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Radiation-Based Treatment Options for Brain Mets: A Case-Based Approach

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Unfortunately, patients with lung cancer often develop brain metastases. Once discovered, brain metastases are most often treated with radiation therapy, sometimes preceded by surgery.

For non-small cell lung cancer (NSCLC) patients with a solitary brain metastasis, that is, only one identifiable “spot” in the brain, surgery is often used in combination with radiation therapy. For NSCLC patients with multiple brain metastases, surgery offers less benefit. However, if the diagnosis is not clear, or if one of multiple lesions in particular is causing symptoms, surgery can helpful for both diagnosis and relief of symptoms. Relieving symptoms with surgery depends on the location of the lesion in regard to accessibility and function. If the lesion is in a non-critical brain area, it often may be surgically removed; however, if it is in a critical area (for example, the brain area that controls motor function of the right leg), surgery can lead to even worse function (of the right leg).

After surgery for NSCLC brain metastasis, radiation therapy is used to decrease the risk of brain metastases reoccurring or causing symptoms. Multiple options for radiotherapy treatment exist – mainly, whole brain irradiation and stereotactic radiosurgery. They can be used alone or together. For decades, standard treatment for lung cancer brain metastases has been whole brain irradiation. In more recent years, stereotactic radiosurgery has increased in availability and has been used increasingly.

Choosing the right treatment depends dramatically on patient circumstances. Let me describe a few situations:

Case #1: Mr. W is a 70 year old gentleman diagnosed with locally advanced squamous cell carcinoma of the lung, stage IIIB. He undergoes treatment with chemotherapy and radiation and the cancer generally responds well. Two months later, he develops a headache and brain imaging demonstrates three lesions in the brain, consistent with brain metastasis, with some associated swelling.

For Mr. W, proceeding to whole brain irradiation would be my general recommendation. Given the multiple brain metastases and short interval in which they developed, he is at high risk for development of additional brain metastases.

 

Case #2: Ms. X is a 36 year old woman with early stage adenocarcinoma of the right lung (T1N0). She underwent a surgery for removal of the right upper lobe of the lung containing the cancer and has no evidence of disease for 2 years. Then, she develops some very subtle weakness in the right leg. Her physician obtains a brain MRI which identifies a 2 cm mass in the region of the brain controlling the right leg, with some swelling. Restaging scans of the chest, abdomen, and pelvis identify no other areas of disease recurrence. She continues to work full time.

For Ms. X, I would recommend focused, single session, stereotactic radiosurgery treatment. Surgical resection is likely not a good option given the location of the metastasis. Whole brain irradiation is an option in this case; however, given the early stage of lung cancer initially and long interval before development of the brain metastasis, I would favor stereotactic radiosurgery, as Ms. X likely has less than the traditional 50% risk of developing additional brain metastasis. As well, in the short term, she will be able to obviate 2 to 3 weeks of daily whole brain treatment, and avoid the possible short term side effects of fatigue, nausea, vomiting, hair loss, and sore throat. She also will be able to keep working, with minimal interruption. In the long term, while whole brain radiation is generally safe, she may avoid the potential long term side effects of whole brain irradiation, such has some decrease in short term memory or ability to multi-task, which may also interfere with her job. If she opts for focused stereotactic treatment, she will particularly need close neurological follow-up and scheduled repeat surveillance brain MRIs.

Case #3: Mr. Y is a 49 year old gentleman diagnosed with stage IV lung cancer, with a large mass in the chest, liver, bone, and brain metastases. He has lost 60 pounds and getting out of bed is difficult.

For Mr. Y, I would recommend no aggressive directed therapy of brain metastases. I would encourage comfort and quality of life related care, with consideration of steroid medications to ease any symptoms related to brain metastases.

