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Q&A Sessions: Brain Metastasis

John Y.K. Lee, MD, Assistant Professor of Neurosurgery, is the Director of the Penn Center for Cranial Nerve Disorders and a national leader in treating cranial nerve disorders.

Mireille asks:
I had breast cancer five years ago. About a year ago the cancer came back to the lungs and later to the brain. In February of this year I had five lesions removed with the Gamma Knife. My latest MRI, done in July, showed 10 new tumors. My doctor is strongly recommending whole brain radiation. I'm very uncomfortable with this decision but also worried about time.

Dr. Lee responds:
Whole brain radiation therapy remains a good option with this number of brain metastases.

Nicki asks:
My 56 year-old sister was diagnosed in six months ago with metastatic melanoma — five tumors in her brain. The largest was surgically removed and biopsied; the remaining tumors (and three new ones) were removed with the Gamma Knife. After three months, a new MRI shows two new tumors and a reappearance at the site of one original. She is set to begin whole brain radiation this week. Can the Gamma Knife be used again to take out the existing tumors?

Dr. Lee responds:
Gamma Knife Radiosurgery can be used to treat the two new metastatic melanoma lesions. In fact, Gamma Knife radiosurgery may be more successful at controlling individual melanoma metastasis as compared to whole brain radiation therapy.

If you have any additional questions or would like to schedule an appointment, please call us at 800-789-PENN. You can also request an appointment online.

TStamper asks:
My mom was diagnosed with adenocarcinoma of the lung (stage two) one and a half years ago. She had a lower lobe lobectomy and it was found in only one lymph node. Recently, she has been having severe headaches and went to the hospital to find out there is a tumor (most likely from the lung cancer) in the right cerebellum and is approximately 3/4" round.

We won't know for sure until she has surgery, however, considering the size of the tumor, would a craniotomy be a good choice or would you recommend Gamma Knife radiosurgery? Would you also recommend WBR to follow the surgery? How likely is it to come back if WBR is not chosen?

Dr. Lee responds:
There are many factors to consider when determining a treatment plan and each patient's situation is unique. However, Gamma Knife radiosurgery is an excellent treatment option for single brain metastasis. Your mother's tumor is of an appropriate size for Gamma Knife radiosurgery.

If you have any additional questions or would like to schedule an appointment, please call us at 800-789-PENN. You can also request an appointment online.

Vishu asks:
My mom is having metastasis of breast cancer to brain. She has a tumor around size of 8cm. She is been treated with radiotherapy and now next step they say is chemotherapy. Will radiosurgery be an option for her?

Dr. Lee responds:
An 8cm tumor in the brain is very, very large. I would recommend conventional surgical resection.

Droptine asks:
Is Gamma Knife a better alternative to remove a single brain metastasis vs open brain surgery?

Dr. Lee responds:
This topic is very controversial. In general, I recommend craniotomy and resection for a large brain metastasis, especially if it is symptomatic. Gamma Knife radiosurgery may be more appropriate if the brain metastasis is small and asymptomatic.

If you have any additional questions or would like to schedule an appointment, please call us at 800-789-PENN. You can also request an appointment online.

Wolf asks:
My mother received gamma radiation to three tumors in her brain from breast cancer now with mets. Can you receive gamma radiation to the same site if the tumor grows?

Dr. Lee responds:
This is definitely possible, but long-term data about Gamma Knife radiosurgery to the same target location is not readily available.

If you have any additional questions or would like to schedule an appointment, please call us at 800-789-PENN. You can also request an appointment online.

Debby asks:
My 65 year-old husband has metastases to brain as a result of melanoma. In August of 2007 he received Gamma Knife radiosurgery which was pronounced successful. He has just finished a course of temodal. His latest MRI and CT scans show four new lesions to the brain, but no growth in the tumors that were shrunk by the Gamma Knife in August. Could he be a candidate for a second Gamma Knife treatment?

Dr. Lee responds:
Gamma Knife can definitely be performed in this situation; however, there have not been any clinical trials that necessarily support or refute this approach.

