Need for base line ct or mri of brain

Portal Forums Lung/Thoracic Cancer Imaging in Lung Cancer Need for base line ct or mri of brain

This topic contains 13 replies, has 5 voices, and was last updated by  catdander forum moderator 1 year, 1 month ago.

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January 31, 2013 at 8:38 am  #1253212    

tjames

I was diagnosed with stage IV NSCLC in November. I do have the ALK mutation and I am on Xalkori. At the time of my initial diagnosis. I did have a chest CT without contrast, followed by a pet scan. However, I have never had any imaging of the brain. Even though I have no symptoms that are suggestive of mets to the brain, should I insist upon some type of a brain image at this point.

January 31, 2013 at 10:57 am  #1253216    

catdander forum moderator

Hello tjames, Your name sounds familiar so I don’t think I should welcome you as a first time poster, so welcome here and glad you’re asking.

I’m not a doctor so I’ll ask a doctor to comment. You should hear back within a day.

edited out an incorrect statement.

All best on Xalkori
Janine
forum moderator

January 31, 2013 at 2:41 pm  #1253245    

tjames

Thank you catdander. I do have a follow up chest ct in about a week, so I will so how that goes and then try to decide if a brain study is something to be done.

January 31, 2013 at 7:20 pm  #1253265    

Dr West

Brain imaging is typically part of the workup for a newly diagnosed lung cancer, since brain metastases are not uncommon and can definitely been seen even in asymptomatic patients. Though we never want to find them, it’s helpful to detect them when small and solitary, rather than because several large ones are present and lead to a seizure as the first sign of brain involvement. It also tends to be helpful to have a good sense of the full extent of disease at baseline, so that if brain metastases become apparent later, you don’t have to guess whether they were there previously or not.

Incidentally, it’s not rare for patients with an ALK rearrangement to develop brain metastases while otherwise demonstrating excellent ongoing control of their disease everywhere outside of the brain. In that setting, because XALKORI (crizotinib) doesn’t penetrate into the brain well at all, it really isn’t considered that the brain disease is resistant to treatment and that the XALKORI has failed, but rather that the brain is a “sanctuary site” in which disease can be protected from effective treatment. In such cases, many experts would favor treating the disease in the brain with local therapy like radiation but continuing XALKORI treatment to control the “extracranial” disease everywhere else.

For these reasons, I would say that most people favor doing brain imaging as part of the initial staging, even if it’s hard to consider it a mandate.

Good luck.

-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.

February 1, 2013 at 6:48 am  #1253273    

tjames

Thank you,Dr. West. Your comments are very helpful.

February 1, 2013 at 10:34 am  #1253283    

catdander forum moderator

tjames, In my previous post I should have left it at, “I’m not a doctor”, however I did edit out my statement so no one will get the wrong info.

I received an email from Dr. Anne Tsao, MD who is not in her office and receiving only spotty internet reception. However she left a comment to your post which states,

“…I would have a baseline staging head imaging. If they had this (even before xalkori) already, there is no need to reimage. I would only reimage if they have neurologic symptoms. Hope this helps – AST”

February 25, 2013 at 8:11 am  #1254178    

tjames

I did just have a brain mri, which showed 2 tiny areas, less than 7mm each, fwhich are apparently brain mets. I will be talking to a nerurosuregeon about having these treated by gamma knife or cyberknife. However, my onclolgist says that because of the small size, we could just watch these and take action it they gety bigger. He also stated that it is not certain whether Xalkori penetrates the brain or not, and there may be a possibility that the Xalkori that I am on will be helpful.

My inclination is to have these treated with the gamma or cyberknife, but I am not sure.Comments would be appreciated.

Terry

February 25, 2013 at 9:58 am  #1254182    

certain spring

Sorry about the MRI. Even though they’re minuscule, nobody wants to hear anything like that. You sound very calm and rational which is great and will help you in deciding what to do.
I notice Dr West commented higher up your thread (Jan 31 7.20pm) – that Xalkori doesn’t penetrate well into the brain. He wrote an interesting post discussing the idea of the brain as a “sanctuary site” that is hard to reach with targeted therapies (but can be reached by radiation):

http://cancergrace.org/lung/2012/06/09/ar-local-rx/

Obviously it is a highly personal decision, but since you invite comments I wouldn’t, myself, want to wait and see what happens.


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.

February 25, 2013 at 11:35 am  #1254186    

laya d.

Hi tjames:

I just wanted to wish you the best of luck with your anticipated targeted radition therapy to the brain. . .and also to let you know that my Mom underwent gamma knife to tiny brain mets on two separate occassions – - and really did not experience any major side-effects from the treatment (other than a sore head for a few days in the area where they had screwed the head-gear on). I know every patient is different, but the gamma knife treatment resolved the tiny mets that she had (and she had no recurrence).

Anyway, just wanted to share this with you…

Good Luck!
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.

February 25, 2013 at 8:24 pm  #1254219    

Dr West

We haven’t had a lot of success with XALKORI leading to responses of brain metastases, but it’s also true that a couple of very tiny brain metastases are not likely to lead to any imminent problems. It would be very reasonable to pursue stereotactic radiosurgery (SRS) now or jump in as needed if there is progression on repeat monitoring scans.

Good luck.

-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.

February 26, 2013 at 7:07 am  #1254228    

tjames

Thank you, Dr. West, and others for your comments, which are appreciated. Will talk to my neurosurgeon and make a decision. However, wil probably opt for SRS now.

February 26, 2013 at 9:59 am  #1254238    

laya d.

I’m with you tjames…just get rid of them. . .

Good Luck!
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.

March 6, 2013 at 7:07 am  #1254506    

tjames

Just an update. I am scheduled to have a gamma knife procedure in a week. The neurosurgeon that I spoke with does both gamma knife and cyber knife, but recommended the gamma knife because only one session is needed. He thinks I am an ideal candidate.

March 6, 2013 at 8:10 am  #1254509    

catdander forum moderator

The best of luck James. I look forward to reports of no problems and no more nasty brain mets.
Janine

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