CASE: ES-SCLC with solitary brain met. When/What to irradiate?

[Palex80]

Here's an interesting case, I'd like to have your input for.

68 year old male patient, extensive-disease SCLC with a solitary (big) brain metastasis. The metastasis is 3 x 4 x 5cm in the temporal lobe, distance to chiasm about 4 mm, lot's of edema. No further lesions in the brain and no other mets, just the primary in the lung and a hilar node (probably cT2 cN1). The patient requires 4mg Dexamethasone for the brain metastasis due to symptoms. He has just started his second cycle of Carboplatin/Etoposide/Atezolizumab and the med onc sent me the patient asking me to irradiate the brain. I think he'd be happy, if he can drop the steroids because of the Atezolizumab.

Question 1: When should I irradiate?
a) Now!
b) Wait till he's done with chemo and treat then.
c) Wait till he's done with chemo, maybe he will reach CR and you don't have to treat at all.

Question 2: What should I irradiate?
a) WBRT! It's SCLC, stupid!
b) Do a stereotactic fractionated treatment, for instance 5 x 6 Gy, leave WBRT for later in case he develops more lesions (FIRE-SCLC). In that case, what should I go for as a chiasm-constraint, bearing in mind I may have to give 20/4 or 30/3 later on?
c) Do WBRT and add a SIB for that metastasis.

Thank you!

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[evilbooyaa]

Interesting case.

I'd Favor fSRT now to lesion 6Gy x 5. Try to keep optics point dose to <20Gy if feasible, definitely <25Gy. Could do 6Gy x 5 to GTV and 5Gy x 5 to say a 1mm PTV as well.

I'd try to do it between cycles of chemotherapy to avoid chemo delays. Imagine they're giving q3 weeks chemo? Would considering starting RT in second week, so that if you do daily you'll be done in a week, or if every other day, done in a week and a half. I generally prefer QOD even for 5fx fSRT, if it's going to 30Gy, but would consider compressing given need to avoid chemo delays.

Look forward to lively discussion.

 

[zpiff]

I would whole brain now. Can come back later if you feel like to need to SRS/SRT something. I would not count on chemo/immuno to do much on something large and currently symptomatic.

 

[thecarbonionangle]

7gyx5, chiasm dmax <20 if possible or 25 (but this wouldnt leave you much room for later)

alternatively i think 30/10 WBRT is totally reasonable and you can consider FSRT later

 

[scarbrtj]

Before the flood, guy woulda got whole brain in between the 3 week chemo cycles. Not sure that any fancy modern nouveau riche stereotactical prestidigitation would alter clinical courses such as these versus how they might have behaved way back when. Can re-stage brain ~1-2 months after WBRT and if any residual, give FSR then. Should be smaller (less chance for toxicity), farther from chiasm (less chance for toxicity) etc etc. And also might be an opportunity to discuss some consolidative RT to chest EDIT: if you're FSR bound and determined now, based on the size (and edema), I would consider "wide margin" 10 Gy/4 fx or 15 Gy/6fx on that now (right before next chemo cycle) , then rescan and replan (1 week after chemo cycle), and do the FSR then.

 

[RadOncDoc21]

A year ago I would have favored SRS (either single or multi-fraction) but I’ve seen to many small cells progress in the brain (and other places) to feel uneasy to not just give whole brain.

 

[BobbyHeenan]

I've been doing more and more SBRT/SRS for small cell....but make no mistake, they eventually have distant intracranial failure almost uniformly. Anecdotally QoL remains higher the longer you can put off the WBRT.

I like 30/5 here focal radiation in between chemo cycles. Get a new MRI after his 2nd cycle, as this thing may have shrunk a lot. Treat between cycle 2/3 or 3/4.

I have zero problems with any of the above answers though and wouldn't even suggest changing plans if my partners presented any of the options at chart rounds.

 

[Ray D. Ayshun]

Don't we regularly monitor asymptomatic NSCLC with brain MRI at 6 weeks if receiving systemic therapy? Good chance this goes away as well. At the same time, what evil said.