Case #4: Ms. Z is a 64 year old woman treated two years ago for a T2N2M0, Stage IIIA non-small cell lung cancer. She underwent surgery, then chemotherapy, then radiation therapy. Three months later, she was restaged with a brain MRI which detected a solitary 1cm brain lesion in the cerebellum (the lower, back part of the brain). She has no other sites of active disease.

Patients like Ms. Z face multiple reasonable choices regarding brain metastasis treatment. First, surgery is not an unreasonable option, given the lesion is likely surgically accessible. Second, whole brain irradiation, alone or in combination with surgery, is also good treatment – Ms. Z is at high risk of developing additional brain metastases, and will likely benefit from whole brain irradiation. Finally, stereotactic radiosurgery is also an option – the important thing to realize however is stereotactic radiosurgery that may only be prolonging an inevitable need for whole brain irradiation, although may cause less in terms of side effects.

In general, whole brain irradiation is safe and effective in suppressing known brain metastases as well as subclinical (no symptoms) and subradiographic (not visible on scans) disease. Stereotactic radiosurgery offers some benefits as a high dose focused treatment which is often only a single day of treatment, with potentially little to no time required for recovery. Altogether, it is important for patients and physicians to discuss these various options for treatment, their effectiveness, their limitations, and their optimal selection given individual circumstances.


14 Responses to Radiation-Based Treatment Options for Brain Mets: A Case-Based Approach

  • ts says:

    Thank you Dr. Loiselle – I hope to never need this information!
    In a discussion earlier this week, the conversation drifted to gamma knife versus sterotactic radiosurgery. There was not a radiation oncologist involved (how often do you think that occurs?) The not so well informed consensus was that gamma knife has an advantage for brain mets – perhaps something to do with being able to maintain the narrow focus through the skull better? Any truth to this idea or thoughts on one versus the other?

  • ssflxl says:

    Dr. Loiselle

    Is the effectiveness of radiation dependent on the size of the tumor or the location of tumor? If you get gamma knife treatment to a lesion, I assume you can’t get radiation in any other form to the same area again – is that correct?

    thanks

    ssflxl

  • Dr Loiselle says:

    Hi ts and ssflxl,

    Whether gamma knife or other treatments (such as whole brain irradiation) have an advantage in the treatment of brain metastases depends on the situation, and the goals of treatment. If one’s objective is to eradicate a known metastasis with high precision, indeed, gamma knife is a superior instrument. If the goal is to treat the entire brain region to treat know metastases AND to prevent additional ones, then traditional whole brain irradiation is best. Therefore, which treatment is best depends on each patient’s specific situation and goals.

    With regard to size and location of tumor, these are very important determinants of radiation effectiveness. If lesions are large, they may not be well controlled by whole brain irradiation. However, if they are too big, then gamma knife may also be difficult, and whole brain radiation or surgery may be necessary to shrink a lesion before it can be addressed with gamma knife.

    If one receives gamma knife to a specific lesion, it can be repeated. The risk of repeat gamma knife causing significant side effects, like edema/swelling, is also size (more specifically volume) dependent.

  • ssflxl says:

    thanks so much for your explanation.

    ssflxl

  • Laya D. says:

    Thank you very much for this information, Dr. Loiselle. The case studies were very helpful for me to understand the nuances for the “individual” treatment option(s) recommended.

    Laya

  • mach7out says:

    Hello Dr,

    Appreciate the article, it was completely helpful, but i would like to add a case on the table, and see what you might think.

    62 y/o male patient presented with lung cancer, non small type in his upper left lung, leading to lobectomy, and followed by chemotherapy.

    Less than 6 months later, a non-fluent aphasia appeared, leading to an MRI and discovery of a 3.8 cm non small cell in his brain.

    Doctors are recommending removal through surgery, and a full brain radiotherapy.

    with the location, size and aphasia, arent there better techniques for the radiology, since full brain radiotherapy will eventually lead to side effects like loss of memory and maybe more aphasia?

