Late delayed radiation toxicity or side effects from SRS on excision site?

Portal Forums Radiation Oncology Brain Metastases / PCI Late delayed radiation toxicity or side effects from SRS on excision site?

This topic contains 35 replies, has 8 voices, and was last updated by  Dr. Weiss 1 year, 8 months ago.

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February 12, 2016 at 1:11 pm  #1272960    
Dr Pennell
Dr Pennell

Hi, I can understand why this would be confusing. Cancer can often contain necrotic (dead) material and may even be mostly dead, especially after treatment such as radiation. However, if the pathologist was able to find intact cancer cells in the specimen amongst the necrotic cells, which it sounds like was seen in your wife’s case, then there is living cancer there and this would mean a recurrence. You would not expect there to be residual intact but dead cells many months after a treatment (you can see this in the days and weeks after radiation). The IMRT is a form of radiation that allows very precise targeting of the tumor to spare the normal brain as much as possible.

Yes the tumor probably will become necrotic (or more necrotic) after radiation, but doing it in smaller doses over more fractions rather than one single very high dose reduces the chances that this will cause problems.


Nathan Pennell, MD
Associate Professor, Solid Tumor Oncology
Cleveland Clinic Taussig Cancer Center

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

February 19, 2016 at 12:57 pm  #1273011    

My wife’s advocate

Dr. Pennell, Thank you so very much for the explanation. Indeed the field of medicine is often times is like an art form. It takes the medical practitioners lots of dedication and effort to provide an individualized care to the patient. That is why this GRACE site is such a “God send” when I first discovered it.

In the case of my wife, she is on a daily 100mg of Tarceva, and she is considered NED with the exception of this recent discovery of radiation necrosis.

Is Tarceva considered a systemic chemo treatment?

Should she be off the Tarceva for the two weeks of pending radiation treatment?

I have read somewhere that a person should not have chemo concurrent with radiation treatment in fear that it would increase the dosage effect of the drug or the radiation and producing greater undesirable side effect of both.

Are there any do’s or don’ts for this upcoming treatment?


Wife, Asian non-smoker, 10/2010 left upper lobectomy, Diag: mod. diff. adenocarcinoma, focal squamous diff. with one AP node involvement. Dec 2010 thru Mar 2011 4 cycle cisplatin/vanorabin doublets completed. July 2011 MRI shown one 1.3 cm lesion with a 2.6 cm cystic component in rt. occipital region. Aug 2011 Neuro excision, confirmed sol. met from lung. Tested EGFR +. SRS irradiation on excision site 9/9/11, started Tarceva 9/26/11. Very difficult side effects. Tolerable after dose reduction to 100mg. Dec 2015 second brain surgery found life cancer cells in large bed of necrotic tissue. Feb-Mar 2016, 12 fractionized IMRT on right occipital lobe. Remain on Tarceva. Aug 2016 to Jun 2017 enlargement of pre-vascular lymph node from 1.4 to 2.2 cm. Mediastinotomy scheduled Sept 2017.

February 19, 2016 at 1:10 pm  #1273014    
Dr Pennell
Dr Pennell

Ah, that is a good question without a good answer. Yes Tarceva is a systemic treatment but it is different than chemotherapy. We do try and avoid giving chemotherapy and brain radiation at the same time if we can because it can increase the side effects. Whether to stop Tarceva during brain radiation is unknown. It can be safely given at the same time for many people, but I also have seen patients who get severe skin rash in the scalp from the radiation while on Tarceva (and many who did not). I would say some doctors hold it and some do not, and I don’t know what the right answer is.

The specific dos and don’t would probably be best answered by the her oncologists there since they can be very specific to the patient and exact treatment.

I know that isn’t very helpful but each case ends up being decided individually in a situation like this where there is no clear right or wrong.


Nathan Pennell, MD
Associate Professor, Solid Tumor Oncology
Cleveland Clinic Taussig Cancer Center

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

February 19, 2016 at 4:31 pm  #1273020    

My wife’s advocate

I also read in GRACE somewhere that stopping Tarceva for whatever good reasons might trigger a flare up of the EGFR mutation with a vengeance. Is this true? What a catch 22 situation!


