Uterine Cancer Metastasis in the Lung and Options for Treatment

00:00:00:00 – 00:00:40:22
Unknown
Hi, my name is Kirby Arthur, and I am the patient uterine cancer patient support coordinator for Share Cancer Support. And before our presentation begins, I’d like to tell you a little bit about share. Share is a national nonprofit that supports, educates and empowers anyone who has been diagnosed with women’s cancers and provides outreach to the general public about signs and symptoms because no one should have to face cancer, breast cancer, ovarian cancer, uterine cervical or metastatic breast cancer alone.

00:00:41:00 – 00:00:52:00
Unknown
For more information about upcoming webinars, support groups and our helplines, please visit our website at share Cancer Support dot org.

00:00:52:00 – 00:01:06:21
Unknown
I am pleased to, to present Dr. Allen Lee, who is a board certified radiation oncologist at UCLA. He completed a fellowship in breakthrough therapy at UCLA in 2019.

00:01:06:23 – 00:01:43:16
Unknown
Prior to this, he finished his residency at Albert Einstein College of Medicine in 2018. Dr. Lee earned his medical degree M.D. from SUNY Upstate Medical University in 2013. Dr. Lee has a particular clinical and research interest in thoracic malignancies radiation as well as procedures break and brachytherapy. So, Dr. Lee, we’re interested in hearing about lung. Mr. Chest metastases.

00:01:43:18 – 00:02:07:13
Unknown
Yeah. Thank you for that great introduction. I really appreciate it. And the opportunity to talk with the Chair Cancer Support Group. Today we’ll be talking a little bit about local therapies for lung metastases, like you mentioned. And yeah, I’m Alan William, a radiation oncologist at UCLA. David Geffen School of Medicine. I have some slides I’m going to share.

00:02:07:14 – 00:03:10:21
Unknown
Let’s see if I can get this to add it. You see that perfectly. Okay. Yeah. So lung local therapy for lung metastasis is the focus of our conversation or our talk today. The local different local therapies are generally categorized into surgery, radiation or focal ablation therapies. I’ll talk a little bit about the differences between the three. Surgery is relatively self-explanatory in the sense that it involves resetting or removing part of the lung, which contains the tumor that we’re trying to get rid of.

00:03:10:23 – 00:03:49:08
Unknown
This can be done via a wedge resection, which is a smaller surgery or a segment activity, which is a slightly larger surgery of a segment or low back to me, which is removing an entire low. The most extreme would be a new connectome, which is very uncommonly done for metastatic disease. But could be done in rare circumstances. The advantage of surgery is that you would be able to get pathology which can then be looked at under the microscope and determined what type of molecular subtype it is or any other systemic therapies that might be allowed to target that particular type or molecular profile of cancer.

00:03:49:10 – 00:04:22:22
Unknown
Ablations, which are done via a needle inserted from the outside of the body through the chest wall into the lung, used primarily either heat or cold to destroy the cancer cells that are within the lung. The needle is heated to a temperature or cooled to a temperature that causes necrosis or destruction of the cancer. This can have some side effects which can be bleeding or a pneumothorax, which is air trapped between the lung and the outside of the chest, outside of the lung, which is the chest pleura.

00:04:23:00 – 00:04:58:10
Unknown
This also requires a procedure and usually it is not required overnight. Stay. But there’s a significant amount of air trapped between the lung and the lung and the chest wall. Then there might have to be an overnight stay for observation purposes and I’ll get a little bit into, you know, a bit more about it later. But there’s many different types of types of Ablations the focus of my treatments is radiation therapy and whereby we deliver ionizing radiation from the outside, very similar to getting a C.T. or an X-ray, very similar to getting a C.T. or an X-ray.

00:04:58:12 – 00:05:02:17
Unknown
There’s no pain or burning or anything like that. The radiation delivered

00:05:02:17 – 00:05:22:10
Unknown
the radiation delivered from the outside via high powered X-rays and the beams on the machine convalesce on one point similar to spokes on a tire or spinal is on a stage, and the full dose of radiation goes to the center. And as you get further away from the center, you get less and less radiation.

