How do you define partial remission?

Hi,

My wife has been through chemotherapy for the last 6 months using taxol and gemzar.  What does stable really mean?  Her last CT scan has stable written six times.

Hepatomegaly, disseminated large and small lesions have not significantly changed or improved on current nonenhanced scans.  

Abnormal adenopathy  (is this just swollen lymph nodes?)   is now seen around the celizc axis, superior mesenteric artery, and superior retroperitoneal levels.  The opacified small bowel loops are not dilated.  Nonenhanced kidneys do not show interval obstruction or neprocalcinosis.

Thank you!

Jim

They couldn't find a good vein so she did not receive the dye for the CT scan.

[Fernando Roque, MD]

Hi.  "Stable disease" means that after several cycles of chemotherapy, the observable tumors on CT have neither shrunk further nor progressively increased in size.  However, to be able to classify the disease as truly "stable", no new or additional tumors should be observed.  If several enlarged lymph nodes are noted on the most recent CT scan, which were not there or were not enlarged in the previous scans, these may represent cancer spread to these nodes and signify disease progression, not stable disease.  My suggestion is to do a PET scan of those nodes.  If the nodes "light up" on PET, they most probably contain tumor metastases.

[Kemal]

Dr. Roque,

Thank you for the information.  My wife's liver blood indicators have been a concern to our Oncologist.  After the initial CT scan at the end of March her liver expanded.  The chemotheropy has been effective and reducing the liver to normal size.  

I don't understand how the liver expands if this does not represent the size of tumor reduction.  I believe if my wife had a CT scan at the end of April or May the comparison would show observable tumor have shrunk.  So it represents a positive note through that observation.  

I will request a PET scan for those nodes.  What other cause would account for th eenlarged lymph nodes?  These lymph nodes are underneath the liver as I see the illistration.  Can this account for inconsistant blood work?  What other indicators can I look at in the blood work which can be discussed with our Oncologist?

Thank you again.

Kemal

[Kemal]

Dr. Roque,

Thank you for the information.  My wife's liver blood indicators have been a concern to our Oncologist.  After the initial CT scan at the end of March her liver expanded.  The chemotheropy has been effective and reducing the liver to normal size.  

I don't understand how the liver expands if this does not represent the size of tumor reduction.  I believe if my wife had a CT scan at the end of April or May the comparison would show observable tumor have shrunk.  So it represents a positive note through that observation.  

I will request a PET scan for those nodes.  What other cause would account for th eenlarged lymph nodes?  These lymph nodes are underneath the liver as I see the illistration.  Can this account for inconsistant blood work?  What other indicators can I look at in the blood work which can be discussed with our Oncologist?

Thank you again.

Kemal

[Fernando Roque, MD]

Hi.  Those enlarged nodes may be due to infection like tuberculosis, but looking at the whole clinical picture, I think this is a remote possibility in your wife's case.  The foremost consideration for those enlarged nodes is still cancer metastases, and this possibility has to be ruled out.  As for other blood parameters, i suppose you can try looking at the liver enzymes and liver function tests.  Abnormalities in the values of these tests may mean increased destruction of the liver resulting either from a further progression of the liver metastases, or toxic effects from the chemotherapy.

[Kemal]

Dr. Roque,

I agree these nodes are most likely cancer metastases.  They were not able to find a good vein for the CT scan so it is without contrast.  I don't think this makes much difference but my wife had to drink the chalky bareum which she hated.  If we know a Pet Scan would be positive do we need to begin a new Chemo. drug or continue the taxol / gemzar?

If other sections of my Wife's body are stable except the enlarged nodes is it advisable to begin hormone theropy for now.  She has had six Zometa treatments.  The damage to her bones have not resulted in too much damage.  Six taxol/gemzar treatments and six gemzar treatments.

We have an appointment in three days with our oncologist.  The original CT scan did not show the enlarged nodes in March but her cancer was much more advance in May.  The chemo has been effective.  If the nodes are enlarged does that me we need to be aggressive to decrease the size now?

She has not had her reconstuctive surgery yet.  She is G cup on one side and now a C cup with an expander on the other side.  She does need a sense of a normal life as she battles this cancer.

Thank you for your advise.

Kemal

[Fernando Roque, MD]

Hi.  If the PET results indicate that those nodes have cancer metastases, your wife has the option of either switching chemotherapy to another regimen, or to start hormonal therapy.  Continuing with Taxol/ Gemzar at this point would not be advisable, since the presence of nodal metastases means that the disease has progressed in spite of the present chemotherapy regimen.  Hormonal treatment cannot be given at the same time as the chemotherapy because it decreases the effectiveness of the chemotherapy drugs.  Hormonal treatment may be started after all the cycles of chemotherapy have been given.  The alternative would be to stop giving chemotherapy and give the hormonal treatment up front.  This would be a better choice if your wife's body has been weakened and she cannot tolerate additional cycles of chemotherapy.  

I should point out that if the goal of treatment is rapid control of cancer progression, then this is better done with chemotherapy, not hormonal therapy.  It takes a while for hormonal treatment to show results.  If your wife's cancer is aggressive and spreading fast, then chemotherapy may need to be done first.

[Kemal]

Dr. Roque,

Thank you for your information.  I don't mean to keep asking the same question and I do want balanced information from a third party and that is way I will ask this question.

How do we know the Taxol/Gemzar was not effective?

My wife took Xedora for a month after her first CT scan at the end of March.  Her surgery to remove the tumor was on March 14th.  She began her Taxol / Gemzar in May.  The liver was very large and after three treatments of chemotherapy the cancer was responsive.

My wife did not have a CT scan until last week.  Can it be the case that the nodes were present and larger in May, June, and July and the Taxol / Gemar was effective to a certain degree?  Her last treatment was three weeks ago.

She not too weak to continue treatment as far as I can see.  She is limited to her mobility due to fatique and this is very hard on her mentally.  

It's interesting you said the Hormone Therapy should not be given with the Chemo.  Our second opioin recommended we provide my wife with Hormone Therapy ASAP with the Chemo.  We listened to our original Oncologist.

Thank you for being patient with my questions.

Kemal

[Fernando Roque, MD]

Hi.  I don't know where the doctor who provided you with a second opinion obtained his information regarding hormonal therapy being given concurrently with chemotherapy.  The decrease in efficacy of chemotherapy when given together with hormonal treatment is well documented in several landmark studies.  The standard of care is to give these two treatments sequentially, with chemotherapy being given initially.

As for your other question regarding the effectiveness of Taxol/Gemzar:  we cannot say for sure whether those nodes seen in the latest CT scan were already present AND larger during the months of May through July.  But if those nodes were truly responsive to treatment, I would like to think that after three cycles of Taxol/Gemzar, they should have been decreased in number and not be AS EXTENSIVE as reported in the latest scan.  With abnormal nodes in "the celiac axis, superior mesenteric artery, and superior retroperitoneal levels", we're talking of a lot of nodes here!

It is not uncommon to see the primary lesions shrink to a large degree after chemotherapy and note the appearance of additional/ new metastatic sites.  Even if the original lesions responded well to the chemotherapy, having new metastatic lesions means that the disease is progressing, not responding to the treatment.

[Kemal]

Doctor Roque,

Thank you.

Kemal