Wife, Asian non-smoker, 10/2010 left upper lobectomy, Diag: mod. diff. adenocarcinoma, focal squamous diff. with one AP node involvement. Dec 2010 thru Mar 2011 4 cycle cisplatin/vanorabin doublets completed. July 2011 MRI shown one 1.3 cm lesion with a 2.6 cm cystic component in rt. occipital region. Aug 2011 Neuro excision, confirmed sol. met from lung. Tested EGFR +. SRS irradiation on excision site 9/9/11, started Tarceva 9/26/11. Very difficult side effects. Tolerable after dose reduction to 100mg. Dec 2015 second brain surgery found life cancer cells in large bed of necrotic tissue. Feb-Mar 2016, 12 fractionized IMRT on right occipital lobe. Remain on Tarceva. Aug 2016 to Jun 2017 enlargement of pre-vascular lymph node from 1.4 to 2.2 cm. Mediastinotomy scheduled Sept 2017.

February 19, 2016 at 5:21 pm  #1273021    
catdander forum moderator
catdander forum moderator

Advo, this flare up is turning out to be pretty rare and thought to be enough so not to keep someone from stopping if it’s thought needed. Dr. West still mentions this from time to time. You can probably find one if you search tarceva flare.

Hope she AND you are feeling alright.
Janine

February 23, 2016 at 10:41 pm  #1273054    

My wife’s advocate

To all esteemed radiation oncology faculty,

I have some questions in how an external beam radiation of the brain or for that matter any part of the body, can focus on the cancer without damaging everything along the path? Case in point is with SRS or IMRT.

I understood that in IMRT, as many as up to 8 beams are used to avoid or spare certain structures of the brain or vital parts of the brain that might be more susceptible to injury to preclude unnecessary damages and preserve vital brain function.

I read and understood only vaguely and simplistically that with multiple beams and the fractionized delivery concept, only the focused point where all the beams meet would receive the most radiation dose while minimizing the collateral damage of the beams along the way.

However can someone please explain if in real practice, would the multiple beams’ individual pathways need to shift and change with each of the fractions delivered to attain the maximum benefit of structures and vital organ avoidance?

From an anxious husband

Ben


Wife, Asian non-smoker, 10/2010 left upper lobectomy, Diag: mod. diff. adenocarcinoma, focal squamous diff. with one AP node involvement. Dec 2010 thru Mar 2011 4 cycle cisplatin/vanorabin doublets completed. July 2011 MRI shown one 1.3 cm lesion with a 2.6 cm cystic component in rt. occipital region. Aug 2011 Neuro excision, confirmed sol. met from lung. Tested EGFR +. SRS irradiation on excision site 9/9/11, started Tarceva 9/26/11. Very difficult side effects. Tolerable after dose reduction to 100mg. Dec 2015 second brain surgery found life cancer cells in large bed of necrotic tissue. Feb-Mar 2016, 12 fractionized IMRT on right occipital lobe. Remain on Tarceva. Aug 2016 to Jun 2017 enlargement of pre-vascular lymph node from 1.4 to 2.2 cm. Mediastinotomy scheduled Sept 2017.

February 24, 2016 at 12:05 pm  #1273062    
catdander forum moderator
catdander forum moderator

Hi Ben, I know how it feels to be an anxious spouse. I’ll try to get our radiation oncology faculty to comment.
Hopes for the best for her and you,
Janine

February 24, 2016 at 12:47 pm  #1273066    

Dr Loiselle

HI Ben –

You are right – IMRT typcially involves multiple beams, crossfiring irregular patterns to paint higher prescription radiation dose across at-risk areas, while other areas in the path of the beam (entrance and exit) receive a fraction of that prescription radiation dose.

The beams are usually fixed per fraction with IMRT, although increasingly, multiple arcs of radiation (beam moving during treatment) are used to deliver radiation in desired dose profiles.