00:05:22:12 – 00:05:49:14
Unknown
The dose drop off is quite sharp for these treatments. The side effects of treatment you might see about halfway through the treatment course can be fatigue or tiredness. Some people can also have some slight skin irritation in the longer term, meaning three months or more after you finish the treatment. Some patients, a small percentage of patients can get radiation pneumonitis, which is inflammation of the lung for radiation.

00:05:49:16 – 00:06:12:01
Unknown
But this usually looks like as a cough, maybe a more severe version, you can get a cough requiring steroids and then the most severe would be an inflammation. So severe that it causes you to put in the hospital the pneumonia. That is quite rare. Probably the percentage of patients that have any side effects, meaning any lung side effects would be about maybe 10%.

00:06:12:03 – 00:06:41:02
Unknown
And then having severe side effects enough to be on steroids or going into the hospital for this type of treatment. In the treatment of lung cancer, lung metastases would be very small. You know, a couple of percentage points, maybe the acronyms you might see when getting one radiation would usually include IMRT or SVR. I put on the screen there, IMRT is the density modulated radiation therapy and SBIR is stereotactic body radiotherapy.

00:06:41:02 – 00:07:00:03
Unknown
But simply put, one just means more than five treatments and one means another one means 1 to 5 treatments of radiation. These are usually delivered daily, although some institutions might deliver them every other day. Most of my patients that get radiation say they didn’t even know they were getting the radiation except for the fact the machine was around them.

00:07:00:05 – 00:07:31:19
Unknown
And I don’t really get too many complaints about it, but other other procedures can also have similar efficacy, but usually carry with them more or different side effects entirely. I thought I would maybe pause here for a second. Maybe if we can answer some quick questions from the audience. Thank you. So what are the guidelines on whether or not you do a biopsy?

00:07:31:19 – 00:08:16:02
Unknown
And how do you know if you don’t biopsy? Why do you know what you’ve got if you don’t biopsy? Yeah. So usually on a scan, patients will look relatively able to relatively similar. I mean, the phrase is usually on a scan. It’s usually pretty obvious if it’s a metastatic lesion versus a primary lung cancer lesion. Oftentimes when patients already have a primary cancer that is metastatic, it’s presumed that the lung, which is a metastatic region, sometimes we’ll get a biopsy in order to evaluate for possible targeted therapies or to confirm the fact that it is a metastases.

00:08:16:04 – 00:08:53:02
Unknown
The confirmation of metastatic type disease sometimes isn’t necessary if there’s been confirmation in other sites. So I really it depends heavily on the situation. If a for super convinced that it’s a metastatic site and it was no reason to get pathology, oftentimes we’ll just proceed with treatment if we do any pathology. And there’s lots of there’s lots of areas that are involved in one lobe potentially you’ll go back to me or surgery to remove that lobe might allow for an analysis of that pathology without a biopsy, because that would function of the biopsy.

00:08:53:04 – 00:09:19:20
Unknown
When doing thermo ablations, they can also do a biopsy. Prior to that, they’re more ablation. However, it requires a different needle entirely. To do so, they have to follow the other needle down using a larger needle used for ablations. Whereas the biopsy needles were smaller. Thank you. And what are the guidelines or how do you decide which treatment is best?

00:09:19:22 – 00:09:44:23
Unknown
Yeah. So there’s a lot that go into that. You know, it’s a lot like asking a watchmaker how a watch is made. But for the most part, if you have one lesion that is barely away from the important structures, that radiation has the highest local control of all the of all the treatments, maybe surgery is higher, but between ablation and radiation, radiation have a much higher local control.

00:09:45:00 – 00:10:08:07
Unknown
We’re able to sculpt our beam much more exactly around important organs or structures that we’re trying to avoid. If we need pathology and there’s a large tumor and it’s involved in just one lobe, potentially surgery would be an option for candidates that are very good surgical candidates or otherwise don’t have issues with getting surgery. And then we would do ablation sometimes.

