WBR only option after Gamma Knife? - 1263633

debye, I'm sorry about your sis in law. I'm not a doctor just a moderator with a little info. It sounds as if she was doing very well on alimta. It's unusual to move into curative mode (radiation/more chemo doublet) after having several points of metastases. It is believed once lung cancer moves out of the primary lung that it is in the blood and/or lymph system whether it shows up on scan or not, until some of the cells settle and grow into tumors. Radiation is usually reserved for problems like painful bone mets or tumors that constrict other organs, there's only so much radiation a person can handle.

It's possible alimta crosses the blood brain barrier/bbb though there's not enough data to know for sure. Some people do seem to have response in the brain. If someone isn't having symptoms from the brain met (steroids can help with swelling that sometimes causes symptoms in the tight space of the brain) alimta may be a choice. This is a blog post on the subject, http://cancergrace.org/lung/2009/09/21/alimta-for-brain-mets/

A second opinion is never a bad idea if the person with cancer has the strength and inclination. We can't say what options any one person might have over this forum but I will ask a doctor to reply.

Only a radiation oncologist can address the question of whether additional gamma knife could be used or whether whole brain is the only radiation option. If the growth is in the same area as before, typically additional gamma knife is challenging.

There have been patients whose cancer spread to brain was controlled on alimta. I'm not sure if the data has ever been published, but I've seen it presented. It's not typically our "go to" treatment, but chemo does sometime work when there are not other options.

Once cancer has spread to multiple sites, radiation is not the standard treatment and cannot be expected to be curative. However, when cancer is well controlled in all but a small spot, doctors do sometimes consider radiating that spot. Here, the goal isn't so much cure as improved control of the cancer.

I would just say that WBR is probably less likely to pose a threat than progressing brain metastases. Though it's wonderful she had such a great response, she did start with widespread disease, so unfortunately I don't think it's realistic to expect that she would remain without evidence of disease for years. The cancer tends to become increasingly resistant to treatments over time.

Like Dr. Weiss, I'm aware of some suggestive evidence that Alimta (pemetrexed) can have activity in the brain, but it's not an established, recommended treatment for progressing brain metastases. It may be reasonable to try Alimta and see whether there is improvement in the progressing brain lesion, which could obviate the need for WBR, but I fear that you're setting yourself up for crushing disappointment by having such high expectations when, in absolute terms, she has done extremely well.

Good luck.

-Dr. West

Since there is only one spot progressing in the brain, surgery can be an option but it is a very individualized decision based on the location of the lesion, the control of the cancer outside the brain and the general health of the patient. It's difficult for anyone not directly involved in her care to evaluate that recommendation.

JimC
Forum moderator

Yes, it's a question that needs to be addressed by someone directly reviewing her scans and her case.

Good luck.

-Dr. West