Whole brain re-irradiation: faisability, benefit and toxicities

[Kroll2013]

Dear colleagues,
I have a 50 yo patient, SCLC , that had prophylactic cranial irradiation 25Gy in 10fr 6mo ago, presents actually 2 symptomatic brain lesions : one in the frontal lobe and the other in the cerebellum, with significant perilesional edema.
Is a whole brain re irradiation faisable? What dose? What are the toxicities ?

Thank you

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[Palex80]

What is the status of her extracranial disease?

 

[Kroll2013]

What is the status of her extracranial disease?

Limited to the lung. No other metastatic sites.

 

[CyberKnife19]

Limited to the lung. No other metastatic sites.

Only two sites in the brain, 50 y/o, no extra-cranial disease and just had WBRT 6 months ago? Without question, I would do SRS. Even with SCLC, if it is limited stage, he/she could live another 12-18 months or could even be in that 15-20% that lives 5 years and I would not want to see the potential neurocognitive and QOL issues that could result from a second course of WBRT.

 

[Gfunk6]

Agree with salvage SRS

 

[OTN]

SRS is the obvious choice here.

 

[medgator]

I'd say SRS as well, but what about a dose-painted WBRT plan with SIB to the lesions? Could be a reasonable alternative? It's small cell, shouldn't need 18-20 Gy in a single fraction to kill it off.

 

[Neuronix]

100% agree with SRS. Want to add:

There could be need for neurosurgery here -- "cerebellum, with significant perilesional edema" makes me think this could be a shunt candidate in the appropriate patient. Depending on the size, location, and extent of edema of the frontal lobe, our surgeons might consider resection there as well.

Also, don't forget to consider consolidation RT to the chest (http://www.sciencedirect.com/science/article/pii/S0140673614610850)

 

[Palex80]

Good point Neuronix, neurosurgery should look into it. And I agree with SRS.
If the patient is also progressive in the lung and in need of systemic treatment, then chemo may also work against further microscopic deposits in the brain.
If the med oncs don't want to do another round of platin/etoposide (although progression is now beyond 6 months and thus the patient is not platin-refractory) they should rather consider topotecan over ACO, since topotecan may have higher efficacy in the brain.

 

[Mandelin Rain]

To the question, it is feasible. Some benefit in some patients. Risks of neurocognitive effects.

But yeah, do SRS, or surgery, or both in this case.

 

[RadRadRad]

Agree with SRS.

I have done simultaneous integrated boost whole brain (20Gy to brain, 30Gy to mets, both in 10 fractions) as Re-RT for small cell patients with more sites of brain met recurrence.

For your reference, the paper I typically use to support for whole brain re-irradiation is below (Heidelberg also has a series). but again in this patient would favor SRS


Int J Radiat Oncol Biol Phys. 1996 Feb 1;34(3):585-90.
Analysis of outcome in patients reirradiated for brain metastases.
Wong WW1, Schild SE, Sawyer TE, Shaw EG.

 

[scarbrtj]

I didn't see any lesional sizes given. If they're volumetrically large-ish (>3-4cm times 2 lesions), some fractionation via conformal "involved field"--or even WBRT--wouldn't be out of the question. The SCLC should respond to that pretty nicely; then go for the sockdolager with an SRS boost. Adding 10-15 Gy of WBRT wouldn't be very risky after 25 Gy WBRT six months ago.

Is anyone using (or believes in) Namenda for WBRT patients?

 

[Gfunk6]

Is anyone using (or believes in) Namenda for WBRT patients?

Yes, I believe in it and use it.

 

[OTN]

Yes, I believe in it and use it.

Same here.

 

[BobbyHeenan]

Yes, I believe in it and use it.

I have had two patients (medicaid) recently in which I Rx'd it. However, I could not get it approved and tried all kinds of avenues. There is a 2 month appeals process for our state run medicaid, so I've started that, but that's a long time to wait for someone with brain mets. I have PCI patient also recently (don't recall her insurer) that had it rejected as well.

Anyone else having insurance approval problems?

 

[Gfunk6]

I originally received flack for Namenda but have not run into issues recently.

 

[Neuronix]

I originally received flack for Namenda but have not run into issues recently.

Yeah, it went generic. So much easier to get it covered now.