Question

My father (age 56 years & weight 70 Kg) has been diagnosed with Non-Small Cell Lung Cancer, Stage 4 with primary tumour in his Left Upper Lobe and metastasis in Liver and Bone. The biopsy report has confirmed it to be adenocarcinoma.
The cancer was detected while he was admitted at a hospital in Mumbai and was undergoing treatment for Acute Paraplegia which happened on 02 Nov 16, due to arteries-Venous Fistula at D-10 level resulting in oedema/ ischemia of the spine from D-5 to Conus. After two failed attempts of embolization, towards treatment of the AVF, surgical clipping of the fistula was undertaken on 10 Nov 16.
As part of post-operative rehabilitation therapy for his paraplegia, he was given 65 session of Hyper-basic Oxygen Therapy at 2.4 ata pressure for about two and a half month and about two hour of Physiotherapy for the same duration.
My father was recovering well and had started walking with the help of support (walker). MRI of the spine taken in mid Jan & Mid June 2017 indicates that the spinal cord oedema had improved significantly, although atrophy of the spine cord is still present.
He complained of wheezing and breathing difficulty and towards ascertaining the cause a X-ray was taken on 23 Feb 17 which showed massive pleural effusion in his left lungs. A series of tests followed with the ultimate result as NSCLC Stage 3B. It was categorised as Stage 3B as the pleural effusion was para-malignant and no metastases was noted in any other body parts.
He was started with CCRT treatment which concluded on 05 May 17. During the treatment he was given daily dose of radiation therapy to his primary tumour site in his left upper lobe using IGRT (60 Gy/ 30 #/6 weeks) and weekly chemotherapy with paclitaxel (150 mg) & Carboplatin (300 mg) for 6 weeks. Despite the treatment, the cancer is advancing and has now spread to Liver and Bones as brought out in his latest PET CT report.
Lung tissue which was obtained during CT guided biopsy conducted in the month of Mar 17, before the CCRT treatment was started, has tested positive for EGFR mutation – “E746_A750del is detected in EXON 19 of EGFR gene”. His doctor has started my father on Erlotinib 150 mg OD since 26 Jun 17.
My father has developed Post Obstructive Pneumonia in his left lung and there is consolidation in his entire left lung. This is evident from a recent X-ray. He is having difficulty in breathing, takes short & fast breath, sweats a lot, feels cold, has irritation in his throat and gets tired very fast. He also has issue eating solid food and had greatly cut down his diet. He was started on Oral antibiotic for a week, but did not respond to it. He is admitted in the hospital and is being injected with antibiotics through IVs and injections. His condition remains to be same with no much improvement. His SPO2 level is also low at 90-92%.
My father also has severe lower back pain and has also been diagnosed with progressive paraparesis. Because of the back pain he is not able to lie down on his back. A recent screening of the entire spine has confirmed that there is no evident compression of the spinal cord but clearly shows a number of metastasis in the vertebrae (Clivus, Dv2, Lv2, Lv4 & Tail Bone). There are plans to start him on Radiation Therapy for his spine. Is this:-
1.The right therapy for him?
2.What other option do we have for treating his spinal mets?
3.Can Radiation to treat his mets in the vertebra, damage his spine and cause further paraparesis?
4.Could you please suggest anything towards treatment of my father?

Dr.Akhil Jain · Accepted Answer

If there is localized backache than radiation treatment may be the right choice for the time being. Though it won't cure lung cancer. It may help in resolving the local pain. Patient is on erlotinib since 26-6-17. The medicine should have shown some benefit by now. Continue it for another one month. It may be stopped for the time /days spinal radiation is given by your treating doctor. Add bisphosphonates taking care of creatinine and calcium levels. Ask for appropriate amount of analgesics. Given the history of spinal cord atrophy, yes there is risk of further damage to spinal cord by radiation. The dose, fractionation and the areas not to be irradiated will be decided by treating radiation oncologist. For EGFR mutant erlotinib is one of the best drugs. Take care of nutrition. It's important.

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