WBR for Brain Mets

Portal Forums Radiation Oncology Brain Metastases / PCI WBR for Brain Mets

This topic contains 16 replies, has 8 voices, and was last updated by  Dr West 1 year, 8 months ago.

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March 27, 2013 at 9:25 pm  #1255225    

njliu

May I ask if WBR is performed to (1) relieve the symptoms; (2) retard the progression of the brain mets; or (3) both? What is the statistics of its effectiveness in dealing with brain mets? Thank you in advance for any advice.
NJ


Wife, 56, Asian, 11/11 Dx Adenocarcinoma 3B, EGFR+. 12/11 Iressa, great response. 12/12 asymptomatic brain mets with possible lepto, 1/13 WBR, continue Iressa, 9/13 Local Progression at primary tumor, 10/13 focal radiation, 1/14 PET Scan:Tumor Resolution, continue Iressa, 6/14 PET shows flare up at same primary. 9/14 CT stable.

March 27, 2013 at 10:59 pm  #1255228    

catdander forum moderator

NJ, I hope your wife is feeling alright.
The answer is both. Here is a link that describes brain met treatment. In the comment section there’s a statement about stats by Dr. Loiselle, “In general, we can control up to about 80-90% of known individual brain metastases with various combinations of surgery and radiation. Whole brain decreases the risk of additional metastases elsewhere in the brain from about 50% down to about 25%.”. Hope this link answers your questions.

http://cancergrace.org/lung/2011/09/11/brain-metastases-in-lung-cancer-still-room-to-personalize-care/

All best,
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.

March 28, 2013 at 5:13 am  #1255230    

njliu

Hi Janine, thank you. I am always amazed by how resourceful you are. I read that article by Dr Loiselle earlier but I missed out the hidden gem in the comment section.
Well, the radiotherapist is of the opinion that there is this one new mets that has to be SRS’ed immediately. We however, decided to do a repeat MRI at 4 weeks apart to be more certain of the response or the lack of it from WBR treatment before we deciding.
It would be helpful if you can refer us to some experiences of people doing SRS after WBR.
NJ


Wife, 56, Asian, 11/11 Dx Adenocarcinoma 3B, EGFR+. 12/11 Iressa, great response. 12/12 asymptomatic brain mets with possible lepto, 1/13 WBR, continue Iressa, 9/13 Local Progression at primary tumor, 10/13 focal radiation, 1/14 PET Scan:Tumor Resolution, continue Iressa, 6/14 PET shows flare up at same primary. 9/14 CT stable.

March 28, 2013 at 5:40 am  #1255231    

JimC Forum Moderator

Hi NJ,

It can take a while to get an accurate picture of the effect of WBR. As Dr. West has said:

“It’s not unusual to recommend stereotactic radiosurgery (SRS) after whole brain radiation (WBR) if there are one or a few areas progressing. Options are certainly limited in that setting, and SRS is a leading option. However, it’s not especially common to do WBR with a plan to go straight to SRS without even seeing the outcome of the WBR. And yes, it takes weeks to even a few months to really be able to assess the results of WBR.” – http://cancergrace.org/cancer-treatments/topic/steriotactic-radiation-after-wbr/#post-2249

In that same thread, Dr. Loiselle added:

“I would repeat the MRI 4 to 6 weeks out from whole brain radiation (sooner or later depends on symptoms and how disease is controlled otherwise). If there are areas of progressive or non-responsive disease within the brain, I would treat them with SRS.” – http://cancergrace.org/cancer-treatments/topic/steriotactic-radiation-after-wbr/#post-2253

On the other hand, if this is clearly a new lesion and/or is large and causing symptoms, there could be more need to move quickly to SRS.

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

March 28, 2013 at 7:59 am  #1255233    

njliu

Hi Jim, thanks. The pre MRI was done about 10 days before WBR while the post MRI was 9 weeks after which revealed one new mets. The doubt is could it be something that have grown in the 10 days between pre MRI and WBR and thus could mean stable. There is no symptom and size is about 1cm. Thus the thinking is another 2 weeks delay should be just fine and the next MRI should yield better certainty of the progression status.
NJ


Wife, 56, Asian, 11/11 Dx Adenocarcinoma 3B, EGFR+. 12/11 Iressa, great response. 12/12 asymptomatic brain mets with possible lepto, 1/13 WBR, continue Iressa, 9/13 Local Progression at primary tumor, 10/13 focal radiation, 1/14 PET Scan:Tumor Resolution, continue Iressa, 6/14 PET shows flare up at same primary. 9/14 CT stable.

March 28, 2013 at 8:08 am  #1255234    

certain spring

Best of luck to you and your wife. I hope she is not feeling too tired from the WBR.


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.

March 28, 2013 at 11:13 am  #1255237    

laya d.

Yes. . .best of luck and please keep us posted. . .

