Lupus and RT case

[CUBuffsgrad98]

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Anyone treat an atypical meningioma, (previously Grade I, GTR in 2000 in temporal region recurred in 2013 with GTR benign features except brain invasion) in a person with SEVERE SLE? (hypothyroid, severe RA scarring, no toe nails, sjogrens, raynauds, on chronic meds)? What if STR? This suggests no real benefit (PMID: 23394332), but even if benefit, does it outweigh risk of 54-60 Gy (per RTOG) plus margin to this area?

Had one neurosurg say yes and a neuro oncologist tell the pt they should get SRS. Am I off base?

 

[seper]

Tough case, but 2 separate issues here: a) is SRS safer than traditional XRT for someone with CTD? IMO, yes. I have treated one pt with scleroderma with SRS, and felt comfortable recommending it.
b) is adjuvant SRS a treatment option for resected meningiomas vs. traditional XRT with margin? Not sure about this one, I'd worry about target delineation.

 

[Gfunk6]

The core issue with systemic CTDs is the amount of soft-tissue that is irradiated. The worst case scenario is hardening and necrosis of said soft tissues as a late side effect of XRT. It seems logical that this risk is based on a straight dose-volume relationship which is why virtually all of the literature we have on XRT in pts with CTD is based on breast data.

If you are treating a meningioma adjuvantly with EBRT, the volume of soft tissue (e.g. skin, muscle, periosteum) outside of the skull would be minimal as would, presumably, the risk of bad outcomes with XRT. Anecdotally, I've treated one patient with systemic SLE (managed by daily Rx anti-inflammatory meds) with adjuvant XRT following GTR for a GBM and she is doing fine after 1.5 years. I did discuss the risks with her up-front with caveats as well.

 

[Palex80]

The problem with SRS may be that you will be only be treating the current GTV with minimal margin. However this is a case of a recurrent tumor, where you should also take into consideration the original tumor extension (initial GTV). It may well be that SRS will lead to a field margin recurrence down the road, especially since you are dealing with not-standard grade I meningioma. I've seen it happen in private practice who is treating everyone with Cyberknife repeatedly.
In the case of lupus, I would go with FSRT and low dose per day (1.8 Gy).