If you have any additional questions or would like to schedule an appointment, please call us at 800-789-PENN. You can also request an appointment online.

Deb asks:
My father is 74 years old with a 4cm tumor at the base of the cerebellum. He has undergone 14 radiation treatments. In the past five years he has had a lung removed for cancer, a ruptured appendix, and open heart surgery on June 2, 2006. He is very fragile at this time but still fighting. Doctors have not said or diagnosed the type of tumor. Is he a candidate for Gamma Knife surgery?

Dr. Lee responds:
Although a 4cm metastasis to the brain can be treated with the Gamma Knife, we will have to reduce the dose in order to minimize complications. Your father might be a good candidate if that is his only lesion.

If you would like to schedule an appointment, please call 1-800-789-PENN (7366) or request an appointment online.

Kera asks:
My mother suffers from melanoma. She has nine tumors in her brain (the biggest is 3.5cm and the smallest 0.05cm). Her lymph glands of the left shoulder are also infected. The doctor told us that she cannot be treated with the Gamma Knife because there is a danger of bleeding in the brain and to die. Could the cyber knife help in the case of my mother?

Dr. Lee responds:
Gamma Knife has become a preferred method of treating brain metastasis from melanoma, primarily because melanoma is considered resistant to conventional methods of fractionation. Although there is a risk of hemorrhage in patients with brain metastasis, it does not seem to be increased after Gamma Knife.

Afzal asks:
My 46 year-old brother underwent brain surgery in May 2005 for a tumor on the left side frontal part of the brain. Although large, it was on the periphery. At that time, a small deep seated tumor (approx 1.5 cm) was also detected but was left untreated as biopsy of removed tumour was malignant and he was advised last ditch chemotherapy and radiation to the whole head.

Having lost our father to cancer earlier, and seeing the drop in quality of life after chemotherapy, we opted for no such medical treatment. Instead, then my brother went in for vigourous exercise regime and diet consisting of mainly fruits. His estimated lifespan given by the doctors was about three months. However, by the Grace of God, he is still alive.

After a year of operation, due complacency, the exercise regime slackened and he put on lots of weight. Last week, sensing problem in his memory he underwent MRI in which, although no untoward growth was observed at the site of surgery, the small deep seated tumour had grown to about 3 cm now.

We are now looking at the option of Gamma Knife treatment. This technology having recently come to India where we reside, we are looking at the option of having him treated at the USA. Would you be kind enough to indicate if he can be treated by Gamma Knife and the approximate cost of treatment at your centre?

Dr. Lee responds:
I would be happy to review the case and contact you with my recommendations.

Gina asks:
My aunt has had two Gamma Knife procedures for brain metastasis (two separate lesions on two occasions). Her primary cancer was diagnosed last year as inflammatory breast disease. They have now discovered a third lesion, but as she just had the GK procedure yesterday. How long clinically would she need to wait before the next GK procedure could be scheduled?

Dr. Lee responds:
The timing of Gamma Knife radiosurgery for patients with brain metastasis has never been systematically addressed in a controlled fashion. Hence, there is no right or wrong answer.

Many times, if I discover additional metastasis during the Gamma Knife procedure, I will treat them during the same setting, if it is feasible. Please feel to contact me with specific questions by calling 1-800-789-PENN (7366) and asking to be connected to my office.

Bill asks:
I have three brain mets from melanoma. I am having whole brain radiation (WBR). How soon after it can I get Gamma Knife radiosurgery if the WBR doesn't work? Or should I use it on the mets even if the WBR seems to be shrinking them? My oncologist is a Penn melanoma specialist.

Dr. Lee responds:
Your oncologist is most likely someone with whom I collaborate frequently. I am sure that Gamma Knife radiosurgery has been considered in your case. Nevertheless, I would be happy to see you in consultation.

Depending on each individual case, Gamma knife radiosurgery can be performed either immediately after whole brain radiation therapy, or we can wait to perform radiosurgery after some time. I would be happy to consult with you. If you would like to schedule an appointment, please call 1-800-789-PENN (7366) or request an appointment online.