00:10:08:07 – 00:10:33:19
Unknown
And then, let’s say there’s seven or eight or nine lesions that if I were to do radiation on a large portion of the normal lung would get a lot of radiation, in which case we would use ablations in order to pick up the lesions one by one, and also allowing for active surveillance afterwards because radiation causes a scar to be formed, which makes it difficult to see surrounding normal life in regards to continued surveillance over time.

00:10:33:21 – 00:10:56:11
Unknown
Well, thank you. How long I guess you said how many treatments, but like, how long are all these these radiation treatments? How how long can a patient expect to. Yeah. So usually we would do a CT scan, radiation treatment planning, and then about a week later, we would start the radiation. The radiation treatments are about 15, 30 minutes long.

00:10:56:11 – 00:11:21:19
Unknown
The beam is only on for maybe 5 to 10 minutes at most. A lot of the time is spent just lining the patients up every day perfectly and making sure that the target is right on. And we would do that by doing a cone beam or a miniature CT scan, which is not a very high resolution scan, but it’s used to line up the patients every day internally that would we know we’re getting the right target, not missing or hitting many other important organs.

00:11:21:20 – 00:11:42:18
Unknown
And usually we do the treatments. We used to do it every other day and now we do it every day or every other day. I allow my patients to come whenever they think is easy for them. I patients come from quite far and they want to do all their treatments, condense as fast as possible. Some patients are comfortable quite far and they want to make a three hour drive away every other day and that’s fine with me.

00:11:42:18 – 00:12:11:06
Unknown
Also, there’s no difference in efficacy or toxicity we find between daily versus every other day or every third day treatments. that’s good to know. And well, you already explained our side effects, but how long do people can it be till people go back to their normal activities? Yeah, it’s a good question. I mean, for the most part, a lot of my patients don’t get any fatigue, so I would say maybe one in every three patients gets fatigue.

00:12:11:08 – 00:12:32:21
Unknown
Maybe of those one in every three and a smaller percentage get very severe fatigue. But at fatigue, even at the most severe is usually gone by a month. So a lot of my patients don’t even notice they’re getting radiation. So they return to activities the next day. Some of them get some fatigue and they’re a little bit under the weather for a while and they get back to their activities by about three or four weeks.

00:12:32:23 – 00:13:08:03
Unknown
But most people are able to function on a daily basis for their normal activities the next day. The issue. Thank you. And so we hear about something called proton radiation therapy. Is that an option? What are pros and cons or. Yeah, so proton therapy is akin to having a sharper scalpel or a surgeon. The advantage of that is that potentially you’d be able to spare more normal tissues with a sharper scalpel.

00:13:08:05 – 00:13:43:18
Unknown
But on the flip side, more importantly potentially would be the person that’s holding the scalpel or the operating room that the procedure is being done in, which would include on board imaging on a machine, and then also the physicians that are delivering the radiation and maybe even more importantly is that there’s been lots of data suggest lots of people, physicians that think that protons is better in so many, many millions and millions of dollars have been spent comparing radiation, protons versus protons, and only in very few circumstances is protons better and lung is not one of them.

00:13:43:23 – 00:14:11:22
Unknown
And neither is breast or prostate. okay. Thank you. I think I think I’m okay with the questions right now. You want to go on? Yeah. So I don’t have too much else to to talk about. But essentially there’s very good options for treatment of metastatic disease. A lot of the time patients don’t want a huge surgery because it puts them out for a while.

00:14:11:22 – 00:14:42:11
Unknown
And usually after a surgery you can’t get chemo or systemic therapy for a while while your recovery whereas radiation me would just pause or cause the chemo or radiation or something that cause the chemo or stomach therapy. And I would actually do the radiation in between cycles. There’s really no delay at all anyway, a lot of the time Ablations are also quite that to my patients that have a more than a few metastases, I will send them to my interventional radiologists, which is a separate department for my department that would use the term ablations.

