Presented by:
Gregory J. Kubicek, MD
Assistant Professor of Radiation Oncology
Patient History
The patient is a 45-year-old female diagnosed with left upper lobe non-small cell lung carcinoma (adenocarcinoma) after presenting with worsening cough. Further-work up and imaging shows multiple areas of metastatic disease; PET scan shows areas in bone, liver and several lung lesions, and MRI of the brain shows 11 CNS metastatic lesions, both infra and supratentorial including one lesion in the brainstem (see pictures below). Despite the number and size of CNS metastatic lesions she was neurologically intact and asymptomatic.
Follow-up MRI scan showing either complete response or very good partial response to treated areas (arrows).
Treatment
The patient met the multidisciplinary lung team and neuro-oncology team; she was eligible for a clinical study (Radiosurgery for multiple CNS metastatic lesions, CUH 1234) which involved Gamma Knife radiosurgery to all CNS lesions. The Gamma Knife treatment was delivered in a single day (treatment delivery time was around 3 hours), the treatment was well tolerated with no toxicity. She went on to have chemotherapy later that same week (carboplatin and pemetrexed and started bevacizumab with cycle 2). She had 4 cycles of chemotherapy and then pemetrexed maintenance.
Follow Up
On most recent follow-up imaging one year from the time of diagnosis her systemic disease is stable and her MRI imaging shows no new lesions and either complete response or near complete response to all treated lesions (see pictures above).
Gamma Knife Radiosurgery
Guidelines, including NCCN, state that radiosurgery and whole brain radiation are both the standard of care for patients with 1-4 CNS metastatic lesions and that whole brain radiation is standard for greater than 4 lesions. The reason behind the limit was in large part due to the radiosurgery technology at the time of the initial studies. The newer Gamma knife models are much more efficient in their ability to treat multiple targets. At MD Anderson at Cooper we have the Gamma knife perfection; this technology makes it possible to treat multiple CNS lesions in a short period of time. We feel that radiosurgery is a good option for patients with multiple CNS lesions as it allows for patients to move onto systemic therapy faster, is more convenient for patients and care-givers, and also has fewer side effects than whole brain radiation. We have an ongoing protocol to better evaluate treatment of multiple CNS mestatatic lesions. Eligible patients have 5-25 CNS lesions for any histology other than SCLC and lymphoma, all patients receive radiosurgery and the majority of patients are able to complete treatment in a single session.
Potential cases can be remotely reviewed, please send screen shot and history to: Kubicek-gregory@cooperhealth.edu or call 856.298.2969.