The patient, J.G.G., is a 61 year old male living in Buenos Aires, Argentina, who began to have discomfort in his left shoulder, dysphonia and asthenia some 3 months ago. After being assessed by his G.P., his physical examination showed a right supraclavicular lymph node enlargement as well as two left laterocervical lymph node enlargements each of approximately 2 cm. For this reason a chest x-ray was carried out which showed a mass of 3 cm x 4 cm in the upper left lobe together with a thickening of the mediastine. With the diagnosis of probable lung carcinoma, he was assessed by the area pneumologist, who indicated that a thoracic and abdominal CT be carried out in which a mass with a maximum diameter of 3.4 x 4.1 cm was found in the upper lobe of the left lung, with multiple left bilateral mediastinal and hilar lymph node enlargements and at least 5 hepatic images compatible with metastases. A bone scintigraphy was also carried out, which showed no evidence of tumour disease. On 2nd June 2005 a fine-needle aspiration biopsy was carried out on the tumour mass. The histopathological diagnosis was compatible with a moderately differentiated lung adenocarcinoma. The blood test carried out showed an abnormally high LDH level.

With the diagnosis of pulmonary adenocarcinoma IV, it has been recommended that he begin chemotherapy treatment with cisplatin and gemcitabine.

Tonsillectomy and adenoidectomy at the age of 12. Deep venous thrombosis diagnosed 4 years ago and treated for 5 months with subcutaneous heparin.

Arterial hypertension controlled with ACE inhibitors, slight hypercholesterolaemia controlled by diet, no hyperuricaemia nor diabetes mellitus.

He does not report any toxic habits. He is married and has two children. Lawyer.

Analysis (21/05/05): haemoglobin: 15 g/dl. Haematocrit: 42,1. Platelets: 523.000. Leukocytes: 8,550 (neutrophils 71%). Glycaemia: 112 mg/dl. Urea: 0,35. Creatinine: 1.01 mg/dl. Total bilirubin: 0.93 mg/dl. Sodium: 134 mmol/L. Potassium: 4.2 mmol/L. GOT: 22 UI/L. GPT: 21 UI/L. Alkaline phosphatase: 98 UI/L. Gamma glutamyl transferase: 23 UI/L. LDH: 875 UI/L. CEA: 3.1 ng/ml.

Thoracic-abdominal CT (11/06/05): Mass of 3.4 x 4.1 cm maximum diameter in the upper lobe of the left lung. Bilateral mediastinal lymph nodes, the larger sized one at the right retrocaval paratracheal level measuring approximately 26 mm; left hilar lymph nodes of up to 18 mm. The rest of the thoracic examination was without significant findings. In the abdomen at least 5 hepatic lesions are observed, ranging between 12 and 21 mm in size, of a metastatic aspect. In the rest of the abdomen no images are observed which suggest the spreading of the base disease.

Bone scintigraphy (12/06/05): No pathological accumulations are observed in the osseous skeleton.

Based on the documents and tests supplied, this is a 61 year old male patient with pulmonary metastatic adenocarcinoma, stage IV, by hepatic and laterocervical affectation.

Based on the documents supplied, this is a 61 year old male patient, without significant comorbidity, recently diagnosed with a metastatic lung adenocarcinoma. In this situation, any therapeutic approach that is carried out has to be considered with a palliative intention, that is to say, looking for the best quality of life for the patient, derived from the improvement or delay in the appearance of symptoms of the disease, and a prolongation of the survival time, as curing the disease would be really exceptional.

The initial approach to treatment must be based on the administration of chemotherapy. Surgery is not a treatment option at this time, nor is radiotherapy, although the latter could be an option in the case of the appearance of any complication or problem in the patient at any specific point affected by the disease, such as pain, bronchial obstruction or haemoptysis, despite treatment with chemotherapy.

