Systemic Therapy and Brain Radiation

[evilbooyaa]

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What commonly prescribed targeted agents are people OK treating, with brain radiation (separate categories if necessary for WBRT and SRS) while the patient continues that drug for systemic disease? Main question would be in regards to safety (no increased toxicity profiles). I'm focusing more on targeted agents/IT (rather than cytotoxic chemotherapy) but if there's any chemotherapeutic agents you'd be comfortable treating SRS and/or WBRT I'm all ears.

I know we had a discussion about Ipi/Nivo and safety of SRS in Melanoma patients, but what about other disease sites and systemic treatments?

EGFR inhibitors (Tarceva, Tagrisso, Afatinib, etc.) - OK with SRS? OK with WBRT?
ALK inhibitors (Crizotinib, Alectinib) - OK with SRS? WBRT?
Immunotherapy (Pembro, Nivo say in a NSCLC, Atezolizumab, etc.) - OK with SRS? WBRT? Dependent on histology?

I'm interested in anecdotal tales as well as studies people may know of.

 

[PruritisAni]

EGFRi half-lives are usually about 48hrs. So even when holding the day prior and day of treatment, the drug is still in the system and are treating with it anyway.

Immuno washout is way too long to take off of it.

I'd fire away without much worry unless the patient were on a trial and XRT would remove the patient or drug company not offer it concurrently with XRT.

That said, it seems rates of radiographoc necrosis are higher with EGFR TKi than without, but long term clinical significance less clear.

 

[Gfunk6]

I am ok with virtually all oral oncolytics and immunotherapy. I hold IV chemo.


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[nkmiami]

so, I am more liberal than most, but certainly temodar can be given. In kids, I think they used to give chemo concurrently with the whole brain in medulloblastoma. the vincristine?

I wouldnt give whole brain with gemzar or a taxane, or high dose methotrexate, but I have given it on rare occasions with other chemos depending on the clinical situation, including 5fu/xeloda and cis/etoposide in a small cell and recently palbociclib, and many times with herceptin.

If you end up giving chemo, dont use 6x to avoid skin rxn (mix in high energies - which i do anyway-and no you dont really underdose anything when you do this.)

 

[seper]

I recently saw "lesion necrosis-pseudoprogression" type of reaction with pembro+SRS. Patient stayed in ICU for a week with brain edema. Any data on that?

 

[Palex80]

I recently saw "lesion necrosis-pseudoprogression" type of reaction with pembro+SRS. Patient stayed in ICU for a week with brain edema. Any data on that?

Cerebral vasculitis mimicking intracranial metastatic progression of lung cancer during PD-1 blockade
Vasculitis in the brain during immunotherapy mimicking a brain metastasis, which was actually treated. Not clear of irradiation severed the necrosis, but probable.

 

[BobbyHeenan]

Cerebral vasculitis mimicking intracranial metastatic progression of lung cancer during PD-1 blockade
Vasculitis in the brain during immunotherapy mimicking a brain metastasis, which was actually treated. Not clear of irradiation severed the necrosis, but probable.

Well that's incredibly scary.

I looked at the MRI and said, "yup, I would have treated that with radiosurgery too."

*edit to say I *would* have treated that small met looking thing.

 

[seper]

I wonder if the lesions described were mets, after all. They were killed by SRS and Opdivo caused vasculitis.

 

[Palex80]

I wonder if the lesions described were mets, after all. They were killed by SRS and Opdivo caused vasculitis.

If you look closely at the images you will see that the vasculitis lesion developed at the edge of the SRS-irradiated metastasis. I circled the residual SRS-treated metastasis directly cranial of the newly developed lesion.
It seems that the new lesion was directly beneath the earlier one but not "connected" to it.

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[Palex80]

Well that's incredibly scary.

I looked at the MRI and said, "yup, I would have treated that with radiosurgery too."

*edit to say I *would* have treated that small met looking thing.

Yes, that's scary...