Treva asks:
My mother is 87 and is rather healthy. However, she has just recently been diagnosed with a brain tumor. She had a malignant breast tumor in 2004 and had a mascetomy of her left breast. The tumor (according to her neurologist) is in the center of the brain, directly behind her nose area. He said the tumor is inoperable and he hesitates to perform a biopsy because the tumor is so deep and it the biopsy would undoubtedly leave her with a deficit.

He also says that no one will administer any sort of treatment to her unless she has a biopsy. He is currently treating her with a steroid to keep the swelling of the tumor down. It is not pressing on the brain at this time. Size is estimated to be 1 centimeter. Do you suggest we seek your review? My mother does suffer from macular degeneration in both eyes and she said her vision has worsened since this recent diagnosis.

Dr. Lee responds:
Please call 1-800-789-PENN (7366) and ask to be connected to my office. I would be happy to review the case. Gamma Knife radiosurgery has definitely been performed on brainstem metastasis with good success. In addition, depending on the clinical situation and the imaging characteristics, Gamma Knife can be performed without a biopsy.

Matt asks:
15 months ago, a relative of mine was diagnosed with two extra axial brain tumors. One was surgically removed and founds to be metastatic cancer. The other tumor was left alone. Following surgery, she was treated with whole brain radiation therapy, and the Gamma Knife surgery about one year ago.

Can Gamma Knife surgery be repeated one year or greater after the original GK surgery on a extra-axial tumor that is either a menigioma or metastatic tumor where the original GK has either failed or the tumor is showing signed of growth? If not, why, and what possible alternatives are there?

Dr. Lee responds:
Your case is very complex and requires more details and specifics than can be discussed on this website. Please call 1-800-789-PENN(7366) and ask to be connected to John Y.K. Lee's office.

Bob asks:
A colleague’s mother was diagnosed with stage I adenocarcinoma of the lung a year ago. Last week after she experienced focal seizures; a MRI of the brain revealed 2 lesions in the brain (both < 1.5 cm). The patient is 72 years old. Two questions:

1. What evidence supports that gamma knife procedures achieve superior results to regular external beam radiation? (Please provide citations of literature if published).

2. Does Medicare cover gamma knife therapy for patients describe above?

Thank you for taking the time to answer my questions.

Dr. Lee responds:
The results of a randomized clinical trial have shown that Gamma Knife radiosurgery improves survival when used in conjunction with conventional whole brain radiation therapy. See Andrews et al. Lancet 2004. In addition, Gamma Knife radiosurgery definitely improves the ability to control the growth of all tumors when used in conjunction with conventional whole brain radiation therapy. See Kondziolka et al. IJROBP 1999.

The use of Gamma Knife radiosurgery alone is an attractive option for select patients who do not want to undergo the risks of whole brain radiation therapy, such as dementia or memory loss. See Aoyama et al. JAMA 2006.

Medicare will definitely cover Gamma Knife radiosurgery for patients with brain metastasis. The results of a randomized clinical trial have shown that Gamma Knife radiosurgery improves survival when used in conjunction with conventional hole brain radiation therapy. See Andrews et al. Lancet 2004. In addition, Gamma Knife radiosurgery definitely improves the ability to control the growth of all tumors when used in conjunction with conventional whole brain radiation therapy. See Kondziolka et al. IJROBP 1999.

The use of Gamma Knife radiosurgery alone is an attractive option for select patients who do not want to undergo the risks of whole brain radiation therapy, such as dementia or memory loss. See Aoyama et al. JAMA 2006.

Medicare will definitely cover Gamma Knife radiosurgery for patients with brain metastasis.

Cali asks:
I am a 33 year-old female and I was diagnosed w/ L ductal breast cancer, a 4 cm solid and cystic tumor in 2002 with clear lymph nodes. I underwent chemotherapy; 6 rounds adriamycin/ cytoxin, partial mastectomy, 4 rounds taxol, and radiation and have been taking tamoxifen since.

