WBR only option after Gamma Knife? - 1263633

Tue, 05/06/2014 - 12:51

Hi all,

I'm posting regarding my Sister In Law illness... Long story short> NSCLC IV with mets to spine, brain, adrenal gland and lymph nodes. She underwent Gamma Knife back in Sep/Oct 2013 (she had two lesions) then 6 carbo/alimta rounds and started alimta maintenance. 6 month after dx PET scan showed activity only in 1 lymph node (everything else resolved) and it was recommended rad treatment to get rid of cancer cells in the lymph nodes.

She is finishing her 30 Rad Treatments and just learned that one of her two brain mets has new growth. The rad onc is recommending WBR now. FYI - while getting the rad treat, they started her on carbo/taxol as the onc said it potentiates the rad treat.

The new growth (from what I understood) has grown from the treated met.

Everything seemed to be working so well... she responded to chemo and they wanted to do rad to just get rid of that tiny spot ... I was really hopefull... and now WBR... whit all that it means...

My questions, I guess, are> it is ok to have WBR as her only option now? Can it be that stopping the alimta made the brain mets to re-grow? cant the do GK again?

Are there long term survivors out there that underwent WBR after progression from GK?

Thanks so much!

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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.

dr. weiss

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.

Dr West

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


Thank you Dr West, Dr Weiss and catdander for your Despite the question I asked, the treatment plan has now been changed, and after the neurosurgeon looked at the latest MRI the team finally recommended surgery.

For what I understood the new growth is attached or very close to the lesion previously treated with GK therefore they said it was too risky to do GK again.

They wanted surgery to leave WBR available in case something new shows up.

It makes sense to me, does it make sense to you?



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.

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