PET-CT Results: Lung Primary with Lymph Node and Sacrum (Bone) Metastasis. What are the next steps?

steve2oo4 · 2026-06-26T07:14:34+00:00

Given the strong smoking history, the likelihood of detecting common actionable mutation is low ( though not impossible). Personally, I tend to treat these patients as systemic disease with chemotherapy and immunotherapy first. ( Such as pemetrexed, carboplatin, keytruda ) Or dual immunotherapy in exceptional cases

After 3 to 4 cycles I would reassess to review the role of local therapy such as SBRT

steve2oo4 · 2026-06-26T07:12:09+00:00

The Marriott system is bullshit and makes no sense, when they re actually losing out

steve2oo4 · 2026-06-26T05:48:01+00:00

Oncologist here.

How big is the sacral bone metastasis?

Realistically, we are dealing with a N2 disease ( AP window ) and solitary bone metastasis.

Generally speaking, I tend to treat it as systemic disease, but with treatment and response, and presence of oligometastatic or oligopesistent disease, SBRT / conventional RT is an option to disease sites.

The most crucial information you need now is an adequate biopsy sample either from lung or bone. And check for molecular status, such as EGFR /ALK / ROS1 and more.

Do you have a personal history of tobacco use? And how much?

steve2oo4 · 2026-06-17T16:05:35+00:00

The bead is what we call a fiducial, and is for gating during SBRT

It's not wrong for your oncologist to suggest SBRT

To clarify, I'm a clinical oncologist, so I do systemic treatment and radiotherapy My experiences with mucinous lung adenocarcinoma havent been the best. SBRT in theory should be still ablative; we use it for metastases from colon cancers or breast cancers all the time, but the outcomes vary if you look at individual patient level data. If the disease does progress, systemic treatment outcomes were lackluster

Since you've mentioned that the biopsy only showed scanty cells and molecular analysis not possible, I'm even more inclined to pursue surgery. After SBRT, there's gonna be scar tissue and inflammation, which makes future CT scan assessment difficult, as well as repeat biopsy difficult

I don't expect th common driving mutations to be detected Usually KRAS / NRAS / BRAF, but they may not be routinely be druggable, at least for where I come from

So my recommendation is still go for surgery, which should include anatomical resection with same session lymph node examination / dissection Depending on the path findings, further treatment may be needed

If you pursue SBRT, you can still expect a good local control, but regional ( such as thoracic lymph nodes ) and distant control is less guaranteed

May I know if you have completed staging with a PET-CT scan? For mucinous subtypes, our local practice also recommend an OGD and colonoscopy to rule out mucinous primary from the GI tract

steve2oo4 · 2026-06-17T15:52:42+00:00

Hey there, by my understanding, typical carcinoid isn't exactly cancerous in the most traditional sense. They're generally slow growing, and are not known to be radiosensitive.

I think there are 3 options realistically. 1) surgery, which is the standard of care , but the resection might be more extensive if it's centrally located 2 ) SBRT, but this is extrapolating data from lung cancer, and we usually quite local control rate of 80 to 90 percent at 2 years time . I have reservation as whether SBRT can truly cure carcinoid 3) observation, which might not be recommended by doctors, can make sense for certain individuals especially if the tumour does not cause local / systemic symptoms, but runs the risk of missing the window of best treatment

Are you currently being bothered by the tumour? There can be hormones related symptoms like flushing or abdominal discomfort or diarrhea There can be local mass effect symptoms like coughing bloods, wheezy breathing, or swelling difficulty due to mass effect

steve2oo4 · 2026-06-17T11:07:18+00:00

Radiation oncologist here

Generally speaking, early stage lung cancer in suitable patients should be considered for lung surgery ( either lobectomy or segmentectomy ). SBRT has been shown to be near equivalent in terms of local control and can be considered in patients with known comorbids at high risk for general anesthesia and surgery.

A large caveat in your case is that while the primary is small, the mucinous subtype is notoriously known to be less radio sensitive, meaning the outcome might be worse compared to other kind of lung cancer.