 

[medgator]

Don't we regularly monitor asymptomatic NSCLC with brain MRI at 6 weeks if receiving systemic therapy? Good chance this goes away as well. At the same time, what evil said.

I think that's only in sclc? I routinely will have chemo start and treat after 2-4 cycles if the brain mets are asymptomatic and there is a lot of extracranial disease

 

[Ray D. Ayshun]

I think that's only in sclc? I routinely will have chemo start and treat after 2-4 cycles if the brain mets are asymptomatic and there is a lot of extracranial disease

Sure, but after 2-4 rounds of chemo in SCLC with asymptomatic brain mets, do you do WBRT if there's NED on MRI?

 

[FrostyHammer]

I would radiate his brain now because he's symptomatic. Given the quality of evidence and still high proclivity to recur other places in the brain, it's honestly best to have a joint discussion with the patient whether to do WBRT (the SOC) vs fSRT (per FIRE SCLC) vs HA-WBRT. Depends how much the patient uses his/her higher order cognitive function at baseline and how much they're wanting to balance distant brain failure with cognitive preservation. It shouldn't be a one sized fits all approach.

 

[medgator]

Sure, but after 2-4 rounds of chemo in SCLC with asymptomatic brain mets, do you do WBRT if there's NED on MRI?

I've done repeat brain MRIs vs offering PCI. Tough situation for sure

 

[evilbooyaa]

7gyx5, chiasm dmax <20 if possible or 25 (but this wouldnt leave you much room for later)

alternatively i think 30/10 WBRT is totally reasonable and you can consider FSRT later

Seems a little high for brain met dose, especially in a radiosensitive phenotype, no?

Lesion is 4mm from optics - how are we going to get 35Gy down to 20Gy in 4mm without losing all sense of conformality?

Don't we regularly monitor asymptomatic NSCLC with brain MRI at 6 weeks if receiving systemic therapy? Good chance this goes away as well. At the same time, what evil said.

Rare situations with diffuse punctate mets that are getting say osimeritinib b/c of EGFR mutation, sure, but very small subset. I would hope people aren't doing pembro for NSCLC brain mets outsdie of a clinical trial....

Not aware of any data of chemo/immuno for brain met control in SCLC. Yes, some say lesions respond temporarily to chemotherapy but never heard of a situation where that has been durable response.

 

[thecarbonionangle]

Carbon ion FSRT, duh.

It’s basically an SIB where you can to meet your goals,bystander effect. I try to get 98-99 pct coverage with 30gy when i can. Have had good success with it but i totally think 30/5 is reasonable. Just minor differences. You can probably get 35 to at least 70 pct of the tumor, though i’d have to look at the scan to give a more informed opinion.

 

[evilbooyaa]

Carbon ion FSRT, duh.

It’s basically an SIB where you can to meet your goals,bystander effect. I try to get 98-99 pct coverage with 30gy when i can. Have had good success with it but i totally think 30/5 is reasonable. Just minor differences. You can probably get 35 to at least 70 pct of the tumor, though i’d have to look at the scan to give a more informed opinion.

Ah, fair. 30/5 to margin and trying to heat up GTV to 7Gy x 5 sounds reasonable.

 

[Palex80]

Great discussion, keep it going, I appreciate this! I'm seeing the patient tomorrow, let's see if I can make up my mind until then.

 

[RadOncDoc21]

Great discussion, keep it going, I appreciate this! I'm seeing the patient tomorrow, let's see if I can make up my mind until then.

I would send him/her only to a high volume palliative fellowship trained rad onc personally.

 

[Lamount]

Here's an interesting case, I'd like to have your input for.

68 year old male patient, extensive-disease SCLC with a solitary (big) brain metastasis. The metastasis is 3 x 4 x 5cm in the temporal lobe, distance to chiasm about 4 mm, lot's of edema. No further lesions in the brain and no other mets, just the primary in the lung and a hilar node (probably cT2 cN1). The patient requires 4mg Dexamethasone for the brain metastasis due to symptoms. He has just started his second cycle of Carboplatin/Etoposide/Atezolizumab and the med onc sent me the patient asking me to irradiate the brain. I think he'd be happy, if he can drop the steroids because of the Atezolizumab.

