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弟弟IV期低分化肺鳞癌,8个月又13天,11月19日离世。年轻的他,其实从未离去!

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 楼主| 发表于 2012-6-6 01:55:41 | 显示全部楼层 来自: 美国
本帖最后由 行动矮人 于 2012-6-6 02:08 编辑

四个周期化疗后的效果评估

自5月30日起,为评估效果,做了颈胸腹ECT,左股骨磁共振(MRI),脑磁共振和肿瘤标志物检测。检查结果总的来说还是乐观的:

左肺原发肿瘤继续变小(治疗前是4.7*4.5;两个化疗后是2.3*1.7CM),四个周期后已无法测量;
左股骨转移处继续好转。
纵隔2R区的淋巴结为1.3*1.0CM,较两个化疗周期后(0.7CM)增大。治疗前是2CM。
脑磁共振(MRI):有一点怀疑,不够清楚,应大夫的建议,6月7日将再做一个加强的脑MRI。
五项肿瘤标志物较上次变化不大,仍都在正常值内。

                                 CEA          NSE          CA125     CYFRA21-1   SCC
12年6月4日         1.91    9.3            6.39     1.88               0.8
12年5月14日      2.0       8.63         6.05     2.09               0.9
12年4月18日      2.3       7.58         9.29     1.72               0.9
12年3月9日         5.1       12.57       11.6      5.03               6.3

我做了以下估算:

两个化疗后,靶病灶最大径之和=2.3+0.5=2.8
四个化疗后,靶病灶最大径之和=1.3+0.4=1.7

如此,靶病灶最大径之和减少约38%。所以应该是PR(部分缓解)?弟弟的助理大夫说,她从片子上直接测量,达不到PR,是SD(疾病稳定)。只要脑子没事,"疾病稳定"就不错了。我们Crossing Fingers!希望无事。
有爱,就有奇迹!
 楼主| 发表于 2012-6-6 02:36:45 | 显示全部楼层 来自: 美国
问诊几位化放疗专家

很不凑巧的是,弟弟的主治医出国了,要一周后才回来;而主治医的助理(实习)大夫对弟妹说:四个化疗后,没有必要再化疗了,已经耐药了,应该抓紧时间到放疗科会诊,看能否对胸部纵隔2R区那个增大的淋巴结放疗。

基于助理大夫的意见,我们觉得有必要多看几位化放疗专家,给弟弟会诊。先做好准备,这关系到他的后续治疗方案,十分重要。也可避免万一等主治医回来后,也是这个意见,而我们却措手不及,延误了弟弟的治疗。

肿瘤内科: 要看2-3名专家。
放射治疗科: 要看2-3名专家。

因为我们远在万里之遥,只有弟妹在弟弟身边"鞍前马后"地忙碌。惟恐她问不周全,特意把"问诊提要"短信发到她的手机里。

**肿瘤内科问诊提要:

提供材料:最新出院诊断证明书,3次ECT报告和片子;3次左股骨磁共振报告和片子。1次脑磁共振报告和片子。最新血常规,生化和肿瘤标志物报告。

诊断:左肺上叶低分化肺腺鳞癌,纵隔,左肺门多发淋巴结转移,左股骨转移。

曾经的治疗:4个周期的健择+顺铂化疗;每21天,唑来膦酸。左股骨无痛了。广安门扶正中药。胰岛素(糖尿病)。

看诊目的:后续治疗方案?

问题:
1. 4个化疗后的评估是什么?
2. 是否用原方案(GP)继续化疗两个周期?
3. 若不能或不需要原方案继续化疗,是否要接着做维持治疗?
若接着做维持治疗,用哪种方案? 可否用特罗凯维持?患者以鳞癌为主,曾重度吸烟。


**放疗科问诊提要:

提供的材料:

最新出院诊断证明书,3次ECT报告和片子;3次腿磁共振报告和片子。1次脑磁共振报告和片子。最新的血常规,生化,和肿瘤标志物检测报告。

诊断:左肺上叶低分化肺腺鳞癌,纵隔,左肺门多发淋巴结转移,左股骨转移。

曾经的治疗:4个周期的健择(吉西他滨)+顺铂化疗;每21天,唑来膦酸。左股骨无痛了。广安门扶正中药。胰岛素(糖尿病)。

看诊目的:是否有胸部纵隔放疗指征?

如果放疗专家认为应该对胸部纵隔放疗。

我们的问题:
(1)只是精准定位放疗纵隔2R区吗?不是全肺吧?

(2)已有左股骨远行转移,锁骨淋巴转移。只对胸部纵隔放疗,想要杀死2R区的癌细胞,很有意义吗?

