A 70 year old man with NSCLC after lobectomy 3 years ago developed a single brain metastasis 6 months ago. This was treated with SRS alone. He now has a new contralateral 2 cm brain metastasis in the non-dominant temporal lobe. A comprehensive restaging work up was performed with no demonstrated systemic disease. He has mild neurologic symptoms and a performance status of KPS 80.
What are the treatment options?
His treatment options include:
The ACR indicates that WBRT to 30 or 37.5 Gy is reasonable in 10-15 fractions ranking these a score 7, usually appropriate. They rank SRS+WBRT slightly higher at 8 and surgery + WBRT as slightly lower with a comment that surgical intervention may be less desirable due to previous response to RT and advanced age. In other scenarios, they marked surgery as lower due to concerns about surgical morbidity, thus there is apparent inconsistency in the scoring, although the cases are significantly different in nature. Surgery with post operative WBRT is rated the same as WBRT alone in the scores at 7. Surgery and post-op SRS is scored a 3, usually not appropriate due to limited evidence supporting the treatment. Both Chemotherapy and Best supportive care are scored 1, usually not appropriate.
This patient has recurred once, 6 months ago. SRS alone is possible, and might work, but there is now a recurrence, so I think we need something more. He has not had prior WBRT and I suspect there are occult metastases that will arise in a few months if more than local treatment is offered. WBRT to 30/37.5 Gy is reasonable and reasonably well tolerated. Adding SRS may also be reasonable as is surgical resection followed by WBRT (30/37.5 Gy). Supportive care in a good performance status gentleman with primary controlled disease is always an option, but his RPA status, despite his recurrence is Class I, with a median survival of an additional 7.2 months with treatment and shorter without.
This is a 60 year old gentleman with renal cell cancer who had prior surgical resection of two cerebellar metastases followed by WBRT to 35 Gy in 14 fractions at 2.5 Gy/fraction 18 months ago. He now presents with a new 3 cm left frontal metastasis without edema. Performance Status is KPS 90 without other evidence of systemic recurrence. He is asymptomatic.
What are his options?
His options are limited by his prior treatment. Surgical resection is often successful. WBRT is risky due to his prior radiation dose. A reduced dose may be appropriate at reduced dose/fraction if he has no other options, but he does. Both SRS and surgical resection are available. SRS to a resection cavity is unproven, and may be needed for local recurrence.
My recommendations are to discuss with the patient the type and nature of SRS and surgical resection and to recommend SRS or surgery. Either are good options and the ACR scores these as 8, usually appropriate.
A 44 year old woman with a history of breast cancer (ER/PR neg, H2N neg) presented 9 months ago with multiple brain metastases which was treated with WBRT to 30 Gy in 10 fractions. She now presents with asymptomatic bilateral anterior frontal masses, each measuring between 1 and 2 cm. She has no extracranial disease and her performance status is KPS 80. What are her options?
Her options are quite limited. It is possible to re-irradiate the brain and a current RTOG study is underway examining sparing the limbic system to reduce sequalae, but she has already had WBRT to 30 Gy. A reduced dose may be beneficial, but is very high risk. Neurosurgery is also possible, but would require separate craniotomies. SRS is less invasive and likely to be just as effective without the need for surgical intervention.
This patient is a 49 year old woman with melanoma who presented 6 months ago with multiple brain metastases and was treated with WBRT to 30 Gy in 10 fractions. She now presents with a right parietal 3.5 cm metastases with associated edema causing weakness. Her KPS is 70 and she has no known extra-cranial disease. What are her options?
Her options are quite limited. SRS may be appropriate if she is not an operative candidate, but neurosurgical resection would be preferred. The lesion is approaching the upper bounds of safe SRS treatment and must be treated with a lower dose of about 15 Gy to avoid increased risk of radionecrosis.
For this case, what are the follow up recommendations? Following recommended treatment of surgical resection alone, her performance status is KPS 90 and there is no known extra-cranial disease.
An initial MRI of the brain at between 1 - 3 months would be reasonable. She remains at risk for intracranial recurrence and if caught early would permit the use of SRS with a lower volume of treatment and potentially avoid the need for re-resection, saving a surgical procedure. It is likely that she will re-occur. If her disease is controlled initially, then quarterly MRI imaging is reasonable. Serial PET scans are not needed and the initial PET may be a means to distinguish radionecrosis from recurrence. An alternative, where available to PET might be MRI spectroscopy to distinguish recurrence from radionecrosis. CT is less desirable than MRI due to its decreased sensitivity to subtle soft tissue changes.