Late delayed radiation toxicity or side effects from SRS on excision site? - 1261390

Many thanks to both Dr West and Dr Loiselle for rendering their expert observations. At this point there is no definitive conclusion that my wife is suffering from radiation narcosis or even toxicity or recurrence.

So far, from the multiple MRI's since the SRS given in Sept 2011 the radiologists who read the scans consistently indicated no new lesion noted in the excision site nor any surrounding white matter edema.

All the reports indicated that "There are postsurgical changes with gliosis and amorphous enhancement at the operative site within the right occipital lobe"... and that " there are multiple foci of T2 signal hyperintensities identified within the white matter of both cerebral hemispheres. In this age group, they are most likely from small vessel ischemic changes"....

There are simply too much information for a lay person to understand or too little that is really known in medical science (or is it an art?)

Since wife had the one and only lesion detected in her brain, we decline WBR and she was given the SRS "1800 cGy delivered to 80% line" at the occipital surgical site as a "mop up" measure to assure that all the cancer cells are destroyed.

Q1: What are gliosis and amorphous enhancements?

Q2: Are these post surgical changes and T2 signal hyperintensities the results from too many MRI's or are they results from possibly radiation injuries?

Q3: Is there any new research recommendation on how best to treat a solitary brain met?

Thanks for helping to understand more how to render support to my wife.

Sorry, my last question Q3 should read: Is there any new recommendations for how best to monitor the after care for a patient with a "precocious solitary brain mets"?

I am very concern that the frequent MRI's would cause other potential problems such as toxicities and residual ill effects from the dye used for the MRI contrast. I realized that she is in some uncharted territory. When I asked the few questions, her physician team and oncologists almost always have no definitive answers.

Unfortunately despite her low to no cancer load condition and that she is EGFR positive and responding well to Tarceva, medical statistics has already written her off just because she has outlived the average life expectancy of a typical stage IV lung cancer survivor!!

Dr West,

I am in total agreement and respectful of your position in terms of not being able to provide medical opinion. Regardless, I appreciate much the existence of this website allowing patients and caregivers to share information and gain insight to make sense of life and how to deal with this "C" monster.

So far, her oncologist, radiologists, ophthalmologist and neurologists have not been able to make any sense of the shimmering in her left vision field "blind spot" and the visual migraine that she recently have experienced. I was hoping that the vast membership of this forum and the faculties may shed some light to her condition.

Thank you for taking time to follow her saga in her battle with cancer.

Are there any specific diagnostic tools to clearly differentiate between gliosis (scarring from surgical resection) and radiation necrosis vs. recurrence of cancer met in the brain?

Hello Dear Doctors/Faculty of Grace,

I am very much in distress. We are at a crossroad with the symptoms and condition of my wife. Its seems like medical science is at a standstill when it comes to my wife's treatment. She has been on Tarceva since Sept 2011 (3 yrs & 9 months). Currently she is still considered NED other than the recent finding in her MRI.

On July 2013 she first detected left vision field simmering and eye flashes (with visual migraines and aura) once or twice per week. Now her eye sight and occasional visual migraines has progressively getting worse (24/7 left vision field light shimmering and visual migraines 3 or 4 times a week each with duration of 20 to 30 minutes) MRI's since May 2014 detected light shadows of enhancement at the original surgical site where SRS was done.

The oncology team has not officially ruled out cancer recurrence. But based on the course and the timeline of her medical condition, they think its more likely radiation necrosis She had not been offered any form of treatment. The proposed intervention is to wait till the symptoms are totally intolerable then she will be offered steroid and possibly surgical or chemo with Avastin Just wondering if "wait until your back is against the wall" is the only approach in her situation or if there is any proactive treatment intervention that she should be on now before she is at a point of no return? Is hyperbaric oxygen treatment a possible choice of early intervention?

Any insight from anyone?

Thank you Janine for do some of the leg work in summarizing ahead of the faculty on all the pertinent posts on the subject of treatments for radiation necrosis. However all the embedded reference postings were at least 2 or 3 years old. Just wondering if there are any new data that point to preference of one method over the other when it comes to actually treating radiation necrosis? I have read this 2014 publication in Translational Cancer Research with a few of the co-authors happened to be from Swedish Radiosurgery Center, Swedish Medical Center, Seattle, WA, USA

http://www.thetcr.org/article/view/2950/html

My question is since Hyperbaric Oxygen seems to be pretty safe why is it not recommended as treatment of choice instead of the more invasive or damaging treatment like surgery and chemo with avastine?

Dear Dr. Loiselle and other esteemed faculties,

My wife's most recent monitoring MRI (12/1/15) shows further enlargement of the enhancing area in her right occipital lobe now measuring 3.2 x 2.4 x3.1. In Aug 2015, based on a number of scans including MRI's, perfusion MRI, and PET/CAT scan, the oncology treatment team concluded that my wife is suffering more from radiation necrosis and not recurrence. She was put on a 3 months MRI monitoring schedule.

But now the enhanced area has increased to almost double the size in all three dimensions since first discovered in May of 2014 (1cm AP x 1.8cm transverse x 1.2cm cranio-caudal), not sure the meaning of these units.

In addition to the 24/7 flashing of lights in a third of her left vision field in both eyes (since day one in May 2014) and occasional 2-3 times a week of 10-15 minutes duration of visual migraines, she now experiencing daily, a dull headaches at her right temple area that radiates to her right eye socket that necessitates her taking an extended release extra strength Tylenol.