00:14:42:13 – 00:15:08:12
Unknown
I work with them very closely in order to treat these patients. The last thing that I don’t want to mention is we also have a very novel technique here at UCLA called HDR Brachytherapy for the lung. This is delivered very similar to an ablation where a needle is inserted from the outside into the tumor and we actually load that needle with the radioactive isotope and thereby treating radiation with radiation from the inside out.

00:15:08:14 – 00:15:31:16
Unknown
This treatment modality is not necessarily done in many places and so we do use it on occasion for patients that have previously had radiation before and cannot get another course of radiation from the outside and cannot get surgery and cannot get an ablation for whatever reason that we have an option here at UCLA for patients that don’t have any other good options.

00:15:31:18 – 00:15:57:21
Unknown
And I’ve used that probably like my in my group, we use it probably three times a month amongst the three of us that actually are trained to do that. So I think that for patients that are having lung metastases that would like their questions answered, I think having them come to see a physician at UCLA is, you know, more than a good idea.

00:15:57:23 – 00:16:20:15
Unknown
We work very closely with the medical oncologist that referrals patients as well as the gynecologic oncologists. And so it’s a very collaborative effort here at UCLA to determine the best plan going forward for our patients. And so, you know, always happy to help or have discussions with patients and providers as needed. Thank you. And we have one more question.

00:16:20:16 – 00:16:51:16
Unknown
Sure. Absolutely. Most of us are always concerned about this, about recurrence. So how do you monitor patients for most, you know, what’s the best way? Yeah. So typically your primary oncologist or medical oncologist or gynecologic oncologist will be doing imaging for metastatic disease every 6 to 12 weeks around. For radiation standpoint, the radiation control rate to metastases is over 90%.

00:16:51:16 – 00:17:19:05
Unknown
So we assume that it works. Until it doesn’t, we do a scan every 3 to 6 months afterwards really to surveil for other lesions that might pop up or to look at how the area forms the scar. Over time, we assume that that scars cancer free. And really the scar test helps us determine whether or not a patient is going to is going to be getting radiation pneumonitis or some organ nearby that maybe is getting some scar tissue formation around or in it.

00:17:19:07 – 00:17:50:11
Unknown
We want to talk to people about and then also it allows us to see if other lesions have popped up nearby. So really, it’s not to look at this primary area at all. And so typically we defer systemic imaging or imaging of the body to the person that’s prescribing a systemic therapy such as chemo, immunotherapy or of. So these these scans are they mostly PE, PET CT scans and MRI’s.

00:17:50:11 – 00:18:19:12
Unknown
What what is it, a variety of scans that you use? Typically, we would just do a CT scan for the most part, a PET scan, although it provides us more information, sometimes the information is not necessarily very useful it PET scan to pick up infection as well as inflammation in addition to cancer. Anything that’s proliferating very rapidly or having uptake of the sugar can make the PET scan.

00:18:19:12 – 00:18:48:21
Unknown
But right. And so even radiation goes. Radiation tumor can be bright because of inflammation that’s happening. And so then it doesn’t really provide us additional information. The PET scans are overall good for looking at systemic therapy because hopefully if you’re getting appropriate STEMI therapy, the general rightness of the pet scan should go down slightly in terms of all the tumors that you have, but for radiation that the tumors can actually be brighter in the first one, two or three months after you’ve been.

00:18:48:21 – 00:19:13:15
Unknown
It’s a pretty Asian and even radiation necrosis or radiation fibrosis or radiation pneumonitis, which is inflammation from radiation, can look right on the PET scan. So, you know, we don’t hang our hat on that scan too, too much. Again, we know from historical series that if you control Ray 95% then doing these scans, we have to always sort of air on the side of thinking that it’s working rather than not working.

00:19:13:17 – 00:19:41:03
Unknown
Otherwise you’re subjecting patients to a lot of negative biopsies. Right? Wow. Well, that was really great information, Dr. Lee. And you answered I know you answered most of our questions, questions as far as I can tell. So I thank you very, very much for presenting today. And it’s my pleasure. Okay. I’m going to stop recording.