Question 1: When should I irradiate?
a) Now!
b) Wait till he's done with chemo and treat then.
c) Wait till he's done with chemo, maybe he will reach CR and you don't have to treat at all.

Question 2: What should I irradiate?
a) WBRT! It's SCLC, stupid!
b) Do a stereotactic fractionated treatment, for instance 5 x 6 Gy, leave WBRT for later in case he develops more lesions (FIRE-SCLC). In that case, what should I go for as a chiasm-constraint, bearing in mind I may have to give 20/4 or 30/3 later on?
c) Do WBRT and add a SIB for that metastasis.

Thank you!

I would be worried about treating with concurrent full dose chemo/IO. The chemo alone would make me uncofortable, but the Atezo+RT together could make the tumor swell right into the chiasm. Thus, I would try to sneak in a course of RT a little before he would be due for his next cycle (3 weeks?) and have them hold it until you are done... assuming thoracic disease burden is minimal

I would try to do c) (SIB 30/35 Gy) +/- HA avoidance to the extent that is reasonable.

 

[scarbrtj]

I would be worried about treating with concurrent full dose chemo/IO. The chemo alone would make me uncofortable, but the Atezo+RT together could make the tumor swell right into the chiasm. Thus, I would try to sneak in a course of RT a little before he would be due for his next cycle (3 weeks?) and have them hold it until you are done... assuming thoracic disease burden is minimal

I would try to do c) (SIB 30/35 Gy) +/- HA avoidance to the extent that is reasonable.

FWIW every time chemo (carbo eg) and RT at same time to brain has been looked at in these situations (random Google grab here) no obv neurotox has been shown. The only reason I don’t do this more often (but I do do it on occasion with a simpatico med onc and especially in SCLC) is I just don’t wanna get (incorrectly) blamed for something bad.

Use of Systemic Therapy Concurrent With Cranial Radiotherapy for Cerebral Metastases of Solid Tumors

This review summarizes the neurotoxicity data for combining systemic therapy (chemotherapeutics, molecular targeted agents, or monoclonal antibodies) with concurrent radiotherapy of brain metastases. For most systemic therapies, the currently available ...

www.ncbi.nlm.nih.gov

 

[Ray D. Ayshun]

I just had this exact patient referred for thoracic rt after chemo. Med oncs decided to observe the single brain met. It disappeared and has stayed gone for 6 months. I explained things, but haven't given any gy to the head. Im happy with the decision.

 

[xrt123]

Nobody would do whole brain here? Please update me when the next MRI shows more mets. Throw some memantine at the patient if you need to sleep better at night. We are changing standard of care with some retrospective reviews showing SRS Feasible in small cell?

If your zip code is in the APM and you realize that your not going to get paid for when she/he/preferred pronoun fails in the next 90 days you will be back to whole brain.

 

[seper]

30 Gy/ 10 fx WBRT now

 

[Palex80]

Thank you for this excellent thread.

I've seen the patient now and decided to do the following:

Perform an MRI and treat between the second and third chemo cycle (=in the next 2 weeks) only the lesion with a "soft" FSRT dose, something like 3 x 7 Gy (@80% isodose) probably, provided the lesion has shrunk in the MRI. Then, complete chemotherapy and carry out PCI with 10 x 2.5 Gy, if MRI shows good response and no new lesions.

The argument not to do WBRT now, is to spare toxicity during chemotherapy. I felt uncomfortable ommitting it, thus opted to carry it out later.
I hope that with the FSRT the lesion will shrink fast and allow for the patient to go off steroids.

 

[evilbooyaa]

Thank you for this excellent thread.

I've seen the patient now and decided to do the following:

Perform an MRI and treat between the second and third chemo cycle (=in the next 2 weeks) only the lesion with a "soft" FSRT dose, something like 3 x 7 Gy (@80% isodose) probably, provided the lesion has shrunk in the MRI. Then, complete chemotherapy and carry out PCI with 10 x 2.5 Gy, if MRI shows good response and no new lesions.

The argument not to do WBRT now, is to spare toxicity during chemotherapy. I felt uncomfortable ommitting it, thus opted to carry it out later.
I hope that with the FSRT the lesion will shrink fast and allow for the patient to go off steroids.