(3)了解到胸部放疗的副作用比较大,如放射性肺炎,肺纤维化,甚至间质性肺炎,等等。且常常是不可逆转的。
若是仅仅针对纵隔2R区放疗,也会有上述风险吗?如果有,那么冒这么大风险,只是试图杀死2R区的癌细胞,值得吗?
有爱,就有奇迹!
 楼主| 发表于 2012-6-6 11:00:50 | 显示全部楼层 来自: 美国
      化疗引起的贫血

弟弟因化疗下降了的白细胞,中性粒细胞和血小板,通过食物很快补回到了正常值,但红细胞(2.66)和血红蛋白(86)比较低,贫血。一直服用的"复方阿胶浆"和"生血丸"作用不明显。刚看到"益血生胶囊",想试试看,同时补充铁剂(口服硫酸亚铁或注射右旋糖酐铁)。大家有什么有效方法吗?谢谢!

还有两种方法备用,万不得已时,才会考虑:

(1)应用重组人促红细胞生成素(rHuEPO)--益比奥
据说,见效较慢,一般在用药后平均4周才出现疗效,而且存在着导致高血压、癫痫发作、血栓形成、纯红再障等副作用。是真的吗?

(2)输血
可以快速升高贫血患者的血红蛋白水平,改善患者贫血状态,但是这种方法存在合并感染、免疫抑制、促进肿瘤生长等诸多的缺陷。
有爱,就有奇迹!
发表于 2012-6-6 12:58:34 | 显示全部楼层 来自: 中国广东深圳
行动矮人 发表于 2012-6-2 08:19
请带我去阿尔科,祝福你!或许你想问一下你的主治医,是否"卡铂 + 紫杉醇 + 阿瓦斯丁"更好?

我访 ...

这个6年的案例很鼓励人。

我爸也是左肺上叶鳞癌,纵隔、肺门淋巴转,2型糖尿病,也用GP方案,刚做了第一期。
有爱,就有奇迹!
 楼主| 发表于 2012-6-6 18:21:21 | 显示全部楼层 来自: 美国
穆宁 发表于 2012-6-6 12:58
这个6年的案例很鼓励人。

我爸也是左肺上叶鳞癌,纵隔、肺门淋巴转,2型糖尿病,也用GP方案,刚做了第 ...


穆宁,你爸爸是3A或3B?没有手术指征吗?为你爸爸找一个仁心仁术的主治医很重要。是否胸部放疗,一定要慎之又慎,副作用比较大,如放射性肺炎,肺纤维化,等等。做重要决定前,一定要多问诊几个化放疗专家。祝福你爸爸!
有爱,就有奇迹!
发表于 2012-6-6 20:34:17 | 显示全部楼层 来自: 中国广东深圳
行动矮人 发表于 2012-6-6 18:21
穆宁,你爸爸是3A或3B?没有手术指征吗?为你爸爸找一个仁心仁术的主治医很重要。是否胸部放疗,一定 ...

3A期,是根据增强CT确定的,医院没给做PET。没手术机会,肿块靠近门脉、心脏。

我也不打算放疗了,保证有高的生活质量先。
有爱,就有奇迹!
 楼主| 发表于 2012-6-8 06:46:19 | 显示全部楼层 来自: 美国
本帖最后由 行动矮人 于 2012-11-13 02:37 编辑

Duration of First-Line Chemo in Advanced NSCLC: 4 vs. 6 cycles
Published December 16, 2007 | By Dr West

Although I’ve previously written about the question about optimal duration of therapy for first-line chemotherapy in advanced NSCLC (post here), these conclusions have been based on a limited number of trials. One study randomized patients to three or six cycles of rather old chemo and found no significant differences (abstract here). Another more recent study randomized patients to four cycles of carbo/taxol compared with treatment until progression or prohibitive toxicity, with some patients going for more than 12 cycles, also demonstrating no significant differences in survival (abstract here). Based on the rather modest data, the current guidelines of the American Society for Clinical Oncology (ASCO) are to treat for no more than four cycles in non-responders, and no more than six cycles in patients who demonstrate a response to first-line treatment.

Most US-based oncologists follow a practice of treating up to either four or six cycles, although a reasonable minoriity in the US, and a higher proportion in other parts of the world, still treat beyond six cycles and up to the time of progression. Our current clinical trials, developed to include current best treatment practices, incorporate either four or six cycles of chemotherapy, with no consensus. The ECOG 4599 trial that established the role of avastin with carbo/taxol gave six cycles of chemo and avastin together, followed by maintenance avastin (abstract here). On the other hand, multiple trials that have focused on the maintenance portion or timing of second-line therapy have stopped at four cycles (see prior posts here and here). What’s really the best approach?

A trial by Park and colleagues from Korea that was just reported in the Journal of Clinical Oncology tried to address this question (abstract here). As shown in the schema below, 452 patients with previously untreated advanced NSCLC were treated first with two cycles of cisplatin-based chemo, and then responses were measured. One third who showed progression or toxicity problems came off the trial, leaving 314 who experienced stable disease or a response to be randomized to either four more cycles (total of 6) or two more cycles (total of 4) cycles of the same chemotherapy.

