Radiation Necrosis

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April 27, 2012 at 9:24 am  #1441    

fortmyr

My sister’s onc. phoned her yesterday to tell her that she may have radiation necrosis instead of growth of brain mets. Not that you’d wish anyone to have any of these, but which one is the less damageable? From what I read on the internet, radiation necrosis is hard to treat and tend to expand with time (i.e. it’s no piece of cake), but I’m guessing that brain mets growth is even worst? I read that Avastin (Bevacizumab) could potentially repair some of the dame caused by brain necrosis. Has any of you heard of this research (conducted by MD Anderson)

Any suggestions of treatment for brain necrosis?

Thank you so much for your help,

Myriam


Sister (46 yo), non-smoker, diagnosed stage 4 NSCLC 12/2009 12/09-03/10: 5 cycles cisplatin+navelbine (stopped because of neuropathy) 04/10-06/11:Tarceva (EGFR, exon 21 mutation) 02/11: 15Xrad. to right lung (bronchi blocked) 04/11: MRI shows 10 brain mets. 05/11: 5 sessions of WBRT (20 Gy) 06/11-12/11: maintenance Alimta 11/11 and 01/12: radiosurgery (15 Gy to 2+3 brain mets) 12/11-03/12: re-Tarceva. 04/12: Afatinib (convulsions) 08/12: adding Cetuximab to Afatinib. Left us October 31, 2012.

April 27, 2012 at 4:24 pm  #1442    

fortmyr

Hello, just wondering if anyone has any insights in radiation necrosis (please see question above).

Thank you,

Myriam


Sister (46 yo), non-smoker, diagnosed stage 4 NSCLC 12/2009 12/09-03/10: 5 cycles cisplatin+navelbine (stopped because of neuropathy) 04/10-06/11:Tarceva (EGFR, exon 21 mutation) 02/11: 15Xrad. to right lung (bronchi blocked) 04/11: MRI shows 10 brain mets. 05/11: 5 sessions of WBRT (20 Gy) 06/11-12/11: maintenance Alimta 11/11 and 01/12: radiosurgery (15 Gy to 2+3 brain mets) 12/11-03/12: re-Tarceva. 04/12: Afatinib (convulsions) 08/12: adding Cetuximab to Afatinib. Left us October 31, 2012.

April 27, 2012 at 10:07 pm  #1443    

Dr West

I don’t really have insight about this, except what you’ve said — it can progress, sometimes surgery is done if a clear need, and there is some early work that suggests that Avastin (bevacizumab) may be helpful, though I’ve never used it.

I’ll ask Dr. Loiselle if he knows more.

-Dr. West


Howard (Jack) West, MD
Medical Oncologist

Views expressed here represent my opinion, not those of GRACE or Swedish Cancer Institute. This information does not constitute medical advice and is intended to supplement and not replace medical information provided by your doctor.

April 28, 2012 at 5:39 am  #1444    

fortmyr

Thank you Dr. West. I look forward to hearing from Dr. Loiselle about this,

Myriam


Sister (46 yo), non-smoker, diagnosed stage 4 NSCLC 12/2009 12/09-03/10: 5 cycles cisplatin+navelbine (stopped because of neuropathy) 04/10-06/11:Tarceva (EGFR, exon 21 mutation) 02/11: 15Xrad. to right lung (bronchi blocked) 04/11: MRI shows 10 brain mets. 05/11: 5 sessions of WBRT (20 Gy) 06/11-12/11: maintenance Alimta 11/11 and 01/12: radiosurgery (15 Gy to 2+3 brain mets) 12/11-03/12: re-Tarceva. 04/12: Afatinib (convulsions) 08/12: adding Cetuximab to Afatinib. Left us October 31, 2012.

April 28, 2012 at 8:40 am  #1445    

certain spring

What a horrible phone call for your sister to receive. Sending all sympathy and solidarity.