Many acceptable answer choices to the solution at hand, including this one. Best of luck!

 

[Neuronix]

Here's an interesting case, I'd like to have your input for.

68 year old male patient, extensive-disease SCLC with a solitary (big) brain metastasis. The metastasis is 3 x 4 x 5cm in the temporal lobe, distance to chiasm about 4 mm, lot's of edema. No further lesions in the brain and no other mets, just the primary in the lung and a hilar node (probably cT2 cN1). The patient requires 4mg Dexamethasone for the brain metastasis due to symptoms. He has just started his second cycle of Carboplatin/Etoposide/Atezolizumab and the med onc sent me the patient asking me to irradiate the brain. I think he'd be happy, if he can drop the steroids because of the Atezolizumab.

Question 1: When should I irradiate?
a) Now!
b) Wait till he's done with chemo and treat then.
c) Wait till he's done with chemo, maybe he will reach CR and you don't have to treat at all.

Question 2: What should I irradiate?
a) WBRT! It's SCLC, stupid!
b) Do a stereotactic fractionated treatment, for instance 5 x 6 Gy, leave WBRT for later in case he develops more lesions (FIRE-SCLC). In that case, what should I go for as a chiasm-constraint, bearing in mind I may have to give 20/4 or 30/3 later on?
c) Do WBRT and add a SIB for that metastasis.

Thank you!

Why wasn't brain MRI done before starting chemotherapy?

I would have advocated for resection of this monster. First, there's no faster way to get the edema down and get the patient off steroids. Yes SCLC is radiosensitive but that's no guarantee that they will have a great response to RT. There are several reasons to get the patient off steroids (immunotherapy effect, symptoms, dexamethasone side effects). Second, it's very close to chiasm. Maybe you can get full dose to the whole tumor, maybe not. Depends on your SRS setup when you're talking about 4 mm. Third, is this actually a SCLC met at all? I mean, that's a safe assumption, but one large brain met only is an unusual presentation for SCLC, especially one which is early stage otherwise. Then post-op fractionated SRS of course.

If we're going with SRS, yes would just SRS this beast ASAP. 30-35 Gy in 5 fractions is reasonable. I'd try to keep chiasm/optic nerves to 20 Gy if possible for possible need for re-RT later. I would not take a chance on chemo-immuno alone in someone with a huge brain met that is causing symptoms. I am in the camp of people who treats SCLC just like NSCLC when it comes to brain mets.

 

[Palex80]

Why wasn't brain MRI done before starting chemotherapy?

I would have advocated for resection of this monster. First, there's no faster way to get the edema down and get the patient off steroids. Yes SCLC is radiosensitive but that's no guarantee that they will have a great response to RT. There are several reasons to get the patient off steroids (immunotherapy effect, symptoms, dexamethasone side effects). Second, it's very close to chiasm. Maybe you can get full dose to the whole tumor, maybe not. Depends on your SRS setup when you're talking about 4 mm. Third, is this actually a SCLC met at all? I mean, that's a safe assumption, but one large brain met only is an unusual presentation for SCLC, especially one which is early stage otherwise. Then post-op fractionated SRS of course.

If we're going with SRS, yes would just SRS this beast ASAP. 30-35 Gy in 5 fractions is reasonable. I'd try to keep chiasm/optic nerves to 20 Gy if possible for possible need for re-RT later. I would not take a chance on chemo-immuno alone in someone with a huge brain met that is causing symptoms. I am in the camp of people who treats SCLC just like NSCLC when it comes to brain mets.

An MRI was done before chemotherapy. The med oncs managed the patient, so the tumor board was only after they had started with chemotherapy.
Resection would be tricky. This lesion lies deep in the temporal lobe and it's big. I have doubts about clear margins and neurologic impairment / prolonged recovery may become an issue. You don't want the patient to become that sick due to surgery that he won't be able to get his chemo in due time.

GBM was also considered as a possible diagnosis next to the known SCLC. I guess the next MRI will tell us what happened. If it shrunk, it's SCLC. If not, well then that is one really unlucky patient, I guess...