The 12/1/15 report also suggests surrounding white matter edema and possible internal hemorrhage.

Is there any medical intervention at this point to control the edema and hemorrhage or do we just sit and wait for the symptoms to run its course and hope and pray that her body will take care of the necrosis?

Ben

Sorry I was remiss not including the following. Since July she was put on Trental and vitamin E for helping with the necrosis healing and Depakote for controlling the visual migraines.

I understood that Trental is supposedly to help with blood circulation. Should she stop Trental immediately in case it is causing the hemorrhage?

The treatment team members are each so specialized, that they may not have a good integrative picture! God have mercy.

Surgical excision of this "Necrosis" was done. Surgical notes stated "removed obviously necrotic tissue" for biopsy.

Biopsy report however stated "By immunohistochemistry, the tumor is positive for TTF-1 and Napsin: The morphology and immunophenotype are compatible with lung cancer origin"

My wife is now scheduled for repeat radiation of the "necrotic" site.(she had SRS back in 2011 of the same site where the original solidary cancer met was removed)

Question:

1) Could this positive pathology result is from simply a histological footprints of the original cancer met and not a real recurrence?

2) Now they are treating it as if its a recurrence with 10 fractionized IMRT (something they called Intensity modified radiation treatment?? not sure if I understood correctly) late February. We have to go there 10 consecutive days.

3)Is this second radiation going to cause more necrosis? They said 10 fractions will cause less problem.

.

Dr. Pennell, Thank you so very much for the explanation. Indeed the field of medicine is often times is like an art form. It takes the medical practitioners lots of dedication and effort to provide an individualized care to the patient. That is why this GRACE site is such a "God send" when I first discovered it.

In the case of my wife, she is on a daily 100mg of Tarceva, and she is considered NED with the exception of this recent discovery of radiation necrosis.

Is Tarceva considered a systemic chemo treatment?

Should she be off the Tarceva for the two weeks of pending radiation treatment?

I have read somewhere that a person should not have chemo concurrent with radiation treatment in fear that it would increase the dosage effect of the drug or the radiation and producing greater undesirable side effect of both.

Are there any do's or don'ts for this upcoming treatment?

I also read in GRACE somewhere that stopping Tarceva for whatever good reasons might trigger a flare up of the EGFR mutation with a vengeance. Is this true? What a catch 22 situation!

To all esteemed radiation oncology faculty,

I have some questions in how an external beam radiation of the brain or for that matter any part of the body, can focus on the cancer without damaging everything along the path? Case in point is with SRS or IMRT.

I understood that in IMRT, as many as up to 8 beams are used to avoid or spare certain structures of the brain or vital parts of the brain that might be more susceptible to injury to preclude unnecessary damages and preserve vital brain function.

I read and understood only vaguely and simplistically that with multiple beams and the fractionized delivery concept, only the focused point where all the beams meet would receive the most radiation dose while minimizing the collateral damage of the beams along the way.

However can someone please explain if in real practice, would the multiple beams’ individual pathways need to shift and change with each of the fractions delivered to attain the maximum benefit of structures and vital organ avoidance?

From an anxious husband

Ben

If the beams are fixed then each of the 10 or 12 fractions beam all passing through the same pathway. Would it not injure all the live cells along the way just the same?

Again I know very little if not nothing how this works. I can only imagine the radiation beams like a bunch of kids gathering around in circle each with a magnifying glass trying to aim the beam of light from the sun at a single match just to try to light it up on fire. Though the heat from each beam coming through the magnifying glass is relatively weak, but with all the beams concentrating on the same match, it catches up on fire in no time.

Is this pictorial analogy somewhat correct? Or am I all wet?

I am just too busy to worry about my wife's IMRT to come up with this question. Thanks for reading.

Dear Dr. Loiselle,

Thank you for your patience in explaining what I was asking. This is exactly why I love this site so much. Information presented patiently in layman's term is what brings people back to this site time and time again.

We are with a large HMO in Southern California. Most of the time we do not have such luck and luxury to communicate with our provider team. Thank you once again for the information you have given.

My wife has just completed (on March 9th) a 12 fractions IMRT on her right occipital lobe of her brain. This was a follow-up on the second brain resection done on Dec 12 2015.

The neurosurgeon found some viable cancer cell in the midst of a massive necrotic tissue, supposedly built up from 2011 after surgery removal of a solitary mets followed with SRS.

For some unexplained reasons, in this past week after the IMRT treatment, the hair on her entire left side of her head started falling off. The hair on her right side of her head is still intact.

Is this normally expected or did they zap the wrong side of her head?

Thank you Dr Weiss for attempting to answer my question.

That was exactly why I posted the earlier question in this thread. Radiation treatments, be it SRS or IMRT or for that matter WBRT are so brutal, scary and damaging that I wish there is a better alternative treatment.

One would think that if they can send a man to the moon and back they could have design a better form of treatment for brain cancer.

What I posted begs the question as to why in each consecutive fractionized multiple-beam radiation treatments would we not intentionally alter or change the entry and exit points (or the pathways) so as to minimize the repeat and cumulative damaging effect of the fixed beams passing the same set of healthy tissues or skin surfaces along the way? This procedure is so barbaric! God have mercy on us.