49-year-old non-smoker, dx stage IV NSCLC May 2010 (squamous tumour of the left lung with multiple brain metastases). Radiotherapy to chest and brain; progressed through two cycles carbo/gemcitabine. Repeated lung collapses; pneumonia in collapsed lung, Nov 2010; bronchial stent placed, Dec 2010. Declined second-line Taxotere. Mutation testing Feb 2011, surprise EGFR exon deletion 19. Started Tarceva (150mg), Feb 2011. Progression in liver and elsewhere, May 2013.

April 28, 2012 at 9:22 am  #1446    

Dr Loiselle

Hi –

Radiation necrosis is a process of scarring, inflammation, and swelling which can occur in areas of normal brain after treatment with radiation.

First off – radiation necrosis is only a problem after treatment of metastases if it is causing symptoms/problems. This is much less common after treatment of brain metastases than for primary brain because of the way the grow.

Brain metastases spread to the brain and grow by pushing normal brain out of the way… thus, when the metastasis with high dose radiosurgery, very little normal brain is exposed to the high dose radiation because the metastasis has moved the brain out of the way.

Primary brain tumors grow in a much more infiltrative manner (like dropping a handful of sand in a bucket of water). When primary brain tumors are irradiated, a lot more normal brain tissue is potentially treated to a dose at which resultant scarring/inflammation/swelling can cause problems.

Most of the literature on treatment of radiation necrosis pertains to patients with primary brain tumors rather than patients treated with brain metastases, because after treatment of metastases, it is typically not a problem (although it is occuring).

Regardless, some radionecrosis (scarring/inflammation/swelling) is expected with nearly every treatment. The hope and goal is that this is a minimum amount, and does not cause symptoms. What can be difficult is delineating on followup MRI the difference between radionecrosis and tumor progression.

In the setting of brain metastases, if your physician thinks that followup imaging demonstrates radionecrosis, this is potentially not at all problematic and likely perhaps even a good thing.. indicating a local scarring effect around the treated area.

Thus, in the situation you have described, the fact that there is radionecrosis is more likely ambiguity on the imaging, rather than a clinical problem that needs treatment with a drug like Avastin.

If the patient is having problems related to treatment, there are a few options for treatment, of which Avastin is one of a few options…

I hope that helps…

-Dr Loiselle


Chris Loiselle, MD
Radiation Oncologist
Swedish Cancer Institute

Views expressed here represent my opinion, not those of GRACE or Swedish Cancer Institute. This information does not constitute medical advice and is intended to supplement and not replace medical information provided by your doctor.

April 28, 2012 at 10:33 am  #1447    

fortmyr

CS: thank you for your kind words.

Dr Loiselle, I’m sorry for not providing more background here, I had posted an update about my sister somewhere else. So here it is: last Saturday, her right arm started moving on its own, i.e. she had convulsions. The paramedics came but she did not want to go to the ER so we waited until Tuesday so that she could see her reg. onc, which she did. I went with her to the appt. and her onc had her brain scanned right away. The results showed some swelling in the left part of her brain which can be caused by brain mets growing again and/or radiation necrosis. He started her right away on decadron + Keppra (thanks to Dr. West). She’ll be having a MRI in a couple of weeks so I guess we’ll know more then (i.e. is it the brain mets acting up or the radiation necrosis). However, given that she is symptomatic, I guess neither of these options is good news… Apart from Avastin, what can be done for radiation necrosis? Should we expect that her situation will deteriorate (I read on the internet that radiation necrosis tends to expand with time).

Thank you so much for your reply,

Myriam


Sister (46 yo), non-smoker, diagnosed stage 4 NSCLC 12/2009 12/09-03/10: 5 cycles cisplatin+navelbine (stopped because of neuropathy) 04/10-06/11:Tarceva (EGFR, exon 21 mutation) 02/11: 15Xrad. to right lung (bronchi blocked) 04/11: MRI shows 10 brain mets. 05/11: 5 sessions of WBRT (20 Gy) 06/11-12/11: maintenance Alimta 11/11 and 01/12: radiosurgery (15 Gy to 2+3 brain mets) 12/11-03/12: re-Tarceva. 04/12: Afatinib (convulsions) 08/12: adding Cetuximab to Afatinib. Left us October 31, 2012.

