Lung Cancer Recurrence
During a routine x-ray for prostate surgery, my dad was found to have a lung mass in his lung left lower lobe. He had a PET scan that concluded it was cancer. While at his appointment with the surgeon, he discovered a carotid artery was blocked. He said he needed that surgery first. So, they did that, and the following week he had a lobectomy for the tumor. We were told that there was no lymph node involvement, no other metastasis, and that he anticipated a cure for my dad. Two months after his surgery, he was hurting so bad in the left chest, and they said it was from the surgery and sent him to a pain specialist for a shot. The shot did nothing. They did an x-ray and saw nothing. But when the pain did not go away the surgeon did another PET scan and said that he now has a mass somewhere near his back (on his lung I presume) and several little spots on both lungs. My dad just had his second round of taxol/carboplatin, and he is going to have a CT scan after his third cycle. They said they planned on doing radiation on the larger spot after the chemotherapy. I don't even know if they are still doing that or not. I have asked the oncologist what type of cancer he has and he said it is the same as the one before. How do they know that if they have not done any kinds of biopsy on this one? His original pathology report says, "poorly differentiated non-small cell carcinoma with predominantly squamous differentiation and a minimal component of glandular adenocarcinoma differentiation." Does that mean it's mostly squamous cell, or is it adenocarcinoma, or what is it? And would that grow as fast as it did? The cancer came back just 2 months after surgery. Also, I asked what his stage was and his doctor said that they do not really stage recurrences, they are just recurrences. But his surgeon told us that a recurrence is stage IV. We are so confused. If there is still no lymph node involvement, and just nodules in the chest, is it a stage four? Can you please help me? Thank you so much for your time!
Barbara Campling, MD, Medical Oncologist, responds:
You have been overwhelmed with information about your father's cancer, and you and your mother are rightfully having difficulty making sense of it all. His lung cancer was first discovered as an incidental finding on a chest X-ray done prior to prostate surgery. Although most lung cancers cause symptoms by the time of diagnosis, it is not uncommon for them to be discovered incidentally. Your dad then underwent testing to determine the extent of the cancer. The PET scan was very important to determine whether the cancer was localized and potentially operable. The surgeon was wise to examine the carotid arteries prior to surgery. It is common for lung cancer patients to have other serious health problems, such as this. The carotid surgery was done first to reduce the risk of stroke during the lung cancer surgery. From what you say, the surgery went well. There were no lymph nodes involved, and no sign of spread elsewhere, and the surgeon had good reason to be optimistic. Unfortunately, your dad then developed pain, which turned out to be from the spread of the cancer to both lungs. You are wondering how they know for sure that these !0spots!1 in the lungs are from cancer that has spread from his original cancer, when there has not been a biopsy. That is a good point. In a patient who has had surgery for lung cancer who develops new masses in both lungs, recurrence of cancer is the most likely explanation, although one still needs to think of other causes. Often the appearance on X-ray is so typical that a biopsy is unnecessary.
Unfortunately, once lung cancer has spread to both lungs, generally it cannot be cured with any form of therapy. Some patients with lung cancer that has spread (metastasized) can benefit from chemotherapy. This treatment can have significant side effects, but patients often feel better on it, especially if the cancer shrinks. Overall, there is an improvement in survival in patients who get chemotherapy for metastatic lung cancer compared to those who do not, although this does not automatically mean that all patients will benefit.
Here is my explanation of the pathology report: Lung cancers are divided into two major categories, namely !0small cell!1 and !0non-small cell!1. Non-small cell is the most common variety, and is further subdivided into !0squamous,!1 !0adenocarcinoma,!1 and other categories depending on what the malignant cells look like under the microscope. Adenocarcinoma and squamous cell carcinoma are the most common types of non-small cell lung cancer. Your father's cancer had features of both squamous cell and adenocarcinoma, but squamous cell predominated. It is not unusual to have more than one cell type in a single lung cancer specimen. His cancer was classified as !0poorly differentiated.!1 This means that the cells appeared more abnormal than a cancer that is !0moderately differentiated!1 or !0well differentiated.!1 Unfortunately, generally speaking, poorly differentiated cancers behave more aggressively than well differentiated ones.
The stage of the cancer is classified at the time of diagnosis. In your father's case, the stage at diagnosis is the stage at surgery, probably stage I, since no lymph nodes were involved. If his cancer had already spread to both lungs by the time of diagnosis, then the stage would be IV. Your father would be considered to have a history of stage I lung cancer that is now metastatic. Lung cancer can be very unpredictable. In your father's case, the cancer has spread at a very alarming rate. While it is unusual to develop a recurrence so soon after surgery, it can occur, as you have seen. All this must be very distressing for you and your family. You might like to talk to other people who are in similar situations. Try these websites:
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