Cancer Treatment Today » Brain Metastases

How often to scan the brain after radiosurgery

M Levin, MD — Thu, 22 Nov 2012 15:25:50 +0000

How to follow a patient with brain mets after radiosurgery is becoming a more and more common question becasue treatments that control cancer in the rest of the boady are getting to be more and more effective and patients are living longer before cancer comes back in the brain or in the body. One does not want to overmonitor but also not to miss metastses when they come back. Many patietns remain disease free for many months even years after radiosurgery of the brain. For example, one study reported a median time of 8.8 months to new metastasis becoming visible after radiosurgery. Patients with 3 or more brain metasttses and cancers other than NSCLC were more likely to have future metastasis. Based on these facts, there was a published recommendation for close surveillance with a 3-month interval between magnetic resonance imaging (MRI), in order to identify new metastasis early enough to start treatment. However, much is not known about this. Clearly, more frequent imaigng is warranted soon after radiosurgery and less frequenlty as time goes on. As the most sensitive tests, MRI is the preferred surveillance tool, even though newer methods, such as spectroscopy, diffusion-weighted imaging, and perfusion-weighted imaging are coming to the fore.

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Irinotecan for brain metastases of lung and breast cancer

M Levin, MD — Fri, 09 Nov 2012 15:38:40 +0000

Because irinotecan penetrates the brain-blood barrier and has an effect in primary brain cancer, there is some interest in using it for brain metastasis, especially for lung cancer and breast cancer. Most studies of irinotecan had been for brain mets of small(SCLC) and non-small cell lung cancer(NSMCLC) and not breast cancer and have had mixed results. One study enrolled several different cancer types and reported complete responses with irinotecan-based chemotherapy for brain metastases in three patients with SCLC, parotid cancer, and esophageal adenocarcinoma. The combination of cisplatin, ifosfamide and irinotecan in treatment-naive patients with NSCLC led to a response rate in the brain of 50%. A study of temozolomide (200 mg/m²) on days 1 to 5 and irinotecan (200 mg/m²) on days 1 to 5 every 4 weeks in previously untreated patients with NSCLC brain metastases reported no responses.

There are several ongoing studies for lung cancer. For breast cancer, there is also a study: Irinotecan and Temozolomide in Treating Patients With Breast Cancer Who Have Received Previous Treatment for Brain Metastases, NCT00617539.

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Temodar for small cell lung cancer

M Levin, MD — Fri, 24 Aug 2012 17:39:22 +0000

Among solid tumors, small cell lung cancer(SCLC) is unusual in that it has the highest incidence of brain metastases. Several phase II trials have been reported using Temodar(TEM) for patients with brain metastases from solid tumors, including SCLC. In one study, two out of five patients with SCLC pretreated with whole brain radiation therapy showed disease stabilization with TEM. A second study explored the use of whole-brain radiation therapy with concurrent and adjuvant TEM in patients with metastatic cancer and three patients with SCLC were included in this study, two of whom demonstrated a complete response in the brain. Anecdotally, single-agent TEM has been used in patients with SCLC with response. Memorial Sloan-Kettering Cancer Center has an ongoing phase II study using TEM in second- or third-line treatment of SCLC: Temozolomide for Relapsed Sensitive or Refractory Small Cell Lung Cancer, NCT00740636. Most of this work appears to have been done by one investigator in a single institution, Dr. Pietanza in Memorial, who is also the author on the two reported phase II trials, which seem based on the same body of experience.

In first line, small cell lung cancer patients usually get radiation. For second line chemotherapy, NCCN recommends many single agents on SCL-B,1, including paclitaxel, etoposide, irinotecan, topotecan, ifosfamide and others but not Temodar at this time.

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Brain MRI: Routine for All Cancers?

M Levin, MD — Sun, 05 Aug 2012 14:32:09 +0000

In adults the primary tumors most likely to metastasize to the brain are located, in decreasing order, in the lung (minimum 50%), breast (15–25%), skin (melanoma) (5–20%), colon–rectum and kidney, but in general any malignant tumor is able to metastasize to the brain. The primary site is unknown in up to 15% of patients. Brain metastases are more often diagnosed in patients with known malignancy, when they present with neurological findings or complaints. In some cancers with a high risk of brain mets, such as small cell lung cancer, CT of head with contrast or brain MRI are recommended at the initial staging. A non-contrast CAT scan is not considered adequate to completely rule out brain metastasis. Therefore, an MRI or contrast CT is medically necessary at initial staging for small cell lung cancer but not in other cancers, unless there are signs or symptoms suggesting brain metastases.

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