April 28, 2012 at 11:05 am  #1448    

Dr Loiselle

Thanks for the added background (sorry I missed it).

What to do now depends on whether she still has symptoms, and the appearance of the MRI. Some quantitative assessment of the vascularity of the treated areas on MR can also be helpful in determining whether this is more likely to be radionecrosis vs. tumor progression.

If the symptoms were caused by radionecrosis and the dexamethasone and keppra has stopped the symptoms, great. In that situation, hopefully the radiation related inflammation over time will continue to resolve, and the dexamethasone can be tapered and eventually stopped.

If the symptoms persist despite the dexamethasone and keppra, then they really need careful assessment by your physician team as to what is the most likely problem, and what are the possible solutions…

I hope that helps.

Best wishes.

-Dr. Loiselle


Chris Loiselle, MD
Radiation Oncologist
Swedish Cancer Institute

Views expressed here represent my opinion, not those of GRACE or Swedish Cancer Institute. This information does not constitute medical advice and is intended to supplement and not replace medical information provided by your doctor.

April 28, 2012 at 11:51 am  #1449    

fortmyr

It sure does. Thanks again for your help,

Myriam


Sister (46 yo), non-smoker, diagnosed stage 4 NSCLC 12/2009 12/09-03/10: 5 cycles cisplatin+navelbine (stopped because of neuropathy) 04/10-06/11:Tarceva (EGFR, exon 21 mutation) 02/11: 15Xrad. to right lung (bronchi blocked) 04/11: MRI shows 10 brain mets. 05/11: 5 sessions of WBRT (20 Gy) 06/11-12/11: maintenance Alimta 11/11 and 01/12: radiosurgery (15 Gy to 2+3 brain mets) 12/11-03/12: re-Tarceva. 04/12: Afatinib (convulsions) 08/12: adding Cetuximab to Afatinib. Left us October 31, 2012.

April 29, 2012 at 8:52 am  #1450    

catdander forum moderator

Myriam, I’m adding my support and thoughts for a best result. Always in my thoughts,
Janine


My husband, 53 @ dx of stage 3 squam nsclc R. pancoast tumor 8/09 caused destruction of 3 ribs, touching brachial plexus. 2 core and 1 VATS undx biopsies. Open thoracotomy for 1 positive biopsy (unresectable). Chemorads, 9/09. MRI by pancoast specialty surgeon 11/09 spine met found, stage IV, Rad to spine, Chemo changed from cis/etop to navelbine/carbo. 6 cycles total. Tarceva 2/10-11/10. 3cm tumor L lung, biopsy undx w/collapsed lung. Gemzar, 12/10 through 7/12. NED 3/12, stop tx 7/12. Remains NED as of 8/14.

April 29, 2012 at 11:55 am  #1451    

fortmyr

Thank you Janine. That’s very kind of you,

Myriam


Sister (46 yo), non-smoker, diagnosed stage 4 NSCLC 12/2009 12/09-03/10: 5 cycles cisplatin+navelbine (stopped because of neuropathy) 04/10-06/11:Tarceva (EGFR, exon 21 mutation) 02/11: 15Xrad. to right lung (bronchi blocked) 04/11: MRI shows 10 brain mets. 05/11: 5 sessions of WBRT (20 Gy) 06/11-12/11: maintenance Alimta 11/11 and 01/12: radiosurgery (15 Gy to 2+3 brain mets) 12/11-03/12: re-Tarceva. 04/12: Afatinib (convulsions) 08/12: adding Cetuximab to Afatinib. Left us October 31, 2012.

April 29, 2012 at 2:18 pm  #1452    

certain spring

I wanted just to come in and state the obvious – to say how much Dr Loiselle’s contributions are valued.