When you say "I am in the camp of people who treats SCLC just like NSCLC when it comes to brain mets." does it mean you wouldn't give WBRT to this patient (few of us would give WBRT to a patient with a single brain metastasis from an NSCLC, I presume)?

 

[Neuronix]

When you say "I am in the camp of people who treats SCLC just like NSCLC when it comes to brain mets." does it mean you wouldn't give WBRT to this patient (few of us would give WBRT to a patient with a single brain metastasis from an NSCLC, I presume)?

Correct

 

[xrt123]

Correct

Do you do PCI in limited stage? If you do then how do you justify SRS in somebody with single met?

 

[Neuronix]

Do you do PCI in limited stage?

Only on trial (CC003 or MAVERICK). Off trial I discuss with the patient and they pretty much always refuse. Very hard to even enroll on trial.

 

[Palex80]

Only on trial (CC003 or MAVERICK). Off trial I discuss with the patient and they pretty much always refuse. Very hard to even enroll on trial.

That's interesting and certainly not the experience I have. Most patients (>80%) witth LD-SCLC want PCI.

 

[Neuronix]

Whole brain radiation in my area is like the devil. Patient advocacy groups and Internet forums have demonized whole brain radiation to the point where many patients or their families are deathly afraid of it. Heck, I went on a ski trip once and met someone (a high power executive type), and when they found out I was a rad onc went on a half hour tirade about how whole brain radiation killed their mother (ovarian cancer brain mets) and how can anyone do that to people.

I have had two patients with active brain mets refuse whole brain radiation therapy due to fears about side effects and go to their death of progressive brain disease. I dread the 2 hour phone calls I have to have with patients and their families to convince them to get whole brain RT when it is strongly indicated. Obviously this isn't everyone, but 50% wouldn't be an exaggeration. I'm about to give SRS to mets #40-54 later this week for such a young patient with breast cancer brain mets. Few surgeons or med oncs in the institution will back me up on whole brain RT--the mantra is to avoid whole brain radiation at all costs. I was a speaker on a panel recently for brain mets management, and yes the audience was surgeons, but they would do SRS to just about anything. So in some ways I am the product of my environment here.

Regardless of all that, for PCI I don't believe the data. A meta-analysis of several old, heterogenous, and individually negative trials with no MRI brain met surveillance is not high quality data. I'm glad that Chad Rusthoven was able to get MAVERICK going and hope it accrues. There's like this dogma of PCI in SCLC. We now know it has serious neurocognitive effects. It's been proven ineffective in ES-SCLC, and PCI for all SCLC including extensive stage was dogma just five years ago. I strongly suspect the same is coming for LS-SCLC.

 

[OTN]

Whole brain radiation in my area is like the devil. Patient advocacy groups and Internet forums have demonized whole brain radiation to the point where many patients or their families are deathly afraid of it. Heck, I went on a ski trip once and met someone (a high power executive type), and when they found out I was a rad onc went on a half hour tirade about how whole brain radiation killed their mother (ovarian cancer brain mets) and how can anyone do that to people.

I have had two patients with active brain mets refuse whole brain radiation therapy due to fears about side effects and go to their death of progressive brain disease. I dread the 2 hour phone calls I have to have with patients and their families to convince them to get whole brain RT when it is strongly indicated. Obviously this isn't everyone, but 50% wouldn't be an exaggeration. I'm about to give SRS to mets #40-54 later this week for such a young patient with breast cancer brain mets. Not a single surgeon or med onc in the institution will back me up on this--the mantra is to avoid whole brain radiation at all costs. I was a speaker on a panel recently for brain mets management, and yes the audience was surgeons, but they would do SRS to just about anything. So in some ways I am the product of my environment here.

Regardless of all that, for PCI I don't believe the data. A meta-analysis of several old, heterogenous, and individually negative trials with no MRI brain met surveillance is not high quality data. I'm glad that Chad Rusthoven was able to get MAVERICK going and hope it accrues. There's like this dogma of PCI in SCLC. We now know it has serious neurocognitive effects. It's been proven ineffective in ES-SCLC, and PCI for all SCLC including extensive stage was dogma just five years ago. I strongly suspect the same is coming for LS-SCLC.

