of hidden disease spreading as a result of surgery without having systemic chemo first?

If members can weigh in with their thoughts and experiences, that would be great!

[Tom Galli]

Greekgirl,

Am responding on an iPhone from a cruise ship so I'll be brief.

Risks and recovery from resection: Of course, you are asking this question to her surgeon. Generally surgical risk is low. My right lung removal was safely done and my problems didn't start till about 10 days after surgery. I was discharged 5 days after surgery but caught something that caused an infection and re-hospitalized. Keep her away from all children for at least a month after surgery. In fact, limit contacted with everyone is something I'd suggest until she is well recovered (fully mobile, sutures removed and released by doctor).

Post surgical chemo is normally given from 15 to 30 days after surgery. She should (I'd say must) have it. It kills cancer cells in the bloodstream. My surgical complications didn't allow for post surgical chemo and tumors appeared in my remaining lung.

I can't answer the chance of metastasis after surgery or if post surgical chemo is not given with any precision. Cancer spreads. The longer it remains in the body, the higher the chance it will spread. As tumors grow, they direct the body to form blood vessels to feed the tumor. Doctors have likely concluded your moms tumor has not yet developed these vessels thus the proposed surgery. But they are looking at imagery and scan results. They won't know for sure till they do surgery. Depending on the type of surgery (minimally invasive) they might not know. Surgery is the best chance for achieving a NED (no evidence of disease) for your mom. I'd take it if offered.

I apologized in advance for errors in this post. Am hampered by small text and large fingers.

Stay the course.

Tom

[Greekgirl3]

Hi Tom!

Thanks so much for the response.

Do you have any idea why they would have decide to move straight to surgery after first telling us to get chemo or Nivolumab first?

Also, a second opinion has a conflicting course of Treatment suggested. Recommends chemo first because it might make he surgery less invasive and feels my k would definitely get he chemo as it is intended bc after survey she might be too weak. Thoughts on that?

First opinion is too fearful of disease progression and rather do it now before she possibly becomes unresectable.

[Tom Galli]

Greekgirl,

You are asking hard but appropriate questions. Understand I'm not a doctor.

Why surgery first? Lots of reasons. Most practices have what is called a tumor board. Various medical specialists discuss your mom's medical situation and often a change in treatment approach emerges. Given resection is the best way to achieve NED, her doctor could have reconsidered. You should ask.

As to your second opinion's treatment recommendation, I had pre-surgical chemo and radiation for exactly the same reason your second opinion physician suggested: to shrink my tumor to allow surgery. There are downsides to presurgical chemo. First, it may not work, and second it could further complicate your mom's general medical condition. In my case, presurgical radiation and chemotherapy did shrink my tumor but it introduced complications of wound healing and my sutures failed requiring two more repair surgeries.

Her surgeon ought to make the call as to your mom healing with or without chemo. Ensure the surgeon is aware of her medical condition. If the surgeon agrees resection is possible now, I'd be inclined to agree. I've found thoracic surgeons to be risk averse.

As concerns risk, medically, remember your mom is facing a disease of death. Do nothing and it will occur sooner. Treat and it MAY prolong her life. There is little that is certain in this disease. Statistics predict for most, not all, surgery gives the best chance for life. It may not be a "life before diagnosis" but it can be an enjoyable life.

Stay the course.

Tom

[Greekgirl3]

Hi Tom.

Thank you for all the info.

Well, we met with the surgeon again today and she strongly recommended neo-adjuvant therapy before surgery. Clearly, there was miscommunication between the surgeon and the oncologist. Seems like they sorted it out.

Surgeon suggested chemotherapy and then possibly a low-dose radiation together depending what the scans show as we progress.

Surgeon said tumor size isn't her concern, it is the location. And prefers to get the surgery as minimally invasive as possible.

Surgeon also recommended the immunotherapy, again. But we decided as a family to do chemo with the possibility of radiation.

[Tom Galli]

Greekgirl,

Glad you got the clarification. The location of your mom's tumor is indeed of concern. Radiation is a killing agent. Chemo mostly disrupts or precludes cell division or growth. Both can shrink tumor sizes. Sounds like you are on the right track.

Stay the course.

Tom

[Greekgirl3]

Hi again, Tom!

I do trust the surgeon, she seems very knowledgeable and matter-of-fact, which I can appreciate.

I was retreading your story, and I realize each patient is different, but out of curiosity, which factor of the neoadjuvant therapy brought you most complications-the chemo or radiation?

Also, did you need post-surgery therapy? Do others?

Just trying to decide which therapy route to go with.

[Tom Galli]

Greekgirl,

For me my 6 weeks of radiation came in like a lamb and left like a lion. There was some skin redness and sore throat but they were controlled by medication. Not controlled was my loss of energy. I started getting really tired at the start of the third week. By week six, I was bed-bound save for trips to the clinic. My adjunct chemo - low dose Taxol and Carboplatin - was given once per week. This low dose caused me no immediate side effects. So it was radiation and energy loss was the biggest problem.

I was supposed to have post surgical chemo (we call it dust-up chemo). But, surgical complications resulted in almost a year's worth of surgical procedures and recovery. Thus I didn't get it and the disease migrated to remaining lung. Had I had dust-up, my treatment would have been much easier.

There is a term called standard of care that you will hear mentioned often. Post surgical chemo is a standard of care and that means that better outcomes result from those who have it then those who don't.

Stay the course.

Tom