NSCLC IV Adeno ALK+ resolution for brain lesion - 1293155

Hi ikhlaq1,

I'm sorry to hear of the progression of your brother's cancer. Although it is understandable to have concern about brain radiation, it is the best option to treat brain metastases. Often, when there is only 1-3 metastases present, focused radiation such as Gammaknife or Cyberknife can be used. They are pretty much the same, just different trade names for the same type of high-dose, focused radiation. When there are more brain mets present, then whole brain radiation (WBR) is favored. WBR uses a lower dose per treatment, but a greater number of treatments.

In your brother's case there may be concern that there are more lung cancer cells in the brain which will in time produce additional metastases. With that in mind, WBR can more or less "sterilize" the brain of cancer, destroying all the cancer cells which may be present. It certainly makes sense to contact your brother's doctor to discuss the reasons for recommending WBR rather than radiation targeting only the existing brain met.

As far as stopping Zykadia during radiation, although there isn't a great deal of data, many oncologists will stop any systemic therapy, especially if it is known (as is Zykadia) to penetrate to blood brain barrier. As GRACE faculty member Dr. Nathan Pennell states "Both alectinib and Zykadia have been shown to have efficacy in brain metastases, in addition to the rest of the body." - http://cancergrace.org/lung/tag/zykadia/

Xalkori, on the other hand, does not tend to reach the brain, so it is possible that the brain met formed and started to grow before switching to Zykadia. Only a brain scan performed prior to the switch would help determine that.

In any event, when a systemic therapy is controlling disease in the rest of the body, it's not uncommon to continue that therapy after treating the brain mets with radiation.

Good luck to your brother in treating the brain metastasis and keeping the rest of his cancer under control.

JimC
Forum moderator

ikhlaq1,

Yes, alectinib has proven to be effective in the brain for many people in whom alectinib is effective in the rest of the body. Since leptomeningeal disease (lepto, cancer in the lining of the brain) is so difficult to treat alectinib would be a leading choice of treatment. Since this is a new treatment many oncologist still want to use radiation for areas that are causing symptoms. If your brother has symptoms from the brain met outside the lining stereotactic radiation may still be an option then move on to alectinib. Again, being a new drug without much research directed at lepto in ALK + patients his oncologist may not have that info and may need to be introduced to the idea. This is an excellent example of being partner in ones own treatment (a busy medical oncologist who is treating many types of cancer may not know of this new practice that is very promising but isn't written in standard practice flow charts.)

The following quote along with the article from the National Institute of Health may be helpful in talking to your brother's onc. " Additionally, alectinib was reported to have activity in ALK+ NSCLC patients with leptomeningeal disease (15,16)."
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5401676/

In case your not aware of the new conference videos this is from the Targeted Therapies in Lung Cancer Patient Forum held in Cleveland, OH a couple of weeks ago, http://cancergrace.org/lung/2017/09/28/targeted-therapies-in-lung-cance…

Keep us posted and Best of luck to your brother.
Janine

ikhlaq1,

The standard treatment for brain metastases is radiation, which has a high rate of success and tends to provide symptom relief faster than systemic therapy (chemo or targeted therapy). Although alectinib does not have the long track record of success that radiation has, it is an option. But in making that choice it would be important to consider the current level of symptoms from the brain mets and whether those symptoms are getting worse relatively quickly. More significant/burdensome symptoms and a fast rate of progression of those symptoms would tend to tilt the balance in favor of radiation. If the mets are less symptomatic, then it's reasonable to try alectinib. If a follow-up scan doesn't show it to be effective or if symptoms start to get worse, then radiation would still be an option.

If Alimta was stopped due to side effects and not disease progression, then it could be tried at some point, but most likely only if the brain mets were brought under control and Alimta was being used to treat the disease in the rest of the body.

JimC
Forum moderator

Hi khlaq1,

I understand your desire to make a good treatment decision. Here at GRACE, we can provide information but not specific advice as to what a patient should do. Your brother's medical team has a great deal more information about his situation than you have provided or could provide, which is needed to make good therapy choices.

I will add that it is premature to state that "Alectinib is very good for leptomeningeal". The article at the link Janine provided states that there is evidence that alectinib "was reported to have activity in ALK+ NSCLC patients with leptomeningeal disease." The footnotes to that statement reference two reports, one which discussed a single patient, and another dealt with four patients. As you might imagine, doctors tend to write about success stories, but we don't necessarily hear about the patients who did not respond; that information is more likely to appear in the results of large clinical trials. We don't yet have full data on just how effective alectinib is for leptomeningeal disease in lung cancer.

In addition, the report states that "Early small data sets showed that the intracranial response rate of alectinib ranged from 40% to 57%." Two things to note from that statement: these are small data sets, which may not reflect the experience observed in a larger group of patients, and the response rate quoted indicates that 43 to 60 percent of patients treated with alectinib did not respond.

I'm not in any way attempting to talk you out of trying alectinib, but the purpose of this site is provide relevant information to help you and your brother and his doctors make good choices. Leptomenigeal disease is difficult to treat, and the reports cited in the article are encouraging, warranting further study, but we just don't have enough data at this point.

JimC
Forum moderator