There are lots of ways to deliver safe and effective radiation in this scenario.

I would ask your radiation oncologist to show you the isodose plan from the initial stereotactic treatment and the current isodose plan.

Best regards,
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.

February 24, 2016 at 1:51 pm  #1273070    

My wife’s advocate

If the beams are fixed then each of the 10 or 12 fractions beam all passing through the same pathway. Would it not injure all the live cells along the way just the same?

Again I know very little if not nothing how this works. I can only imagine the radiation beams like a bunch of kids gathering around in circle each with a magnifying glass trying to aim the beam of light from the sun at a single match just to try to light it up on fire. Though the heat from each beam coming through the magnifying glass is relatively weak, but with all the beams concentrating on the same match, it catches up on fire in no time.

Is this pictorial analogy somewhat correct? Or am I all wet?

I am just too busy to worry about my wife’s IMRT to come up with this question. Thanks for reading.


Wife, Asian non-smoker, 10/2010 left upper lobectomy, Diag: mod. diff. adenocarcinoma, focal squamous diff. with one AP node involvement. Dec 2010 thru Mar 2011 4 cycle cisplatin/vanorabin doublets completed. July 2011 MRI shown one 1.3 cm lesion with a 2.6 cm cystic component in rt. occipital region. Aug 2011 Neuro excision, confirmed sol. met from lung. Tested EGFR +. SRS irradiation on excision site 9/9/11, started Tarceva 9/26/11. Very difficult side effects. Tolerable after dose reduction to 100mg. Dec 2015 second brain surgery found life cancer cells in large bed of necrotic tissue. Feb-Mar 2016, 12 fractionized IMRT on right occipital lobe. Remain on Tarceva. Aug 2016 to Jun 2017 enlargement of pre-vascular lymph node from 1.4 to 2.2 cm. Mediastinotomy scheduled Sept 2017.

February 24, 2016 at 2:15 pm  #1273071    

Dr Loiselle

yes and no…

again, ask your radiation oncologist to review the “isodose plan” with you. this should help.

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.

February 24, 2016 at 6:25 pm  #1273073    

My wife’s advocate

Dear Dr. Loiselle,

Thank you for your patience in explaining what I was asking. This is exactly why I love this site so much. Information presented patiently in layman’s term is what brings people back to this site time and time again.

We are with a large HMO in Southern California. Most of the time we do not have such luck and luxury to communicate with our provider team. Thank you once again for the information you have given.


Wife, Asian non-smoker, 10/2010 left upper lobectomy, Diag: mod. diff. adenocarcinoma, focal squamous diff. with one AP node involvement. Dec 2010 thru Mar 2011 4 cycle cisplatin/vanorabin doublets completed. July 2011 MRI shown one 1.3 cm lesion with a 2.6 cm cystic component in rt. occipital region. Aug 2011 Neuro excision, confirmed sol. met from lung. Tested EGFR +. SRS irradiation on excision site 9/9/11, started Tarceva 9/26/11. Very difficult side effects. Tolerable after dose reduction to 100mg. Dec 2015 second brain surgery found life cancer cells in large bed of necrotic tissue. Feb-Mar 2016, 12 fractionized IMRT on right occipital lobe. Remain on Tarceva. Aug 2016 to Jun 2017 enlargement of pre-vascular lymph node from 1.4 to 2.2 cm. Mediastinotomy scheduled Sept 2017.

March 14, 2016 at 10:17 pm  #1273258    

My wife’s advocate

My wife has just completed (on March 9th) a 12 fractions IMRT on her right occipital lobe of her brain. This was a follow-up on the second brain resection done on Dec 12 2015.

The neurosurgeon found some viable cancer cell in the midst of a massive necrotic tissue, supposedly built up from 2011 after surgery removal of a solitary mets followed with SRS.

For some unexplained reasons, in this past week after the IMRT treatment, the hair on her entire left side of her head started falling off. The hair on her right side of her head is still intact.

Is this normally expected or did they zap the wrong side of her head?


