Her2/Neu brain mets

[Gfunk6]

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I am trying to identify literature which reports the incidence of leptomeningeal dissemination (LM) in patients with resected HER2/neu amplified brain mets in the posterior fossa. Can anyone help point me in the right direction?

 

[evilbooyaa]

Not necessarily specific to Her2+ brain mets, but there is data that:
1) Resection leads to a high risk of leptomeningeal dissemination (comparing pre-op to post-op SRS, 3% vs 16%): Comparing Preoperative With Postoperative Stereotactic Radiosurgery for Resectable Brain Metastases: A Multi-institutional Analysis. - PubMed - NCBI

2) This is especially true with piecemeal resections and in posterior fossa (where anecdotally, piecemeal resections are more common): Comparative risk of leptomeningeal disease after resection or stereotactic radiosurgery for solid tumor metastasis to the posterior fossa. - PubMed - NCBI and https://www.redjournal.org/article/S0360-3016(17)31488-8/fulltext

The second link suggests that breast cancer mets that are resected are more likely to result in LMD as well

Can't find anything on a brief google search for the exact answer to the question you're looking for

 

[BobbyHeenan]

Sorry - don't have time to find them directly (other than evilbooyaa), but if you look into the background on some of these pre-op radiosurgery trials (I believe UAB and WashU have them) for larger brain mets, then you will see citations like those above from evilbooya.

Agree that I don't know of anything Her-2 specific though. So probably not that helpful.

RADI-12. LEPTOMENINGEAL FAILURE AFTER PREOPERATIVE VERSUS POSTOPERATIVE RADIOSURGERY

Abstract. INTRODUCTION: Postoperative stereotactic radiosurgery (postop SRS) is potentially complicated by difficulty defining the target volume and the ri

academic.oup.com

 

[scarbrtj]

I guess it (significant CNS involvement in HER2/neu breast cancer) happens frequently enough that people have countenanced "crazy" stuff like this. Definitely have heard more than a few old school med oncs complain that the HER2 era has "caused" more brain mets (haven't you?) because the HER2 therapies are so effective extracranially I suppose. I haven't seen a post-craniotomy HER2 brain met patient. If I did, this would be a scenario where I would go postop whole brain and not go involved-site, as invidious as that sounds.

 

[evilbooyaa]

While doing PCI for Her2 disease seems ridiculous to me, I do wish it pushed our med oncs to at least get a screening MRI brain on all metastatic Her2+ patients. Routinely see folks 2 years into their MBC diagnosis without a single MRI brain who develop symptoms and get referred for big 3-4cm mets.

 

[Palex80]

While doing PCI for Her2 disease seems ridiculous to me, I do wish it pushed our med oncs to at least get a screening MRI brain on all metastatic Her2+ patients. Routinely see folks 2 years into their MBC diagnosis without a single MRI brain who develop symptoms and get referred for big 3-4cm mets.

TNBC is also an issue...

 

[taserlaser]

This is one of those situations where preop SRS might make reasonable sense. Maybe in a handful of years with trial results

 

[Palex80]

This is one of those situations where preop SRS might make reasonable sense. Maybe in a handful of years with trial results

Indeed, but the question will then arise: How many of these surgeries could one have avoided with SRS?

 

[RickyScott]

Not necessarily specific to Her2+ brain mets, but there is data that:
1) Resection leads to a high risk of leptomeningeal dissemination (comparing pre-op to post-op SRS, 3% vs 16%): Comparing Preoperative With Postoperative Stereotactic Radiosurgery for Resectable Brain Metastases: A Multi-institutional Analysis. - PubMed - NCBI

2) This is especially true with piecemeal resections and in posterior fossa (where anecdotally, piecemeal resections are more common): Comparative risk of leptomeningeal disease after resection or stereotactic radiosurgery for solid tumor metastasis to the posterior fossa. - PubMed - NCBI and https://www.redjournal.org/article/S0360-3016(17)31488-8/fulltext

The second link suggests that breast cancer mets that are resected are more likely to result in LMD as well

Can't find anything on a brief google search for the exact answer to the question you're looking for

I have had rash of recent Dural failures sp resection and cavity xrt in lung ca. (Yes, I put extra margin along dura.) Decided on 267 x 15 to failure given overlap with prior cavity srt. Initially was inclined to give whole brain but talked out of it by thought leader.