Patients were then followed, received a CT every three months after chemo ended, and in most cases received subsequent chemo (off protocol) at that point.

The results demonstrated that the patients who received a total of six cycles had a significantly longer progression-free survival, but both groups had the same overall survival.

实验结果表明,化疗6个周期的病人无进展生存期显著长于化疗4个周期的病人,但两组病人总的生存期是相同的。

Differences in side effects weren’t very different between the two arms, with a little more toxicity in the patients who received more chemo, as you’d expect. Quality of life was also measured, and while there were no overall clear differences, a few parameters favored the shorter treatment arm, and none favored the longer treatment arm.

The results are noteworthy for a number of reasons. The authors make the point that the survival is quite favorable, and if the numbers you see look especially good, that is largely because the numbers reflect survival of a group of patients who remained after the third who had progressed or otherwise done poorly came off the study — the only ones randomized were those with stable disease or better after two initial chemo cycles. Second, more than half of the patients on the trial received Iressa, and we know that Asian patients are more likely to do particularly well with EGFR inhibitors. At the same time, however, some trials that compare results in Japanese vs. North American trials that used the exact same chemo in the same setting produced more favorable results in the Japanese population. It is possible that patients in Japan do better because something about the supportive care is better, they have more responsive disease, or some combination of factors.

I don’t get a clear answer to the question of whether four cycles or six cycles is a better choice, and frankly I don’t think it matters much. I think that if patients tolerate chemo well and are still demonstrating stable disease, it’s perfectly great to continue to six cycles, but four is going to get people to pretty much the same place. I think the main reason for this is that there’s a dilution of any differences with second line and often third line treatments. An advantage of stopping after four cycles is that it may deliver more patients to later therapies with a good performance status and “bone marrow reserve” — the capacity to have the bone marrow make more blood cells quickly after subsequent chemo. Overall, I wouldn’t have any hesitation about participating in a trial that includes four cycles, nor would going to six cycles be a problem, as long as a patient continues to feel OK on chemo. With several later treatment options available now, and a real possibility (and I’d even say probability) of more new treatments emerging as 2nd, 3rd, or even 4th line options for advanced NSCLC, subtle differences in what happens in first line treatment are increasingly likely to get washed out over time.

简言之,Dr. West 认为,对于晚期非小细胞肺癌患者,一线方案做4个周期还是6个周期,分别不大。若病人能耐受且化疗有效(稳定),尽管做6个周期;否则,只做4个周期也无大碍。随着后续2线,3线,甚至4线的治疗,一线做4个或6个周期的细微差别会被冲淡的。

(Dr. West 毕业于美国普林斯顿大学,后获得"富布赖特奖学金"(Fulbright Scholarship)到英国剑桥大学研修。返美后,进入哈佛医学院,受聘为霍华德·休斯医学研究所研究员。后来,他在华盛顿大学的弗雷德哈钦森癌症研究中心做实习和住院医师。自那时以来,他一直从事胸和泌尿生殖系统肿瘤的临床研究,是国际公认的肿瘤学家。我看过不少他发表的有关非小细胞肺癌的文章,很相信他。)
有爱,就有奇迹!
 楼主| 发表于 2012-6-11 19:14:15 | 显示全部楼层 来自: 美国
密切观察,休息一个月

在弟弟的主治医回国前,我们问诊了一位肿瘤内科的专家,他认为弟弟4个周期的化疗结果很好,建议再做两个周期;建议不考虑胸部纵隔放疗,毕竟放疗是局部的。6月8日,弟弟的主治医回来了,他看了各项检查结果后,做了如下决定:密切观察,同时让弟弟回家休息一个月,调养身体,一个月后再酌情化疗。这个意见主要基于两个因素:弟弟左肺的原发肿瘤和其它转移病灶都几乎看不见了,也没有新病灶,单单纵隔2R区的一个淋巴结增大,不能肯定是肿瘤增大,可能是耐药,也可能是炎症,需要观察;另外,病人贫血比较严重,不适宜马上化疗。

我们有一点担心,总觉得4个周期就停下来,对一个低分化的晚期癌有点单薄,可是也没有更好的办法了。因贫血,弟弟不能接着用原方案化疗;我们提出是否可以用"特罗凯"做维持治疗,主治医说还不到时候。我试探地问弟弟,是否再听听别的专家的意见,他觉得没必要,他很相信他的主治医。

针对这种意外,我这两天使劲看了不少4期NSCLC临床实验报告,我发现,4个周期一线化疗后,如果没有任何后续治疗,最早复发的时间一般在2.5月以后。一个月空窗,应该没事。希望那低分化的晚期癌,能发善心,默默地呆在一个角落,给我可怜的弟弟一段时间休息。

此外,加强的脑MRI结果出来了,没有发现肿瘤。

弟弟今天还看了林洪生大夫,她给开了抗肿瘤的中药和治疗贫血的汤药。弟弟和弟妹回家了。
有爱,就有奇迹!
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