NS Says That WBR Was The ONLY Realistic Tx Option

[Bill]

Here's the verbatim commentary from my wife's brain MRI radiology report that was used as the basis for deciding to employ WBR in late May ' 04. The NS says that any patient with a comparable brain MRI need not second guess a decision to employ WBR. Use of WBR as a " preventative " measure or radiation associated with localized brain tumor(s) are entirely different matters that he wouldn't speculate about or compare. Most of you that have had WBR should have a corresponding brain MRI radiology report in your possession for comparison. I hope that this information helps some of you feel better or more at ease about your condition and your decision to go with or pass on WBR :

" Findings : Multiple areas of abnormal enhancement are identified. Two areas are identified within the right cerebellum, largest measuring 2.0 cm. and the smallest measuring 0.9 cm., both ring enhancing in nature, seen on image # 19 of # 20 series. A third area, approximately 7.0 mm. is identified in the posterior left parietal lobe on images # 25, ring-enhancing, as well. There is also probable extra-axial abnormal region of enhancement, best seen on axial image # 19 and on coronal image # 20, broad in nature, aligned along the dural surface and perhaps with associated dural enhancement, and suggestion of loss of normal inner low signal of the inner table of the skull, very suspicious for bone metastatic process or extra-axial meningeal metastic disease with bone erosion. This measures approximately 4.0 cm. in diameter, approximately a centimeter in thickness. There is another lesion seen in the left frontal lobe, likely intra-axial, adjacent to the dural surface in the left frontal region, hyperintense on T1 but also with some enhancement suggesting possible hemorrhagic lesion. Smaller lesions are detected in the periventricular region without definite appreciable enhancement but are suspicious nature. This is seen on image # 13, FLAIR imaging, and on image # 18 of FLAIR imaging, as well, in the right frontal region. "

P.S. I consider GDPAWEL the in-house expert on the subject of WBR and it's (in)appropriate use. I have personally invited him to post his opinion as to whether or not WBR was a reasonable tx choice given these findings.

[gpawelski]

Bill, I would not consider myself an in-house expert on the subject of whole brain radiation treatment, although I have a very good grasp of it, from personal experience, medical research and many other patient's anecdotal evidence via emails. My primary experience had been with whole brain radiation and a solitary brain metastasis. From what I experienced with my wife and information obtained from years of research (i.e. the Mintz and Cairncross' editorial, UCLA's Metastatic Brain Tumor Program, and a JAMA paper, etc.), I would never encourage the use of postoperative whole brain radiation for a solitary brain met.

Last year, I even came across information from MD Anderson and the University of Pittsburgh that focal radiation instead of whole brain radiation is advisable for more than one brain met (not just solitary). MD Anderson (as noted in their OncoLog) stated that whole brain radiation may be the standard for four or more (but not for three or less). The recent study from the University of Pittsburgh School of Medicine indicated that treating four or more brain tumors with (focal) radiosurgery is safe and effective and translates into a survival for patients. Focal treatment spares normal brain tissue and function, and allows retreatment of local and new recurrences (whereas, whole brain radiation is a once and done treatment).

Your wife's diagnosis (as posted here) indicates "multiple areas of abnormal enhancement." This is not a solitary brain metastasis. With her doctor's limited research knowledge of the studies on radiation treatment, this may have been his only recourse at the time. More recent studies are beginning to show the advantages of using focal radiation for more than one brain met (not just a solitary). Hopefully, as more and more doctors become aware of these findings, it will change the antiquated protocols of the past.

And again, all is not lost. Hyperbaric Oxygen Therapy is now a useful therapeutic option for patients with confirmed symptomatic radiation necrosis from whole brain radiation. Until the new millenium, the only treatment for patients was pentoxifyline or heparin therapy, and it was almost always unsuccessful. The diagnosis of radiation-induced necrosis is difficult to confirm. Many patients have a mixture of tumor and radiation necrosis and a biopsy may be necessary to distinguish it. However, the FDG-Pet Scan, PET/CT Scan and the T1-SPECT studies are useful in differentiating radiation-induced necrosis from recurrent tumor (which would help in knowing what treatment is necessary). A combination unenhanced/enhanced MRI may be of some help.

You may want to look at virtualtrials.com about a Chemosensitivity assay for malignant brain tumors (brain mets). Chemosensitivity testing might help you find the best option. It's an idea worth looking into.

http://virtualtrials.com/trialdetails.cfm?id=96100226

[gerbil runner]

Bill, I'm sorry your wife is suffering from the WBR, but even though I'm no expert, it sounds like there was an awful lot of "actvity" in many different areas, which would point toward WBR for treatment.

Even so, it seems the dr.'s should have been more upfront about the risks. You probably would have made the same choice, but you would not feel so betrayed now.