49-year-old non-smoker, dx stage IV NSCLC May 2010 (squamous tumour of the left lung with multiple brain metastases). Radiotherapy to chest and brain; progressed through two cycles carbo/gemcitabine. Repeated lung collapses; pneumonia in collapsed lung, Nov 2010; bronchial stent placed, Dec 2010. Declined second-line Taxotere. Mutation testing Feb 2011, surprise EGFR exon deletion 19. Started Tarceva (150mg), Feb 2011. Progression in liver and elsewhere, May 2013.

April 29, 2012 at 2:35 pm  #1453    

fortmyr

Absolutely, I could not agree more!

Myriam


Sister (46 yo), non-smoker, diagnosed stage 4 NSCLC 12/2009 12/09-03/10: 5 cycles cisplatin+navelbine (stopped because of neuropathy) 04/10-06/11:Tarceva (EGFR, exon 21 mutation) 02/11: 15Xrad. to right lung (bronchi blocked) 04/11: MRI shows 10 brain mets. 05/11: 5 sessions of WBRT (20 Gy) 06/11-12/11: maintenance Alimta 11/11 and 01/12: radiosurgery (15 Gy to 2+3 brain mets) 12/11-03/12: re-Tarceva. 04/12: Afatinib (convulsions) 08/12: adding Cetuximab to Afatinib. Left us October 31, 2012.

April 29, 2012 at 7:05 pm  #1454    

Dr West

I forwarded the link…it’s always nice to get positive feedback. I’m also grateful for his excellent participation, but I think it’s nicer for him to get the comments from others.

-Dr. West


Howard (Jack) West, MD
Medical Oncologist

Views expressed here represent my opinion, not those of GRACE or Swedish Cancer Institute. This information does not constitute medical advice and is intended to supplement and not replace medical information provided by your doctor.

May 7, 2012 at 9:08 pm  #1464    

laya d.

Absolutely. . .Dr. Loiselle is awesome and a GREAT asset to GRACE. I’ve personally learned A LOT from him. THANK YOU DR. LOISELLE!!!!

Laya


1/10 – My Mom (58) dx w/ NSCLC-Adeno 3a; 1 cycle of neoadjuvent Carbo/Alimta before finding out EGFR+ (Ex. 19), then switched to 7 wks of neoadjuvent Tarceva/150 mg (major shrinkage); 4/10 – right pneumonectomy; 6/10 started 3 rounds of adjuvent Cis/Alimta w/ concurrent chest radiation (7 wks); 8/10 – NED; 11/10 – small nodule in left lung; 1/11 – 3 small nodules in left lung, start Tarceva/100 mg; 4/11 – suspected sclerotic met to hip, continue w/ Tarceva, add XGEVA, brain MRI clear; 9/11 – solitary 3 cm met (adeno w/ T790m mutation) to cerebellum, surgery and gamma knife, up Tarceva to 150 mg; 11/11 – 2 left lung nodules growing, biopsy on 1 shows mutation from adeno to squamous (shocker!), brain MRI clear, continue Tarceva & Xgeva; 2/12 – brain MRI clear, CT scan, remaining nodule slightly bigger – – monitor for now, Tarceva (reduced to 100 mg) & Xgeva continued; 4/12 progression and rebiopsy (confirmed adeno), stop Tarceva, switch to Carbo/Alimta; 6/12 maintenanceAlimta; 8/12 back to Tarceva; 10/12 Gemzar; 11/16 difficulty breathing; 12/12 hospice initiated…my Mom passed away peacefully on 12/19/12. Heartbroken.

May 13, 2012 at 9:44 pm  #1470    

brettb

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  • This reply was modified 2 years, 7 months ago by  brettb.
  • This reply was modified 2 years, 7 months ago by  brettb.
May 14, 2012 at 3:17 am  #1471    

fortmyr

Hello brettb, thanks a million for the information, this is quite useful. I will let my sister know about this. The timing is quite good as she’s had her MIR last Thursday and is meeting with her onc this upcoming Thursday.