STRONGLY agree that the "NEVER DO WHOLE BRAIN!!!!!1111!1!!" virtue signaling on Twitter and other places is so forceful it's become damaging to patient care. There still remains a role for whole brain RT from time to time, and those who suggest otherwise are being unnecessarily dogmatic.

 

[Palex80]

I do not have the MAVERICK trial protocol. It is designed as a non-inferiority trial with 2-years OS as a primary endpoint.
Based on the (old) trials we have on LD-SCLC, PCI seems to add something like 5% OS-benefit at 5 years (yes, yes, with all the shortcomings of these old trials).


I have three questions:

1. What non-inferiority margin for 2-years OS was assumed for the MAVERICK trial?
2. Does the protocol specify how patients in the non-PCI-arm are supposed to be treated in case of progression? Is it "SRS for up to X lesions?" or "WBRT at first sign of progression" or "SRS, if feasible, for first progression and WBRT for any subsequent progression"?
2. I question whether or not looking at 2-years OS is a good endpoint. One can probably "bridge" some relapsing patients with SRS (and perhaps systemic therapy, which does have activity in the brain in SCLC) +/- WBRT down the road and keep them alive for 2 years, without being "curative". LD-SCLC is a scenario where cure is possible in up to a quarter of all patients, looking at 2-years-OS seems odd to me.

Don't get me wrong.
I fully understand and support the importance of running a trial on LD-SCLC testing PCI against MRI, but the methods on how we test it should be correct.
It could very well be that this trial shows non-inferiority at 2 years, but is that enough proof?


One a side note:
The "shortcomings" of the old trials by not-utilizing MRI for staging are fully understandable, stage migration is certainly an issue, since some of these patients were probably ED-SCLC when they were randomized to PCI or not, however:
a) Can PCI with 25/2.5 actually "cure" macroscopic brain mets and uphold a survival benefit at 5 years rather than treating those brain mets when they became evident on CT or symptomatic? I doubt that.
b) Stage migration works both ways. Yes, there were patients with macroscopic mets (on MRI) that were receiving PCI in those trials while the control arm did not get it, yet there were also patients with 1cm liver mets or small bone marrow mets or small affected lymph nodes which were all missed with "old school" CT-staging in both arms, but which we would pick up with FDG-PET-CT nowadays. Thus, both arms (PCI and not-PCI) included patients with ED-SCLC with mets outside of the brain, which clearly have little to no benefit from PCI. Thus one can speculate that in retrospect the true benefit of PCI is LD-SCLC may even be bigger that what these trials showed, which were "contaminated" with extra-cerebral ED-SCLC patients.

 

[Ray D. Ayshun]

Is there a trial or review that's shown wbrt has prolonged os? Other than the slotman pci trial.

 

[Palex80]

Is there a trial or review that's shown wbrt has prolonged os? Other than the slotman pci trial.

The Slotman trial is the only pure ED-SCLC showing PCI prolongs survival. Its results have been challenged by the Japanese trial, which showed no benefit with PCI and included MRIs for inclusion (which only a fraction of the patients in the Slotman trial received).

There are several other trials on LD-SCLC and on mixed cohorts of LD-/ED-SCLC showing PCI improves survival. These trials are older and thus did not use MRI for staging, but mostly CT/scintigraphy.
A metaanalysis of these trials: Prophylactic cranial irradiation in small cell lung cancer: a systematic review of the literature with meta-analysis - PubMed

 

[Ray D. Ayshun]

The Slotman trial is the only pure ED-SCLC showing PCI prolongs survival. Its results have been challenged by the Japanese trial, which showed no benefit with PCI and included MRIs for inclusion (which only a fraction of the patients in the Slotman trial received).

There are several other trials on LD-SCLC and on mixed cohorts of LD-/ED-SCLC showing PCI improves survival. These trials are older and thus did not use MRI for staging, but mostly CT/scintigraphy.
A metaanalysis of these trials: Prophylactic cranial irradiation in small cell lung cancer: a systematic review of the literature with meta-analysis - PubMed

Sure, but with any malignancy. Im not aware of wbrt for metastatic disease prolonging survival in any study. The slotman pci trial is dismissed bc there was no mri staging and presumably gross disease. Fair enough. But if that's true, it's the only randomized trial to ever show an os benefit for wbrt.