Although at this time no mandatory or obligatory treatment exists in this context, chemotherapy based on the administration of medication such as cisplatin or carboplatin in combination with some other medicine that is active against this type of cancer constitutes the best initial therapeutic treatment. This is, in fact, what has been recommended to this patient. The administration of this chemotherapy is beneficial in approximately two out of every five patients treated, fundamentally in the form of improvement of the symptoms of the disease, or a delay in the appearance of these and the consequential deterioration, as well as prolonging the life expectancy of the patient who responds to this treatment. The chemotherapy models which have offered the most hopeful results are those which combine some of the following drugs with platinum: gemcitabine, paclitaxel, docetaxel or vinorelbine. However, none of them have proved to be clearly superior to the others¹, thus all of them would initially be equally valid.

The side effects that the said treatments may produce (hair loss, decrease in defences, infections, weakness and nausea, among others) are usually slight or moderate in intensity, and nowadays are prevented or improved very efficiently with supportive medications (except hair loss.) The duration of the treatments will depend on how well the patient tolerates them, as well as the anti tumoural efficiency of the treatment administered, which is why radiological tests of the evaluation and control of the state of the disease should be repeated every 2 or 3 cycles. Therefore, the number of treatments is not determined, although the average is usually about 4 to 6 months of initial chemotherapy and, if this has been efficient, there is a tendency nowadays to use a more bearable treatment of maintenance of the tumoural reaction, thus avoiding the physical exhaustion that on-going administration of aggressive chemotherapy models could mean for the patient.

There are other more aggressive, but less widely tested, alternative treatments, like, for example, the administration of combinations of three active drugs for this disease, instead of two. The objective of this approach would be to try to improve the results of more conventional treatments, possibly at the cost of a greater toxicity, although there is not sufficient data to date to recommend these treatments obligatorily. Because of this, the administration of 2 or 3 drugs simultaneously should be individually evaluated, according to the general condition of the patient, his organic functions, the extent of the disease, etc., and this alternative should be discussed in detail with his oncologist.

The simultaneous administration of three chemotherapy medicines is under discussion as the said combination can usually only be given at the expense of assuming a greater risk of toxicity or side effects of the treatment and also usually requires a decrease in the dose of the different medications to enable them to be administered. Nevertheless, and even though there is data of well designed comparative research which does not seem to find any benefits in the use of some of these more aggressive combinations, some recent clinical research exists which appears to demonstrate a benefit in terms of the life expectancy of patients treated with this triple chemotherapy combining paclitaxel, carboplatine and gemcitabine². The positive effect of adding the administration of the monoclonal antibody bevacizumab (Avastin®) to the standard chemotherapy has also been demonstrated in some types of lung cancer. This drug is aimed selectively and specifically at blocking a molecule which activates the formation of tumoural blood vessels (in such a way that, by its action, it would cut the supply of nutrients and oxygen to the tumour). In particular, it has been observed that the combination of the said "intelligent" medicine with the chemotherapy medicines paclitaxel and carboplatin in patients with metastatic lung cancer has been associated with a greater prolongation of survival time³, at the expense of new side effects, some of which may be serious, such as bleeding or arterial hypertension.

If there are no beneficial effects with this first chemotherapy model, or, if the disease responds but then returns, there are other alternative treatments with proven activity, among which are included drugs such as erlotinib (especially in non-smoking female patients, and whose type of lung tumour is of the type known as adenocarcinoma, as it is known that this group of patients have a greater possibility that their tumours have a mutation which makes them especially sensitive to the effects of this medication, which is administered in very well tolerated tablet form), docetaxel (if it has not previously been used) pemetrexed or drugs undergoing well designed clinical research. In all of these cases, these would be second-line treatments in patients whose disease is more resistant to chemotherapy and difficult to treat because of having progressed despite the previous treatment. In addition, the results are generally less positive, as they benefit a lower percentage of patients who would basically enjoy an improvement to their day-to-day quality of life.

Thank you for the trust you have placed in our consultation. We are at your disposal for anything that you may need.

year 2006

Note: This Second Opinion consultation is based on the medical information and documents received, not on personal assessment of the patient by the doctor. Therefore, our Second Opinion service cannot, not does it try to, be a substitute for the medical act of assessment of the patient by his/her oncologist. It is, rather, an addition to said medical act and aims to help the patient to know more about his/her illness and the different therapeutic approaches and, in this way, assist in decisions related to the cancer.

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