3 new brain mets 6 months after SRS - treatment options - 1258584

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jitesh
3 new brain mets 6 months after SRS - treatment options - 1258584

Dear Doctors at Cancer Grace,

I have been following your advise at this site for last 6 months but posting for the 1st time as i am a bit worried. I know you cannot give specific advise but could you please guide. My dad is 61 healthy never smoker and was diagnosed with NSCLC Adeno in February 2013.

Dad had two brain mets when he was diagnosed and he was treated with surgery for large met + SRS for small met + 6 cycles of Carboplatinum + Alimta for primary tumor in right lung + adrenal met + low grade tumor in right lung.

CT after 3rd cycle showed 50% shrinkage of primary tumor only and CT after 6th cycle showed stable (no different from previous CT). But the MRI scan of the brain yesterday and it showed 2 new mets about and one more brain met at original site all about 1cm large.

We were planning on Alimta maintainence before the MRI scan came in and we will do that anyway probably but need to tackle the brain mets 1st. The location of current brain mets i think is superficial and can be tackled by SRS. But we are worried why they came back so fast. I am not sure if my dad has poorly differentiated or well differentiated adeno.

Should we just do SRS or follow up with WBR or intrathecal chemo for the brain. I am really worried & dont want to put dad through WBR or intrathecal chemo if not required as dad is doing great otherwise but also afraid what if the brain mets come back deep inside where they cannot do SRS.

Please help and advise your experiences and knowledge.

catdander
Reply To: 3 new brain mets 6 months after SRS – treatment

Hello Radha, I'm so sorry that your dad's having such a difficult time. There's been much written on the subject of brain mets. Injecting chemo directly into the brain hasn't shown to be helpful though there are several other personalized practices being done. Here are a few blog posts that will explain the thinking behind some of them. The last one is a page of links. Also there's more on tab General Cancer Info/radiation treatment

http://cancergrace.org/lung/2011/09/11/brain-metastases-in-lung-cancer-s...
http://cancergrace.org/radiation/2012/01/18/sbrt-and-optimal-candidates/
http://cancergrace.org/radiation/2012/12/07/video-on-systemic-rx-for-bra...
http://cancergrace.org/lung/category/lung-cancer/general-lung-cancer-iss...

Feel free to read up on our doctors' thoughts on the subject and ask even more specific questions afterward.

All best,
Janine

Dr West
Reply To: 3 new brain mets 6 months after SRS – treatment

It's not likely that brain metastases came back as much as that there are very small or even invisible microscopic brain metastases in the background that are not treated at all by SRS to 1-2 other sites. So SRS doesn't address the very significant risk that these other spots will grow over time, which is why we favor WBR when there are more than about 3 brain lesions. When there are multiple brain lesions, it's very probable that there will be more appearing if WBR isn't done.

I would say that while SRS could be done, there is a very high risk that there will be more brain mets later; in contrast, that risk will be far lower if WBR is done. There is no role for intrathecal chemotherapy in this setting.

-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Medical Oncologist
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

jitesh
Reply To: 3 new brain mets 6 months after SRS – treatment

Thanks a lot for your reply Dr. West and Janine.

Dr West -thanks for clarifying there is no role for intrathecal chemo - i was really scared of that thought. I guess lung cancer is a roller coaster ride. Dad had been enjoying great quality despite a brain surgery+ SRS+6 cycles of chemo till now. But I'm worried if WBR will change that and also make it difficult for him to start the systemic therapy (altimta maintainence) and keep it going on.

Could you please advise if a PET CT will help understand how much risk we can take regarding possibly delaying systemic maintainence and also if the third brain met which came back in the same original spot where did they SRS is actually radiation scar? Will it be unreasonable to postpone WBR for now and look at other options - 1) SRS + pulsed Tarceva (dad is EGFR-ve ALK-ve) 2) keep doing SRS if more brain mets come back?

Please note that I highly value your opinion Dr. West and understand it's not always in the best interest / long term survival to only think about quality of life. I am just wondering if my dad could be considered a borderline case between few brain mets vs too many brain mets.

Thanks again
Jitesh

Dr West
Reply To: 3 new brain mets 6 months after SRS – treatment

As you know, it's not my place to tell you what to do. I think that the risks posed from WBR are not negligible but are often far greater than is justified.

I don't see a value in a PET/CT in assessing whether to hold chemotherapy. That is something that I would consider to be determined by the bulk and pace of the disease up to this point -- not something that is likely to be informed by a PET scan.

Also, I'd say that there is likely to be somewhere between extremely little and absolutely no value of pulsed Tarceva (erlotinib) in someone who doesn't have an EGFR mutation.

The individual management questions are ones you need to discuss with his doctor.

Good luck.

-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Medical Oncologist
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education