I have now been diagnosed with a 1.4 cm lesion in my right occipital lobe (most likely a met). I am waiting to see the Gamma Knife surgeon, but my neurosurgeon feels as though surgery followed by Gamma Knife may significantly reduce my chance of reoccurence. If I opt out of surgery and get just Gamma Knife, will I have an increased chance of reoccurence?

Also, with the surgery there is a chance of vision loss. Is there also a chance of vision loss w/ Gamma Knife? The benefit to the surgery is that they will be able to biopsy it. Am I correct in assuming that with Gamma Knife they will not be able to biopsy the lesion?

Dr. Lee responds:
Treatment of brain metastasis is a field in evolution. Fifteen years ago, we had good evidence that if you have a single brain metastasis, surgery followed by whole brain radiation therapy offered the greatest chance for survival. More recently, we now have even better evidence that if you have a single brain metastasis, Gamma Knife followed by whole brain radiation therapy offers a great chance for survival. Nobody, however, has compared Gamma Knife versus open surgery. Hence, a lot depends on your preference. Most patients do not want to have their head cut open, and hence Gamma Knife is a great option.

Complications from Gamma Knife are related to the location of your tumor. Hence, visual field loss is a potential complication. Without having seen your films, I cannot make specific comments about the benefits of surgery versus radiosurgery.

Conventional surgery allows the surgeon to send a piece of the tissue/tumor to the pathologist for review. Gamma Knife does not allow for that. Hence, if there is any doubt about the diagnosis, then surgery is a better option. Most brain metastasis can be diagnosed confidently with modern MRI imaging.

Dmdoro asks:
My father was diagnosed and treated for stage 4 melanoma last year. On Monday, after months and months of follow up, his surgeon said that he is cancer free, and can go back to work. On Thursday, we rushed him to the ER to find that the cancer has spread to his brain. Apparently, the doctors concentrated on his chest and shoulders, not his head. The current doctor has recommended Gamma Knife for treatment. Can you please tell me if this is the best option for my father, and what the survival rate for patients is?

Dr. Lee responds:
Whole brain radiation therapy followed by Gamma Knife radiosurgery is an excellent treatment for metastatic tumors. If you would like to discuss this further, please call 1-800-789-PENN (7366) and ask to be connected to Dr. John Y.K. Lee's office. You can also request an appointment online.

MikeB asks:
Can you explain why Gamma Knife radiosurgery is primarily for tumors inside the brain? My friend has melanoma that has mestestisized to his lung and adrenal gland. The tumors are too close to vitals such as the pulmonary artery to be operated on conventionally.

Dr. Lee responds:
Radiosurgery was invented by a neurosurgeon, because the brain is extremely unforgiving of any kind of injury even simply moving it aside to get to the tumor. Hence, a neurosurgeon by the name of Lars Leksell created the Gamma Knife to deal with this problem.

Because Gamma Knife radiosurgery has become so successful for brain tumors, more and more people have investigated ways to perform radiosurgery for tumors outside of the brain. For example, the Cyberknife can be used to perform radiosurgery on spinal tumors and lung tumors. These efforts are only recent and are still being performed at only a few centers.

Susan asks:
My mother-in-law lives in the Philadelphia area and she has just been diagnosed with recurrent lung cancer. We have heard that the Gamma Knife is being used to treat lung cancer tumors. Will the University of Pennsylvania Health System be able to offer such a treatment for lung cancer if her doctors concur?

Dr. Lee responds:
Yes, we definitely treat patients with metastasis with the Gamma Knife. I generally make sure that patients with metastasis are treated within two weeks.

Please call 1-800-789-PENN (7366) to schedule an appointment. You can also request an appointment online.

 


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Gamma Knife and Leksell Gamma Knife are U.S. federally registered trademarks of Elekta Instrument S.A., Geneva, Switzerland. Photo credits: Susan Pardys, Elekta, Inc.

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