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Oncodoc question on repeat bronchoscopy (7th biopsy)

Guest bean_si (Not Active)

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Hi Cat, sorry to hear you've had so much confusion with your case. First of all, the call between adeno with neuroendocrine features versus pure high grade neuroendocrine cancer (i.e. small cell ca) is very difficult, especially with what sounds like a small necrotic sample. I suspect if you sent it to another 10 pathologists you would not get 10 identical diagnoses. The other issue is that tumors are very often mixed histology, i.e. some small cell and some non-small cell within the same tumor. Cancers are very heterogeneous which is what makes them hard to treat. The good news is that from a treatment standpoint, the chemotherapy and radiation you received for small cell is also very good treatment for non-small cell so I wouldn't feel that your initial treatment was compromised by the difference in path opinion.

The question now is should another biopsy be attempted. Did your doctor explain why he wants to do this? Is it to see if there is any viable cancer or to try again to clarify the pathologic type? If it is to see if any viable cancer remains, I guess I wouldn't think that is worth doing. The problem if you get a negative biopsy is that it will be very unreliable after treatment. You almost certainly have extensive areas of dead tissue within the tumor and if you get back scar tissue, there is no way to confidently say you didn't just miss the viable stuff. If the biopsy is to try to classify your tumor then again I doubt you will get a better sample after the tumor has been radiated. So I guess in my opinion (which should be taken with a million grains of salt since I don't really know the details of your case) I don't think the risks of a post treatment biopsy are worth the limited benefits.

The more important question for you is treatment which at this point will largely be determined by the results of your next scans. The one difference that would be made after radiation (I'm not sure when that was) would be whether to give further chemo with something like Taxotere. This has been shown to be beneficial in NSCLC, not in SCLC. I guess I would tend to believe the path report from MD Anderson. At our institution, if the the path is not a slam dunk, we send it to the lung pathologist at Mayo and he is generally the tie-breaker when deciding the diagnosis. I'm assuming the pathologist at MD Anderson who read your path is a lung pathologist so given his expertise, would likely trust his opinion.

Anyways, those are my rambling thoughts on your case. I really hope your next scans look good!

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Forgive me for butting in here, but I am going to do it anyway.

One thing that has bothered Cat (she has written about it before) and others of us is this:

Can the Pet/Cat Fusion Scan tell the difference between necrotic tissue and active cells?

Some of her Doctors have said it is basically necrotic while others speak of it in terms of active cancer--.

How will she or they or anyone know whether to continue treatment now?


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Ah the lovely lovely PET scan......

PET scans are terrific for many things, particularly for staging of cancers at original diagnosis. They also can be usefull to get an idea of how well chemotherapy is working. Interpretting PET scans in large tumors that have been radiated is dicey to say the least. Unfortunately, PET shows not just cancer but also inflammation and there can be considerable inflammation after lung radiation. Often that inflammation kicks in about 3 months after radiation is completed (typical time when radiation pneumonitis starts) so the PET/CT may look worse at that time for reasons unrelated to the cancer. I struggle with this myself and have to rely a lot on the clinical setting and my radiologist. If someone is having a lot of coughing and shortness of breath, esp with wheezing and/or low grade fever, I lean towards pneumonitis and treat with steroids. If patient is having no symptoms and PET is lighting up, then more likely residual cancer.

Another confounder is that if you get the PET say a month after radiation, the full effect of the radiation has not completed (keeps working at least a couple months after completion).

So if things seem unclear when the doctor is explaining things to you, its because it is unclear and in the real world, often not as cut and dry as some of the published studies on PET would suggest.

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