NSCLC with brain mets

[zobell]

Hey all,
Im doing an assignment for the treatment I would give the following patient;
58 year old woman, presents with nausea, headaches and short term memory loss. CT and MRI show multiple (5) intracranial lesions with vasogenic oedema and ring enhancement. She has no known primary so a CT TAP was done and a 5.1cm lesion in the rUL was noted with right mediastinal, hilar and supraclavicular lymphadenopathy. Biospy indicated NSCLC stage IV - squamous type. KPS of 80 so she would be RPA II, as the primary is not controlled?

How would other people treat this patient? I have said because of the multiple lesions no surgery and because of high overall tumour volume no SRS. 16mg a day of Dexamethasone. She has no symptoms of her primary disease so I am unsure with regards to chemotherapy; should I give her chemo after her WBRT, or at all? if so, what agent should I use. As she is SCC it can be presumed that she is EGFR and ALK neg and so I have not mentioned Erlotinob...
Am not using a radiosensitizer as I live in Ireland and its use is uncommon here.

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[zobell]

I know this is such a simple concept but I just am having difficulty understanding;
If a patient presents with symptomatic brain mets and then it is discovered they have stage 4 NSCLC, which is asymptomatic, the primary disease would be UNCONTROLLED yes? even though it has no symptoms?

 

[gutonc]

You didn't really need to make 2 threads for this.

What do you think you should do?

And yes, the primary disease is uncontrolled because the primary disease is lung cancer metastatic to the brain. And she's symptomatic from brain mets. Therefore she's symptomatic from the primary disease.

 

[zobell]

sorry Im just confused because we had a breast patient who was treated two years ago and presented recently with brain mets but her primary is considered controlled, however I thought she was symptomatic from brain mets, hence symptomatic from primary disease?

 

[gutonc]

sorry Im just confused because we had a breast patient who was treated two years ago and presented recently with brain mets but her primary is considered controlled, however I thought she was symptomatic from brain mets, hence symptomatic from primary disease?

But that's not the question you asked here. Pick one question and ask it.

And then remember that the answer to this particular question is completely irrelevant.

 

[zobell]

But that's not the question you asked here. Pick one question and ask it.

And then remember that the answer to this particular question is completely irrelevant.

You said that because the lung cancer patient has symptomatic brain mets that the primary is uncontrolled as these are symptoms of the primary disease. I said we had a breast patient who was treated two years ago and now has brain mets. She still has symptoms of the primary disease (from your explanation) as she has mets, so why is she considered to have controlled disease whereas the first patient is not

 

[gutonc]

You said that because the lung cancer patient has symptomatic brain mets that the primary is uncontrolled as these are symptoms of the primary disease. I said we had a breast patient who was treated two years ago and now has brain mets. She still has symptoms of the primary disease (from your explanation) as she has mets, so why is she considered to have controlled disease whereas the first patient is not

So, first off, you started with 2 separate posts about met lung cancer. Then halfway thought, you switched it up to breast cancer. That's fine. Whatever. But don't pretend that I'm the one being daft here.

But the key here is that you are asking a question that nobody cares about the answer to.

Let's get back to your initial, moderately relevant question. How would you treat that patient?

 

[zobell]

No sorry, Im coming across all wrong, I know no one cares about the answer to that question, I just am having difficulty understanding when the primary disease is controlled and uncontrolled and thought someone could help me out

 

[zobell]

So, first off, you started with 2 separate posts about met lung cancer. Then halfway thought, you switched it up to breast cancer. That's fine. Whatever. But don't pretend that I'm the one being daft here.

But the key here is that you are asking a question that nobody cares about the answer to.

Let's get back to your initial, moderately relevant question. How would you treat that patient?

No sorry, Im coming across all wrong, I know no one cares about the answer to that question, I just am having difficulty understanding when the primary disease is controlled and uncontrolled and thought someone could help me out
I would treat with dexamethasone and WBRT 30Gy in ten. maybe assess for chemo in the weeks after??

 

[Nivakia]

radiation whole brain vs stereotactic, whats the verdict on this? The reason I am asking is because whole brain rad has traditionally caused side effects such as mental status and functional decline

 

[gutonc]

radiation whole brain vs stereotactic, whats the verdict on this? The reason I am asking is because whole brain rad has traditionally caused side effects such as mental status and functional decline

Since this is the med onc forum, not the rad onc one, most people here won't be able to give a definitive answer. But the answer I would give for this is "it depends". It basically depends on your radiation oncologist. The guy I send these folks to has a Gamma Knife and will treat a surprisingly large # of mets with it if possible. Size and location matter as much, if not more than, total # (to a point).

 

[RadOncDoc21]

Sorry, could not help but pass through this thread and came across a rad onc question. There is a lot of controversy in regards to radiosurgery vs. whole brain radiation. A lot has to do with marketing and much less in regards to actual data. I think there is a push for more radiosurgery (does not matter if it's a cyberknife, gamma-knife, or linac-based... all do the same thing), but only because we can.

Cognitive impairment is what comes up in every tumor board and I can find data to support both sides of each argument. Academics with fancy machines will push for SRS, while community docs with less fancy machines will likely push for Whole brain if they don't have the machines.

Ultimately, it all comes down to what kind of equipment your rad onc has and if they have the number of procedures to pay for the machine.

Stage IV lung cancer is still stage IV lung cancer and uncontrolled brain mets will lead to cognitive impairment.