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 28, 2013 at 3:12 pm  #1255246    

marisa93

Best wishes to you and your wife…will be watching for updates

Take care,
Lisa


Nov 23, 2010 husband(49/smoker) dx IV NSLC mets to brain/liver, Nov-Dec, 2010 15 WBR tx, Jan’11 MRI much improved, Dec ’10-Mar’11 4 txs carbo/alimta/avastin w/good response, Apr ’11 MRI mets almost gone, Apr ’11 start maintenance alimta, Jul ’11 MRI still good, Jul ’11 carbo/taxol for new lung met and 2 liver mets, Oct ’11 MRI new brain mets and major progression in liver, Nov 2, ’11 GK, Nov 19, 2011 at peace
Since then: http://cancergrace.org/forums/index.php?topic=11426.0

March 28, 2013 at 9:34 pm  #1255253    

Dr West

I don’t think I have anything to add, since Janine and Jim have provided great direction to the best information we’ve got here. I’m not aware of real data beyond that, just some anecdotal experience that we often do stereotactic radiosurgery (SRS) after whole brain radiation (WBR) and can see very good results.

-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.

March 30, 2013 at 1:42 pm  #1255279    

njliu

Thanks to everyone for sharing of info and support.
Dear Dr. West, it is reassuring to know SRS after WBR in not uncommon and can see good result. My question is both are basically the same in delivering radiation to zap the cancer cells, why would cells not responding to WBR force would give in to SRS? Is SRS delivering heavier concentrated dose and could inflict more damage to the brain tissue on its path and surrounding that target?
NJ


Wife, 56, Asian, 11/11 Dx Adenocarcinoma 3B, EGFR+. 12/11 Iressa, great response. 12/12 asymptomatic brain mets with possible lepto, 1/13 WBR, continue Iressa, 9/13 Local Progression at primary tumor, 10/13 focal radiation, 1/14 PET Scan:Tumor Resolution, continue Iressa, 6/14 PET shows flare up at same primary. 9/14 CT stable.

March 30, 2013 at 2:00 pm  #1255280    

JimC Forum Moderator

Hi NJ,

SRS is delivered in a high-dose, concentrated manner, often in just one session as opposed to the multiple sessions of WBR. While the total amount of radiation in one SRS treatment is greater than that of each WBR treatment, SRS uses multiple lower dose beams which take different paths through the brain before converging on their target. So except for the lesion being radiated which gets the full dose, surrounding tissue along each beams path gets much less. With WBR, all of the brain is radiated multiple times, so the radiation received by the entire brain is greater than that received by surrounding tissue as a result of SRS.

Hope that helps,

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

March 30, 2013 at 5:19 pm  #1255284    

Dr West

Jim’s exactly right. Essentially, SRS delivers a higher dose in a very limited area, which is appealing if there’s just one or very few areas to treat, but it’s less ideal if you need to treat many areas effectively, especially since the presence of many areas involved at once is associated with a higher risk that there are also other areas of disease that might not be visible yet.

-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.

March 30, 2013 at 7:22 pm  #1255285    

njliu

Thanks to Jim and Dr. West for the details. While there has been much written about the side effects of WBR, there is little that can be found on SRS. Would you please elaborate on that please?
NJ


Wife, 56, Asian, 11/11 Dx Adenocarcinoma 3B, EGFR+. 12/11 Iressa, great response. 12/12 asymptomatic brain mets with possible lepto, 1/13 WBR, continue Iressa, 9/13 Local Progression at primary tumor, 10/13 focal radiation, 1/14 PET Scan:Tumor Resolution, continue Iressa, 6/14 PET shows flare up at same primary. 9/14 CT stable.

March 30, 2013 at 7:26 pm  #1255286    

double trouble

I just wanted to say that I’m thinking of you and sending positive thoughts your way. Please keep us posted.
Debra

March 30, 2013 at 9:28 pm  #1255288    

Dr West

There is very little risk of side effects, but it depends on the location and size of the lesions being treated. The radiation oncologist planning the treatment should be able to provide a better sense of what side effects might possibly occur.

-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 17, 2013 at 12:00 am  #1255715    

njliu

Dear Dr. West, I read at another thread “moving forward” where you suggested holding off EGFR TKI for a couple of days before and after SRS while there is another post of yours indicates that concurrent Tarceva and WBR is fine. May I confirm that this it correct and the difference is due to the worry of SRS radiation of about 20 grays delivered at one shot vs the much lower individual shots of less than 3 grays each in WBR?
Thanks.
NJ


Wife, 56, Asian, 11/11 Dx Adenocarcinoma 3B, EGFR+. 12/11 Iressa, great response. 12/12 asymptomatic brain mets with possible lepto, 1/13 WBR, continue Iressa, 9/13 Local Progression at primary tumor, 10/13 focal radiation, 1/14 PET Scan:Tumor Resolution, continue Iressa, 6/14 PET shows flare up at same primary. 9/14 CT stable.

April 17, 2013 at 12:36 am  #1255719    

Dr West

That’s exactly right. WBR is different from SRS, and it’s inappropriate to extrapolate from one setting to another. Even with WBR, my preference is still to hold Tarceva, just to be safe, even if the limited data suggest it’s not excessively dangerous to have them overlap.

-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.

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