Brain mets survivor > 1 year; new imaging?

[Gfunk6]

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I have a pt with inflammatory breast cancer who underwent trimodality therapy. One year later, she had a single brain met and resection showed dural invasion so she received WBRT. Her brain was re-imaged q3mo x 1 year per NCCN guidelines and she had no evidence of mets. PET/CT showed no evidence of extracranial disease.

Now that she is > 1 year out and NED, is there a role for further imaging of the brain? I was thinking MRI Brain q4mo for year 2, q6mo for year 3, and then annually after that. I did a literature search but could not find guidelines after one year follow-up.

 

[medgator]

No data or protocol that I know of. Seems reasonable, although some might argue just to follow her clinically and to re-image her if she has Neuro sx and/or relapse locally/systemically, since that will likely be what determines what happens in the brain, going forward

 

[Seldon1985]

I have a pt with inflammatory breast cancer who underwent trimodality therapy. One year later, she had a single brain met and resection showed dural invasion so she received WBRT. Her brain was re-imaged q3mo x 1 year per NCCN guidelines and she had no evidence of mets. PET/CT showed no evidence of extracranial disease.

Now that she is > 1 year out and NED, is there a role for further imaging of the brain? I was thinking MRI Brain q4mo for year 2, q6mo for year 3, and then annually after that. I did a literature search but could not find guidelines after one year follow-up.

Just curious - insurance co giving you any difficulty with your MRIs?

 

[Gfunk6]

Just curious - insurance co giving you any difficulty with your MRIs?

Ding ding ding, we have a winner! 🙂

 

[RadOncDoc21]

Ding ding ding, we have a winner! 🙂

I think insurance companies should just write our textbooks.

 

[Cancerdancer]

RTOG 0933 calls for MRI every 3 months after WBRT, indefinitely (Appendix II), and I bet there are other WBRT studies, PCI etc that mandate MRI's past 12 months...could probably convince some insurance folks that these represent standard of care per expert neuro-oncologists?

 

[Gfunk6]

I think insurance companies should just write our textbooks.

"I'm not telling you that you can't *have* the [imaging/treatment/medication/procedure], I'm just telling you that we can't pay for it." For 99.9% of the patients we see, "not paying" is the same as "no treatment."

 

[Gfunk6]

RTOG 0933 calls for MRI every 3 months after WBRT, indefinitely (Appendix II), and I bet there are other WBRT studies, PCI etc that mandate MRI's past 12 months...could probably convince some insurance folks that these represent standard of care per expert neuro-oncologists?

Very nice, thanks for that reference. That kind of consensus from the neuro-oncology community was precisely what I was looking for!

 

[Cancerdancer]

No problem. Another one...EORTC 22952 (Kocher, JCO 2011) used MRI's q3 months. Figure 2a shows that pts followed in that fashion still have a fairly significant risk of failing after 12 months

 

[Neuronix]

I think insurance companies should just write our textbooks.

If they did, it would be one page that reads:

LET THE PATIENT DIE

Just kidding. Sort of.

 

[deleted4401]

That's annoying. Here, I don't think it would be a problem.
What if she had focal tx to tumor bed? Then she has a high risk of elsewhere recurrence. Is there guidelines that indicate more frequent imaging in these cases?
S

 

[CUBuffsgrad98]

EORTC trial had data at 2 years for recurrence, which also tends to be higher for surgery --> WBRT vs SRS --> WBRT. I work closely with Paul Sperduto who recommends MRI every 3 months for life. This may be a bit much, but after 2 years, I wouldnt go lower than every 6 months. Neuro symptoms are much harder to relieve a patient of once they have started, and catching them before they happen is much more preferred.

 

[OTN]

Ding ding ding, we have a winner! 🙂

You're sure she didn't have a headache?

 

[CUBuffsgrad98]

You're sure she didn't have a headache?

Brilliant!