SRS instead of WBR as initial treatment for bc brain mets, even when not solitary or

[Lani]

tiny is the suggestion of the conclusion of the article.

This article reports significant results, and is not even limited to her2+ bc brain mets, which tend to do better than her2-brain mets which are usually triple negative

Of course it will take more and larger studies to change standard-of-care, if it is warranted. It may also depend on access to and expertise with SRS in any particular geographic area. It will be interesting to see if the requirements for recommending one over the other change and perhaps the recommendation may differ in the end for those that are her2+ and those that are not



Neurosurg. 2010 Oct 1. [Epub ahead of print]
Stereotactic radiosurgery as primary and salvage treatment for brain metastases from breast cancer.
Kondziolka D, Kano H, Harrison GL, Yang HC, Liew DN, Niranjan A, Brufsky AM, Flickinger JC, Lunsford LD.

Departments of Neurological Surgery.
Abstract
Object To evaluate the role of stereotactic radiosurgery (SRS) in the management of brain metastases from breast cancer, the authors assessed clinical outcomes and prognostic factors for survival. Methods The records from 350 consecutive female patients who underwent SRS for 1535 brain metastases from breast cancer were reviewed. The median patient age was 54 years (range 19–84 years), and the median number of tumors per patient was 2 (range 1–18 lesions). One hundred seventeen patients (33%) had a single metastasis to the brain, and 233 patients (67%) had multiple brain metastases. The median tumor volume was 0.7 cm³ (range 0.01–48.9 cm³), and the median total tumor volume for each patient was 4.9 cm³ (range 0.09–74.1 cm³). Results Overall survival after SRS was 69%, 49%, and 26% at 6, 12, and 24 months, respectively, with a median survival of 11.2 months. Factors associated with a longer survival included controlled extracranial disease, a lower recursive partitioning analysis (RPA) class, a higher Karnofsky Performance Scale score, a smaller number of brain metastases, a smaller total tumor volume per patient, the presence of deep cerebral or brainstem metastases, and HER2/neu overexpression. Sustained local tumor control was achieved in 90% of the patients. Factors associated with longer progression-free survival included a better RPA class, fewer brain metastases, a smaller total tumor volume per patient, and a higher tumor margin dose. Symptomatic adverse radiation effects occurred in 6% of patients. Overall, the condition of 82% of patients improved or remained neurologically stable. Conclusions Stereotactic radiosurgery was safe and effective in patients with brain metastases from breast cancer and should be considered for initial treatment.

PMID: 20887087

[hutchibk]

Wow, it's nice to see affirmation that my docs (and I) were mavericks on the leading edge of this school of thought 3 1/2 years ago when we decided to do "anything and everything except WBR" - which included Tykerb and IMRT/SRS.

[Ellie F]

Brenda
Always knew you were a trailblazer!!
Can anyone explain the difference between SRS and gamma knife? I am really interested as in the UK the treatment recommended by NICE (really nasty beancounters) is WBR?
Thanks Ellie

[hutchibk]

Ellie - Gamma knife is SRS... and so is Cyber knife. SRS is a method of delivering an ultra-precise, highly focused dose of radiation to an intracranial target. (I copied the below from Wiki, just for a quick explanation).

Stereotactic Radiation

Stereotactic radiation is a specialized type of external beam radiation therapy. It uses focused radiation beams targeting a well-defined tumor using extremely detailed imaging scans. Radiation oncologists perform stereotactic treatments, often with the help of a neurosurgeon for tumors in the brain or spine.
There are two types of stereotactic radiation. Stereotactic radiosurgery (SRS) is when doctors use a single or several stereotactic radiation treatments of the brain or spine. Stereotactic body radiation therapy (SBRT) refers to one or several stereotactic radiation treatments with the body, such as the lungs[9].
Some doctors say an advantage to stereotactic treatments are they deliver the right amount of radiation to the cancer in a shorter amount of time than traditional treatments, which can often take six to 11 weeks. Plus treatments are given with extreme accuracy, which should limit the effect of the radiation on healthy tissues. One problem with stereotactic treatments is that they are only suitable for certain small tumors.
Stereotactic treatments can be confusing because many hospitals call the treatments by the name of the manufacturer rather than calling it SRS or SBRT. Brand names for these treatments include Axesse, Cyberknife, Gamma Knife, Novalis, Primatom, Synergy, X-Knife, TomoTherapy and Trilogy.[10] This list changes as equipment manufacturers continue to develop new, specialized technologies to treat cancers.


