Brain mets: to continue Gefitinib or another chemo? - 1260616

vidoo
Posts:1

Hello !

My name is Vera and my mother, 58 yo, has cancer of the Lung since 2011. She has a moderately differentiated adenocarcinoma of the lung.
05 /2011 - surgery. Bilobectomy of the right lung. T2N1M0. The oncologist didn’t appoint chemo after surgery!
10/2011 - 2 brain mets . Made WBRT. Shrinkage of the mets, there is no new ones.
03 /2012 - CT scan: enlarged mediastinal lymph nodes . EGFR mutation detected .
since 06 /12 Iressa (Gefitinib). Iressa 250mg per day. Mediastinal lymph nodes were not enlarged, no metastases .
04 /13 - new brain metastases.
06 /13 - Gamma Knife. Iressa 1000mg 1/5 days
08/ 13 - more new brain metastases.
10/13 - Gamma Knife
She has no any chemo treatment, only Iressa. But new metastases in the brain appear again and again. According to the CT, no more metastases in the body, only in the brain . Feels good, but big problems with memory and logic.

Are we urgently need to do another chemo? What medications are best suited for lung mets in the brain? (Carbo, Taxotere, Pemetrexed, Bevacizumab, Etopozide, Gemzar, Temozolomide…?)
Could it be that Iressa «helps» the entire body except the brain?

Thank you very much for your help!

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Reply # - November 21, 2013, 02:44 AM

Dr West
Posts: 4735

Yes, targeted therapies for people with an activating mutation like EGFR or ALK are often quite effective in treating disease throughout the body but not in the brain because they don't get into the central nervous system (brain and fluids surrounding it) to a meaningful degree at standard dosing. No chemotherapy commonly used for lung cancer is known to be any better at treating or preventing brain metastases.

There is no clear standard here, but many/most experts favor treating brain metastases with radiation and not changing systemic (whole body) therapy in the absence of progression outside of the brain, since we can't hold systemic therapies responsible for the disease they can't get access to. The cancer isn't truly "resistant" to the drug if the drug isn't getting into the central nervous system effectively.

For people with multiple brain lesions, we typically favor whole brain radiation. Gamma knife is an effective treatment for a few lesions, but the more there are, the more likely there will be more appearing over time if whole brain radiation isn't done to treat the likely microscopic areas of disease that are likely present but unseen on scans in people who already have many brain lesions.

Good luck.

-Dr. West

Reply # - November 25, 2013, 10:52 AM

carrigallen
Posts: 194

There is very limited data that pemetrexed (Alimta) is able to achieve some brain penetration. This makes sense, since its cousin (methotrexate) is commonly used for brain lymphoma.

Here are some publications which provide evidence to support the use of Alimta for brain metastases, with some objective responses:

http://www.sciencedirect.com/science/article/pii/S0169500209003729

http://www.sciencedirect.com/science/article/pii/S0169500209001433

http://annonc.oxfordjournals.org/content/22/11/2466.short

http://www.sciencedirect.com/science/article/pii/S0169500212006770

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