When to administer stereotactic radiosurgery for brain metastasis? - 1257993

ishy
Posts:9

My father is aged 55years, never smoked tobacco, diagnosed with T2 N2 Adenocarcinoma of the lung (Pathological staging) with a solitary asymptomatic left temporal lobe ring enhancing lesion measuring 5mm.

28th Feb 2013: Right sided lobulated mass on CT
17th April 2013: Given tissue diagnosis of adenocarcinoma. Delay with diagnosis& surgery due to tissue diagnostic delay &SUV uptake for neck/spine on PET investigations were negative for cancer.
7th May 2013: Underwent right pneumonectomy. (Planned RUL lobectomy but peri-operatively tumour was crossing the horizontal fissure). Unfortunately 1-2mm pleural seeding resection biopsy +ve for adenocarcinoma
19th June 2013: Commenced chemotherapy (4 cycles) carboplatin/pemetrexed
27th June 2013: Contrast CT of thorax/abdomen revealed no new disease. However repeat cranial MRI showed an increase in size of the left temporal lobe lesion to 11.2mm & a further speck of a signal in the cerebellum which was not visible on previous MRI- but too small to report a size.
2nd July 2013: EGFR status for the tumour is NEGATIVE.
30th July 2013 – Due a repeat PET scan

My concern is that the temporal lobe lesion has doubled in size over 3 months.
Further PET arranged 13 days’ time &then to discuss the case in an MDT (multidisciplinary team) before deciding stereotactic brain surgery or WBRT and whether or not to give radiotherapy to the chest.

My questions are:
1. Should we request stereotactic radiosurgery for the brain ASAP (mid-chemotherapy?)
2. Can a solitary brain metastasis send further seeds of brain metastases?
3. Should we wait until the chemotherapy is completed as hopefully the pemetrexed could shrink the metastasis and then proceed to radiosurgery?

I am very grateful to Dr West and his team for the GRACE online service that you have provided. I practice as a primary care physician in the UK, however oncology itself is a rapidly developing specialty itself and I am grateful for your views and opinions on

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Reply # - July 17, 2013, 01:59 PM

catdander
Posts:

Hello ishy, I'm very sorry to know you and your father are going through this. You're right about cancer care being so specialized. Doctors on Grace have often said it's impossible for an oncologist to keep up with everything going on across the board in cancer care, making specialization ever more called upon.

I will ask a doctor to comment on your concerns. I hope your father will well with treatment.
Janine
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Reply # - July 17, 2013, 10:20 PM

Dr West
Posts: 4735

Ishy,

Though I admit I don't have the relevant details, I have to confess that I cringe when I think of someone who had a brain metastasis and pleural seeding at the time of resection undergoing pneumonectomy, a very debilitating surgery that almost certainly caused serious harm and no hint of benefit in this setting and which, I can't help but think, was absolutely not indicated. I hate to say that, but it's hard for me to wrap around the medical decision-making that would lead to such an unfortunate turn of events.

Given the size and the solitary nature of progression of the brain lesion, I don't think that timing is critical here. It would be misleading to say that we know exactly what is happening in terms of the pattern of metastatic spread in everyone, but we would suspect that new brain metastases are more likely from circulating tumor cells and not at all likely to be seeded by a solitary brain metastasis.

As we highlight in the guidelines, we really can't provide answers to any SHOULD questions...you're asking for a medical judgment that we can't legally provide, as it's not a situation of established medical standards or clear best practices. It's completely in the realm of judgment, and we can't tell someone who isn't our patient how their cancer should be managed. I'm sorry for that limitation.

Good luck.

-Dr. West

Reply # - July 18, 2013, 04:01 AM

ishy
Posts: 9

Hi Dr West,

Thank you for your opinion on the brain metastasis. It has really helped to clarify things for us as a family.
I would like to sincerely apologise for using the 'SHOULD' words in my questions and I entirely respect the GRACE Forum guidelines.
You are absolutely right, pneumonectomy is a very debilitating form of surgery (especially when you went in for an upper lobe resection and post operatively find out the extent of the surgery). It is very difficult to see my father like this and we as a family really feel for him.
When I spoke to the Respiratory Physician post operatively, we discussed about the CT/PET/MRI. There was no sign of pleural involvement and radical treatment was decided based on the single 4cm right upper lobe mass and solitary left temporal lobe lesion. My father was completely asymptomatic from the cancer and had an ASA score of II (hypertension) and normal Pulmonary function tests.
Fortunately his pneumonectomy has been uncomplicated so far and he is going for longer walks!
We are providing him with lots of love and care, and we pray to God that He blesses him and grants him success of longlasting remission and success with his current treatments.

I have seen your clips on systemic targeted therapies for metastases and this is a very interesting area. Unfortunately my fathers EGFR was negative for the Lung adenocarcinoma. Am I correct in assuming that all systemic targeted therapies will not work in this setting? Or is there scope for possible targeted therapies/newer agents?

Many Thanks

Ishy

Reply # - July 18, 2013, 07:14 AM

JimC
Posts: 2753

Hi Ishy,

In response to your question about targeted therapies, there are mutations other than EGFR for which molecular testing is being done. At present, the only other approved therapy is Xalkori (crizotinib) which targets the ALK rearrangement, which appears most often in non-smokers. You may want to talk to your father's doctor with regard to testing for this marker. There are tests for other markers, but agents targeting those markers remain in the investigational stages, available in clinical trials.

JimC
Forum moderator

Reply # - July 18, 2013, 09:12 AM

dr loiselle
Posts: 37

Hi Ishy -

In regard to your questions above - it does seem like radiosurgery for this lesion or these 2 possible lesions is reasonable. The timing is difficult to comment upon - it is very specific to your father's situtation. We'll need to defer you back to your physicians to help prioritize targeted vs. systemic therapy.

With regard to re-seeding, I agree with Dr. West that a solitary brain metastasis seems unlikey to spread to other areas within the brain... more likely that additional lesions are spreading from underlying systemic disease.

I hope that helps.

Dr Loiselle

Reply # - July 18, 2013, 09:15 PM

Dr West
Posts: 4735

We don't know of particular activity for most targeted therapies for brain metastases for lung cancer, at least in people who don't have a particular mutation, but chemotherapy can actually lead to shrinkage of brain metastases. The studies that have looked at this have showed that chemo tends to be more effective than appreciated. You can learn more about that here:

http://cancergrace.org/lung/2007/10/24/chemo-for-brain-mets/

Good luck.

-Dr. West

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