Myriam


Sister (46 yo), non-smoker, diagnosed stage 4 NSCLC 12/2009 12/09-03/10: 5 cycles cisplatin+navelbine (stopped because of neuropathy) 04/10-06/11:Tarceva (EGFR, exon 21 mutation) 02/11: 15Xrad. to right lung (bronchi blocked) 04/11: MRI shows 10 brain mets. 05/11: 5 sessions of WBRT (20 Gy) 06/11-12/11: maintenance Alimta 11/11 and 01/12: radiosurgery (15 Gy to 2+3 brain mets) 12/11-03/12: re-Tarceva. 04/12: Afatinib (convulsions) 08/12: adding Cetuximab to Afatinib. Left us October 31, 2012.

May 14, 2012 at 9:32 pm  #1472    

Dr West

I would caution that none of these is very well studied, and that surgery is the most accepted of these treatments. I think it is misleading to suggesting that there are treatments that can be discussed as if they are authoritatively demonstrated to be beneficial.

-Dr. West


Howard (Jack) West, MD
Medical Oncologist

Views expressed here represent my opinion, not those of GRACE or Swedish Cancer Institute. This information does not constitute medical advice and is intended to supplement and not replace medical information provided by your doctor.

May 15, 2012 at 2:53 am  #1473    

fortmyr

Thanks for the word of caution Dr. West.

Myriam


Sister (46 yo), non-smoker, diagnosed stage 4 NSCLC 12/2009 12/09-03/10: 5 cycles cisplatin+navelbine (stopped because of neuropathy) 04/10-06/11:Tarceva (EGFR, exon 21 mutation) 02/11: 15Xrad. to right lung (bronchi blocked) 04/11: MRI shows 10 brain mets. 05/11: 5 sessions of WBRT (20 Gy) 06/11-12/11: maintenance Alimta 11/11 and 01/12: radiosurgery (15 Gy to 2+3 brain mets) 12/11-03/12: re-Tarceva. 04/12: Afatinib (convulsions) 08/12: adding Cetuximab to Afatinib. Left us October 31, 2012.

May 15, 2012 at 6:56 am  #1475    

Dr Loiselle

Hi,

I think that brettb modified the recent post, but I wanted to highlight some of the diagnostic and therpeutic challenges with radionecrosis.

Radiation necrosis – that is, long term scarring of an organ of the body due to radiation treatment, can happen anywhere in the body. Risk is related to radiation dose and the volume of exposed tissue.

Radiation necrosis can happen to any organ in the body. Fortunately the risk for symptomatic radionecrosis with modern technology can be dramatically minimized and often well estimated before treatment.

Diagnosis of radionecrosis is pathologic (meaning biopsy or resection with examination under the microscope), and to some extent a diagnosis of exclusion. PET scans and MRI (including spectroscopy and cerebral blood volume analysis) have showed some promise, but also have been disappointing in their specificity. The difficulty for PET and MRI is one of specificity. That is, when a patient has a completely normal brain, they are good at identifying normal. However, when there is an abnormal spot, they are not good at delineating whether it is tumor, radionecrosis, infection, or a demyelinating process such as multiple sclerosis.

As far as treatment, this is challenging as well. Surgical resection can offer relief of some symptoms, but also can be a direct threat to function. Other strategies such as hyperbaric oxygen and avastin have been examined and reported in specific situations, with mixed results. Hyperbaric oxygen has been most studied in necrosis of the jaw following radiation for head and neck cancer. Avastin has less extensively been reported to potentially help renormalize brain vascularity after treatment with radiation and chemotherapy for primary brain tumors. How effective it is at treating or reversing any actual radionecrosis is yet to be seen, though there does seem to be some improvement according to MRI… but then again, we don’t even know how good MRI is at characterizing radionecrosis (see previous paragraph!).

I hope helps.

-Dr. Loiselle


Chris Loiselle, MD
Radiation Oncologist
Swedish Cancer Institute

Views expressed here represent my opinion, not those of GRACE or Swedish Cancer Institute. This information does not constitute medical advice and is intended to supplement and not replace medical information provided by your doctor.

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