 

[Palex80]

Sure, but with any malignancy. Im not aware of wbrt for metastatic disease prolonging survival in any study. The slotman pci trial is dismissed bc there was no mri staging and presumably gross disease. Fair enough. But if that's true, it's the only randomized trial to ever show an os benefit for wbrt.

The Patchell-trial comes into mind but that was postoperative WBRT for a resected brain metastasis. And it wasn't OS but "neurologic death", if I am not mistaken, that was improved.
WBRT as a palliative treatment for brain metastasis does not have a proven benefit in randomized trials. Several years ago actually, the QUARTZ trial showed that in NSCLC-patients with an unfavorable prognosis and not eligible for surgery or stereotactic treatment, WBRT was not beneficial on top of steroids only.

 

[Palex80]

UPDATE on this interesting case (last update is #23):

Following the stereotactic treatment of the solitary lesion last year, the patient went on to complete his chemotherapy and then went on to IO.
A scan at the end of the chemotherapy showed the solitary brain lesion shrinking and the primary tumor responding in the lung. The med oncs asked what I wanted to do. I talked with the patient for quite some time and advised him to treat aggressively.

1. PCI 10 x 2.5 Gy with a SIB on the residual brain lesion up to 10 x 3.5 Gy (I know, it's not really PCI, since he already had one brain lesion).
2. SBRT for the residual pulmonary nodule + affected N1-station with 10 x 4 Gy (@80% isodose)

He agreed to it and tolerated treatment quite well in the winter.


The med onc called me yesterday.
The patient just had a new scan, which now shows 3 new small brain mets (barely 3 months out of PCI).
The primary in the lung is shrinking after SBRT and he's still on IO.

What to do now?

1. Nothing, I obviously failed (maybe I should have given him 10 x 3 Gy rather than 10 x 2.5 Gy?)
2. SRS the 3 new lesions
3. Ask the med onc to keep the patient on IO, rescan at 6-8 weeks, then SRS the 3 lesions if nothing else pops up

 

[Neuronix]

SRS the 3 new lesions.

 

[FrostyHammer]

UPDATE on this interesting case (last update is #23):

Following the stereotactic treatment of the solitary lesion last year, the patient went on to complete his chemotherapy and then went on to IO.
A scan at the end of the chemotherapy showed the solitary brain lesion shrinking and the primary tumor responding in the lung. The med oncs asked what I wanted to do. I talked with the patient for quite some time and advised him to treat aggressively.

1. PCI 10 x 2.5 Gy with a SIB on the residual brain lesion up to 10 x 3.5 Gy (I know, it's not really PCI, since he already had one brain lesion).
2. SBRT for the residual pulmonary nodule + affected N1-station with 10 x 4 Gy (@80% isodose)

He agreed to it and tolerated treatment quite well in the winter.


The med onc called me yesterday.
The patient just had a new scan, which now shows 3 new small brain mets (barely 3 months out of PCI).
The primary in the lung is shrinking after SBRT and he's still on IO.

What to do now?

1. Nothing, I obviously failed (maybe I should have given him 10 x 3 Gy rather than 10 x 2.5 Gy?)
2. SRS the 3 new lesions
3. Ask the med onc to keep the patient on IO, rescan at 6-8 weeks, then SRS the 3 lesions if nothing else pops up

Option 3. If he failed that quickly from brain RT then he's going to get more mets. Might as well save your trump card when you really need it. Not wrong to do option 2 but you're going to have to do a lot more "spot welding" in the future.

 

[Ray D. Ayshun]

Can whole brain plus io cause something like pseudo progression, where subclinical mets become visible due to an inflammatory response? This seems confusing enough to wait and reimage.

 

[evilbooyaa]

We know about pseudoprogression in the brain with IT, and I would worry about early progression presenting as pseudoprogression. Re-scan in 2-3 months if he is otherwise responding to IO and not showing evidence for extracranial progression.