Life can’t just be fun and games, and on Friday I had a needle core biopsy. Yes, my last CT scan showed some progression. Not a lot—characterized in the radiology report as “slight interval increase” but also not a little—“consolidation at the periphery of the remaining left lung has increased in size compared with 6/17/13, now measuring 4 × 1.9 cm in greatest axial dimension compared with 3 × 1.8 cm on 6/17/13.“
It was a great summer and my break from treatment was absolutely worth it. However, my lungs are getting a little noisy at night again and I’ve noticed more shortness of breath as well as a reduction in my level of energy. So…Dr. Shaw and I concluded that it was the right time to start looking into my next option. That may well be an anti-PD-1 human monoclonal antibody; an experimental treatment which falls under the umbrella of immunotherapy. An explanation of PD-1 quoted from InforMEDical: “The programmed death receptor 1 (PD1) and its ligands make up another physiologic immune checkpoint that is co-opted by some tumors leading to immune tolerance. Programmed death ligand 1 (PDL1) is expressed on several tumors, and can be induced by inflammation in the tumor microenvironment. On binding to PD1 on activated T cells, an inhibitory message is delivered to the T cell, resulting in T cell inactivation. Monoclonal antibodies to PD1 and PDL1 can block PD1 messaging, and allow T cells to proceed with a co-ordinated immune attack.“
Essentially, the hope is to kick-start or wake up a specific pathway of my own immune system. For a very accessible overview of PD-1/PDL-1, check out my friend Janet Daily-Freeman’s post on this subject. Janet is smart, funny, kind and a whiz at explaining and I highly recommend that you take a look at her wonderful blog; Gray Connections.
The experimental therapy which I am hoping to get a shot at is MK-3475 or lambrolizumab; this agent has shown impressive results in patients with advanced melanoma. However, before I can be admitted to the trial, a fresh biopsy was required. If PD-1 protein is isolated in my tumor sample, I’m a potential candidate.
So on Friday I had yet another needle core biopsy. The location of the greatest consolidation of my cancer remains problematic; against the pleura and adjacent to my heart. Last time the radiologist went in right through my left breast (!)—this time, the approach was from the side.
Prep involved fasting and although I was initially scheduled for early in the morning, my procedure was shoved back by several hours. The biopsy itself is a curious thing; you are given ‘twilight’ or light anesthesia so you remain awake but in a rather somnolent state (not prone to arguing). After my body was arranged on the table, I was strapped in and instructed to neither move, cough nor speak. I did none of the above and I’m pretty sure that when I was taken back to recovery, I was introduced as the best lung biopsy patient ever (I really though I heard that—may well have been a sweet dream induced by twilight!).
Then the hard part started, as you must lie on your stomach for three hours post-biopsy without moving or talking. Although it was a full house when I was wheeled into recovery, I was the last to leave. At one point two nurses started talking about cider donuts…it was torture. However, not being able to speak or even move a finger, I was unable to express my displeasure.
At hour one and three a portable x-ray machine was rolled in and the condition of my lungs checked. I developed a small pneumothorax and so earned myself a suite in the Swedish Hotel for the night—I mean Lunder Building. Not a bad place for a sleep-over.
Although the main objective of the biopsy was to attain tissue for the clinical trial, we had hoped that sufficient material would be recovered to start a cell line. Dr. Shaw called this morning with the news that once again, there were only enough cells to check for PD-1. Oh well–no cell line or mouse model this time. We also discussed a story on Yahoo News pertaining to Roche’s anti PD-1 antibody; specifically the fact that when the numbers were parsed, smokers showed a greater over-all response (26%) than non-smokers (10%). Although personally discouraging, in the bigger picture, it is great news. Smokers tend to have a more complicated mutation profile at diagnosis, and therefore have not responded as well as non-smokers to the inhibitors that target a specific mutation, and which have monopolized breakthrough status in the treatment of lung cancer in recent years.
I see Dr. Shaw in a week and at that time we should know whether or not my biopsy was positive for the PD-1 protein. If it is, I will likely go on trial and cross my fingers that I’m one of the 10% who respond. And if no PD-1 protein is found in my sample, well, that’s another discussion.