    I also thought of alcohol injection to the tumor, shrinking it, removing it, then using the gamma knife technique or some other localized technique, and if reoccurrences occur, could he be eligible to go through a full brain radiotherapy again?

    Thought I would ask around the net, before I write to his doctors.

    Ps: I am SO not a doctor, just a big Dr. House fan.

    Appreciate it again.

  • Dr Loiselle says:

    Good question. 3.8 cm is a good size lesion. Surgical decompression to shrink the lesion and relieve the symptoms would be helpful if technically feasible and anatomically favorable. Following surgical decompression, focused gamma knife radiosurgery to the area of the metastasis is an option, witholding whole brain irradiation in the event of development of additional metastases is not unreasonable. After surgery alone, there is roughly a 70% chance of the cancer coming back at the original area… either whole brain irradiation or gamma knife can reduce this risk significantly. Only whole brain irradiation addresses the approximate 50% risk of additional brain metastases.

  • reginac says:

    this is a tangential question to the main point, but when do you recommend that a patient receive a brain MRI? After symptoms develop or before, particularly if the patient has been 2+ years dealing with stage IIIB NSCLC (me)? For me, one of the central questions to be answered is whether the radiation treatment is simply to relieve symptoms or it can be used to prolong life. And that’s where the debate is in my case. Plus whether ignorance is bliss .

  • Dr Loiselle says:

    Hi reginac -

    Your question is really an excellent one. I do not have a one size fits all answer here. There is no evidence that I am aware of that screening the brain with MRI after the time of initial diagnosis to try to pick up subsequent brain metastases will be life extending. However, in certain circumstances it potentially could be, and with IIIB NSCLC, you are at a significant risk of developing brain metastases.

    Whether to screen the brain with MRI is a decision that will need to take into account the current status of your cancer, where it is has spread, whether it is active, and whether it has responded to therapy you have had so far. It will also need balance your goals, priorities, fears, and wishes in many regards. I hope that your physicians that know you and your situation well can assess all of this and help guide you in your specific situation…

    -Dr. Loiselle

  • Dr West says:

    I actually don’t do surveillance head MRI scans after including it in initial thorough staging for patients with anything higher than apparent stage I NSCLC (I’m actually rarely the person doing the workup of a patient with apparently resectable, stage I NSCLC). The strongest value for surveillance is to pick up a potentially curable local recurrence, and if there are brain metastases, that is unfortunately not going to be a curable situation except in quite rare cases.

    Because patients will usually do just as well with stereotactic radiation or whole brain radiation once a brain lesion becomes symptomatic vs. detecting it earlier, and because doing intermittent surveillance MRIs would entail hundreds of thousands of additional expensive tests with no clear benefit, routine repeat head MRIs in asymptomatic patients hasn’t been the general practice, and it isn’t mine.

    -Dr. West

  • certain spring says:

    Regina, that’s a hard question, and it is valuable to hear from the doctors that there is no clear-cut answer. Just to offer my own experience: I had an MRI on dx because I had been having headaches. To learn the result was devastating; on the other hand, it did give me the chance to have prompt WBR. Obviously I can’t know what life would have been like if I hadn’t had treatment to the brain, but I am very, very glad that I did.

  • DianaJ says:

    Dr. Loiselle, you were asked earlier to compare gamma knife to SRS. If my brain lesions are in 6mm range or smaller and numbering under 6 lesions; is gamma knife better than linac units ( Novalis TX)?
    Diana

  • Dr Loiselle says:

    Diana – I don’t have personal experience with Novalis. In many cases, linear accelerator based treatment can offer good, focused radiotherapy delivery. For situations like you have described with 6 lesions, the integral radiation dose (the radiation dose exposure to the rest of the normal brain) is likely to be less with Gamma Knife – whether this will make a signficant difference, depends on the location and size of the brain metastases and whether you have had prior radiotherapy….
    I hope that your radiation oncologist will be able to guide you.

    -Dr. Loiselle

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