Virtual simulation, 3-dimensional conformal radiotherapy, and intensity-modulated radiotherapy

The planning of radiotherapy treatment has been revolutionized by the ability to delineate tumors and adjacent normal structures in three dimensions using specialized CT and/or MRI scanners and planning software.[11]
Virtual simulation, the most basic form of planning, allows more accurate placement of radiation beams than is possible using conventional X-rays, where soft-tissue structures are often difficult to assess and normal tissues difficult to protect.
An enhancement of virtual simulation is 3-Dimensional Conformal Radiotherapy (3DCRT), in which the profile of each radiation beam is shaped to fit the profile of the target from a beam's eye view (BEV) using a multileaf collimator (MLC) and a variable number of beams. When the treatment volume conforms to the shape of the tumor, the relative toxicity of radiation to the surrounding normal tissues is reduced, allowing a higher dose of radiation to be delivered to the tumor than conventional techniques would allow.[5]
Intensity-Modulated Radiation Therapy (IMRT) is an advanced type of high-precision radiation that is the next generation of 3DCRT.[12] IMRT also improves the ability to conform the treatment volume to concave tumor shapes,[5] for example when the tumor is wrapped around a vulnerable structure such as the spinal cord or a major organ or blood vessel.[13] Computer-controlled x-ray accelerators distribute precise radiation doses to malignant tumors or specific areas within the tumor. The pattern of radiation delivery is determined using highly tailored computing applications to perform optimization and treatment simulation (Treatment Planning). The radiation dose is consistent with the 3-D shape of the tumor by controlling, or modulating, the radiation beam’s intensity. The radiation dose intensity is elevated near the gross tumor volume while radiation among the neighboring normal tissue is decreased or avoided completely. The customized radiation dose is intended to maximize tumor dose while simultaneously protecting the surrounding normal tissue. This may result in better tumor targeting, lessened side effects, and improved treatment outcomes than even 3DCRT.


3DCRT is still used extensively for many body sites but the use of IMRT is growing in more complicated body sites such as CNS, head and neck, prostate, breast and lung. Unfortunately, IMRT is limited by its need for additional time from experienced medical personnel. This is because physicians must manually delineate the tumors one CT image at a time through the entire disease site which can take much longer than 3DCRT preparation. Then, medical physicists and dosimetrists must be engaged to create a viable treatment plan. Also, the IMRT technology has only been used commercially since the late 1990s even at the most advanced cancer centers, so radiation oncologists who did not learn it as part of their residency program must find additional sources of education before implementing IMRT.


Proof of improved survival benefit from either of these two techniques over conventional radiotherapy (2DXRT) is growing for many tumor sites, but the ability to reduce toxicity is generally accepted. Both techniques enable dose escalation, potentially increasing usefulness. There has been some concern, particularly with 3DCRT, about increased exposure of normal tissue to radiation and the consequent potential for secondary malignancy. Overconfidence in the accuracy of imaging may increase the chance of missing lesions that are invisible on the planning scans (and therefore not included in the treatment plan) or that move between or during a treatment (for example, due to respiration or inadequate patient immobilization). New techniques are being developed to better control this uncertainty—for example, real-time imaging combined with real-time adjustment of the therapeutic beams. This new technology is called image-guided radiation therapy (IGRT) or four-dimensional radiotherapy.

[Ellie F]

Thanks Brenda, that info was really helpful. Pity this is an area that we lag behind in the UK.Hopefully this research will help to move things forward.
Ellie

[Darlene Denise]

Good to see this type of info FINALLY making it's way to women who often times aren't offered anything other than WBR by their community medical resources.

I'm right behind you Brenda on this issue. I had to beg and use my real tears to convince the doctors at UNC to use the Cyberknife (SRS) on my initial low volume 8 lesions in 9/08 and 3 more 6/09. I currently hold the record at UNC for number of brain lesions treated with Cyber and I told them I wanted my case to become part of evidence based medicine for this issue and to open the door for others to have this same choice and to encourage them to stop using only WBR because it has long standing data. Medicine can never move forward it you don't step away from barbaric treatments when there are new technologies and educated patients that deserve them. They have shared with me that they have been able to use my case to get insurance approval for others to have this treatment.

I am glad to see this subject addressed.

Darlene

[Jackie07]

Two of the three tumors in my brain (Central Neurocytoma - unrelated to BC) have enlarged according to the MRI in October. Our hospital has acquired a Novalis Tx in June this year, so looks like I'm going to be the guinea pig pretty soon.

From what I've read so far, it is a marvalous technique/machine that can treat a lot of tumors in different areas of the body. The tumor we are most concerned about is the one that is near my third ventricle because it has the potential to block the CSF (Cerebral Spinal Fluid) flow.

It seems to be befitting (is that the right word?) to try the new device after celebrating my 20th anniversary this summer surviving a huge tumor which took 23 hours to resect. The Gamma-knife I had 9 years ago did control the tumor growth for a while (till 2004?) and I've been wondering if the chemotherapies had had any effect on the tumor.

I'll make a report after I see the radiation oncologist on the 23rd. Going to be an interesting Thanksgiving and Christmas...