Wife, Asian non-smoker, 10/2010 left upper lobectomy, Diag: mod. diff. adenocarcinoma, focal squamous diff. with one AP node involvement. Dec 2010 thru Mar 2011 4 cycle cisplatin/vanorabin doublets completed. July 2011 MRI shown one 1.3 cm lesion with a 2.6 cm cystic component in rt. occipital region. Aug 2011 Neuro excision, confirmed sol. met from lung. Tested EGFR +. SRS irradiation on excision site 9/9/11, started Tarceva 9/26/11. Very difficult side effects. Tolerable after dose reduction to 100mg. Dec 2015 second brain surgery found life cancer cells in large bed of necrotic tissue. Feb-Mar 2016, 12 fractionized IMRT on right occipital lobe. Remain on Tarceva. Aug 2016 to Jun 2017 enlargement of pre-vascular lymph node from 1.4 to 2.2 cm. Mediastinotomy scheduled Sept 2017.

March 15, 2016 at 11:03 am  #1273263    
catdander forum moderator
catdander forum moderator

I’ve asked a doc to comment.
I hope she is feeling alright.
Janine

March 15, 2016 at 3:13 pm  #1273275    

Dr. Weiss

Radiation follows a mostly straight line, so in addition to hitting tumor, there’s some entrance dose to healthy tissue “in the way” on the way in and some exit dose to healthy tissue on the way out. These can certainly cause side effects. If you ask, the radiation oncologist should be able to give you an idea of how much entrance and exit doses there were to see if it fits with the hair loss.

March 15, 2016 at 4:02 pm  #1273276    

My wife’s advocate

Thank you Dr Weiss for attempting to answer my question.

That was exactly why I posted the earlier question in this thread. Radiation treatments, be it SRS or IMRT or for that matter WBRT are so brutal, scary and damaging that I wish there is a better alternative treatment.

One would think that if they can send a man to the moon and back they could have design a better form of treatment for brain cancer.

What I posted begs the question as to why in each consecutive fractionized multiple-beam radiation treatments would we not intentionally alter or change the entry and exit points (or the pathways) so as to minimize the repeat and cumulative damaging effect of the fixed beams passing the same set of healthy tissues or skin surfaces along the way? This procedure is so barbaric! God have mercy on us.


Wife, Asian non-smoker, 10/2010 left upper lobectomy, Diag: mod. diff. adenocarcinoma, focal squamous diff. with one AP node involvement. Dec 2010 thru Mar 2011 4 cycle cisplatin/vanorabin doublets completed. July 2011 MRI shown one 1.3 cm lesion with a 2.6 cm cystic component in rt. occipital region. Aug 2011 Neuro excision, confirmed sol. met from lung. Tested EGFR +. SRS irradiation on excision site 9/9/11, started Tarceva 9/26/11. Very difficult side effects. Tolerable after dose reduction to 100mg. Dec 2015 second brain surgery found life cancer cells in large bed of necrotic tissue. Feb-Mar 2016, 12 fractionized IMRT on right occipital lobe. Remain on Tarceva. Aug 2016 to Jun 2017 enlargement of pre-vascular lymph node from 1.4 to 2.2 cm. Mediastinotomy scheduled Sept 2017.

March 15, 2016 at 5:03 pm  #1273277    

Dr. Weiss

The quick answer to your question is likely already obvious to you: we keep using radiation for the brain because barbaric as it is, lung cancer in the brain is even more barbaric. But, your question is a very good one that deserves a more detailed answer regarding attempts to do better.

First, radiation oncologists are exploring new methods to try to do what you’re describing. Some of the more promising approaches to improved targeting are cyberknife for small tumors, partial brain irradiation in select cases, and attempts to spare key areas of the brain when they’re not involved with cancer. Medications such as memantine are being attempted to lower the cognitive side effects of brain radiation. Second, medical oncologists are working hard on newer drugs that in addition to controlling cancer in the body (south of the brain) can also cross the blood brain barrier and control cancer in the brain.

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