NSCLC, 1 brain met

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July 20, 2014 at 6:52 pm  #1265060    

mizkathryn1

NSCLC URL lobectomy 10/2013, 2l lymph nodes positive & removed, upgraded to IIIA. Followed up with Adjuvant chemoradiotherapy. NED 3 scans since 3/2014.

Admitted through ER, two days ago. Stroke symptom, total weakness left side (leg, arm, face). CT negative for stroke, showed suspicious spot on right parietal. MRI showed 2 cm mass, liquid surrounding it and swelling. Started on Decadon IV immediately.

My concern and confusion is radiation oncologist is adamantly recommending PCI. I cannot find any literature with this as recommended treatment. Cyber knife is available. I understand that PCI or WBR leaves limited treatments for later recurrences and side effects can include cognitive deficiencies, hearing loss and others.

Has there been occasion for this initial treatment for just one 2cm met? I am attempting to get a 2nd opinion at nearest major cancer center as soon and I get MRI completed on rest of body due to significant cervical and back pain (previous existing condition but not this pain level). Am also asking for PET tomorrow.

Your thoughts please on Whole brain radiation for one brain met.

Your thoughts please on Whole brain radiation for one brain met. You have cited a couple of studies that were positive in this direction but were not complete due to lack of participation. Then another post saying in a clinical trial only. Another Dr recommend surgery on the one met then whole brain radiation. What is the consensus? Initially I was opposed to WBR, now leaning that way.

July 20, 2014 at 8:33 pm  #1265062    
JimC Forum Moderator
JimC Forum Moderator

Hi mizkathryn1,

As you’ve read, the standard treatment approach for a solitary brain met is stereotactic radiosurgery. There may be reasons that your radiation oncologist is recommending WBR in your situation; perhaps you can ask him to explain his rationale. Failing that, a second opinion may help.

Dr. Loiselle has written:

“For patients that present with a solitary or limited brain metastasis, there is a fifty percent chance they will develop other brain metastases and may eventually benefit from whole brain irradiation. There does not seem to be a detriment to initially deferring whole brain irradiation in favor of stereotactic radiotherapy for these patients.”

You can read his full post on treatment of brain metastases here: http://cancergrace.org/lung/2011/09/11/brain-metastases-in-lung-cancer-still-room-to-personalize-care/

JimC
Forum moderator


Jul 2008 Wife Liz (51/never smoker) Dx Stage IV NSCLC EGFR exon 19
4 cycles Carbo/alimta, 65% shrinkage
Tarceva maintenance
Mar 2010 progression, added Alimta, stable
Sep 2010 multiple brain mets, WBR
Oct 2010 large pericardial effusion, tamponade
Jan 2011 progression, start abraxane
Jun 2011-New liver, brain mets, add Tarceva
Oct 2011-Dx Leptomeningeal carcinomatosis; pulsed Tarceva
At rest Nov 4 2011
Since then: http://cancergrace.org/blog/jim-and-lisa

July 21, 2014 at 4:29 am  #1265066    

mizkathryn1

Hi Jim,

I read the blog you are referring to. I tried to repost adding that I read two posts by Dr West about two incomplete studies that offered PCI for NSCLC and brain mets. He seemed excited about the results and I felt after reading that he was leaning towards this treatment method. It seems the rate of recurrence is high and PCI would lower to 25%.

In regards to your earlier post surgery could still be an option followed by PCI or focused tx on the tumor and simultaneous PCI. This is my grasp of the overview of the posts plus your response.

Kathryn

July 21, 2014 at 6:23 am  #1265068    
Dr West
Dr West

First, because PCI is prophylactic cranial irradiation, that doesn’t apply in a setting where you have a known brain metastasis. It’s not prophylactic , but rather treatment for an identified problem. The dose in PCI is lower than in WBR, and that wouldn’t apply in a setting of treating one or more brain metastases.

As Jim said, Gamma Knife is readily used for patients with one or a few brain metastases. WBR is certainly feasible, and it still leaves the chance for Gamma Knife for stray new brain mets that might appear (as well as sometimes repeating whole brain radiation when really necessary). However, I agree that it would be most common to favor stereotactic radiosurgery (Gamma Knife, Cyber Knife) these days for a single brain metastasis. Jim suggested that you ask the radiation oncologist while WBR is being favored over Gamma Knife, and I think that makes sense.

As for surgery, that’s certainly possible, but frankly we do far less of that now that Gamma Knife is readily available for many patients. Unless you don’t know what the lesion is and need tissue, that’s much more to go through just to treat a single lesion and still leave the rest of the brain vulnerable. At our center, the leading reason patients undergo surgery for one or more brain metastases is that an ER doc contacts the neurosurgeon, who is often happy to oblige. However, the docs who specialize in lung cancer have much less enthusiasm for brain surgery in the majority of patients with brain metastases and overwhelmingly favor having brain metastases handled with radiation of one type or another.

Good luck.

-Dr. West

July 21, 2014 at 6:32 pm  #1265075    

mizkathryn1

I did ask. Met with treating Radiation Onc and Gamma Radiation Onc. Repeated MRI’s today. Much concern 2cm tumor wrapped in edema, small edema on left side also.

I initiated complaints of some symptoms twice at ER and again with Primary Onc beginning on 4/6/2014 right after completion of adjuvant therapy, in May and June. Everyone investigated pulmonary embolisms and blood clots in the leg. Focus was mainly on Lung cancer and not mets outside the chest. Also had an extended period of pneumonitis during the last 3 months also. It was simply missed and that happens.

Presented to ER this past Saturday, ER Doc immediately suspected stroke and initiated CT, then MRI which I am very thankful.

All three ONCs agree high possibiliity there are more smaller mets that are not visible and concern with malignancy of fluid that is present. Now treating with Steroids to control swelling. Good news no midline shift. Plan is WBR and still Gamma/Cyber will be available at any point.

July 21, 2014 at 6:48 pm  #1265077    
catdander forum moderator
catdander forum moderator

Good luck with treatment. I suspect just getting the plan in place and hopefully the steroids will help you feel better already.
Keep us posted,
Janine

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