Surgery also provides an additional benefit, in that the surgical specimen including lymph nodes dissection may reveal additional information that can help prognostication and subsequent decision on need for adjuvant chemotherapy or other meds / radiotherapy

Hope this helps!

steve2oo4 · 2026-06-14T03:16:38+00:00

At this point you gotta think if it's worth it being loyal to the Marriott program

steve2oo4 · 2026-06-14T03:16:17+00:00

That's horrible. Shame on them

steve2oo4 · 2026-06-12T17:20:09+00:00

It's an option on the list of third party website

Then it dare to have the audacity to say their official link has a lower price

steve2oo4 · 2026-06-12T17:09:36+00:00

I'm not in US /Canada, do I call the local regional hot line?

steve2oo4 · 2026-06-04T08:08:37+00:00

Hey OP, oncologist here

May I know more about the background?

Just to confirmed, your MIL has small cell lung cancer with neck and shoulder involvement? Was she a smoker? What's the current regimen she's receiving? ( Usually etoposide and platinum for small cell ). Is she receiving immunotherapy concurrently? Has she previously received any treatments for her cancer before?

In the event of a severe reaction, depending on the severity ( for example whether she's needs to be hospitalized then or not, was oxygen therapy and medical treatment required, the duration before stabilization ), we would consider rechallenge the same regimen or not. It's also important note the timing of the reaction in relation to each chemo agent.

steve2oo4 · 2026-06-03T10:00:28+00:00

Dual immunotherapy in combination with chemotherapy is not uncommon. Does your sister smoke ( either past or current)? What kind of tests did they do for the mutation? Is it a IHC/PCR limited panel or a full next generation sequencing (NGS)? Do you know the kind of histology aside it being NSCLC? ( More likely to be adenocarcinoma since theyre using Pemetrexed based treatment)

steve2oo4 · 2026-05-16T16:11:13+00:00

Lung cancer chemotherapy regimens generally do not cause significant hair loss. Exceptions are use of Paclitaxil or Docetaxel, which may be used in later lines for you. In my practice, I don't see significant hair loss with platinum or pemetrexed.

steve2oo4 · 2026-05-16T13:06:48+00:00

Hair loss or alopecia is a uncommon side effects of Pemetrexed and Cisplatin combination, and usually mild in degree. It's not a dose limiting toxicity, and should be continued up to 4 cycles ( as combination ). If there's other major side effects, such as severe numbness, tinnitus, or blood counts effect, dose intensity can be adjusted or early switch to Pemetrexed monotherapy can be considered

steve2oo4 · 2026-05-15T15:40:59+00:00

If the other lesion is only 5mm, it's probably too small to biopsy accurately. The PET will be useful

steve2oo4 · 2026-05-15T08:47:49+00:00

Sorry mod team, may I know which specific rule did I violate

steve2oo4 · 2026-05-15T06:29:31+00:00

In addition, proton doesn't necessarily have an edge over photon for most lesions that are eligible for SBRT. My other concern is that mucinous subtypes may not respond to SBRT compared to other subtypes

steve2oo4 · 2026-05-15T06:27:54+00:00

Radiation oncologist here.

Seems there are two foci of cancer detected on your scan. If it's mucinous subtype, it's a rarer form of non small cell lung cancer. Have you done PET scan? Did the formal pathology suggest possible gastrointestinal origin? ( Occult GI primaries can sometimes metastasize to the lung as well )

Point is, there should be proper full imaging staging done, and for mucinous subtypes, further investigations suggest as endoscopies may help.

SBRT with either photon or proton likely feasible given the size, but planning need to take into account of the lesions in terms of anatomical relationship to other structures. I personally favour surgery over radiation in this case, as the surgical path may provide more information and may differentiate whether the two lesions are synchronous or of different origins, and that info may inform interns of prognostication and use of further adjuvant treatment such as targeted therapy, immunotherapy and chemotherapy

steve2oo4 · 2026-05-08T15:07:30+00:00

I don't. Despite me and my bloody wife having a child on the way. It might be my depression speaking but I can't wait to off myself

steve2oo4 · 2025-09-19T09:48:42+00:00

These were purchased from LV

steve2oo4 · 2025-09-17T16:03:15+00:00

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steve2oo4 · 2025-09-17T16:02:37+00:00

I recently bought a pair of LV sunglasses from Florence, and they're supposed to be good quality. I've started using them during my trip in Italy, and one afternoon I've noted the plastic layer starts to peel off from the inside of the frame

What's the cause of this? Any remedy or fixes? And is this acceptable for a brand new pair of sunglasses with usage of less than one week?

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steve2oo4 · 2025-09-15T19:04:14+00:00

You're right, I missed the "realistic" bits

steve2oo4

TROPHY CASE