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Case of the Month
This is a case of a 62 year-old woman with metastatic lung cancer. She was found on imaging to have three small brain metastases, the largest of which is shown on the left image. Treatment options included whole brain radiotherapy, which would treat all three lesions in addition to the rest of the normal brain tissue, generally over 2-3 weeks. The alternative was stereotactic radiosurgery, which utilizes a newer technique in which only the three individual tumors are treated while the rest of the brain is spared any meaningful dose of radiation. The patient chose the latter option and her post-treatment scan is shown on the right. The tumor and the associated swelling have completely resolved and is no longer visible. A similar response was with the other two lesions (not shown). Consequently the patient was spared the long-term effects of radiation to the unaffected brain as well as the short-term effects of anti-inflammatories (which are typically recommended for whole-brain radiation). This type of radiosurgery is offered at Palomar (Dr. Coleman), Grossmont (Drs. Uhl and Dewitt), and Memorial (Drs. Volpp and Weinstein). It will be offered at Chula Vista (Dr. Zentner) once the new cancer center is completed. Case of the Month - August / September 2010RAPID RESPONSE AND PALLIATION OF SYMPTOMS WITH RADIOSENSITIVE CARCINOIDPatient is a 63 y/o surfer who has a diagnosis of metastatic carcinoid tumor. He was becoming short of breath and developed a debilitating cough with insomnia. He underwent a CT scan of the chest showing occlusion of the right mainstem bronchus (airway) as well as partial occlusion of the left mainstem bronchus. He was treated with local radiation to the two major airways daily for 2 1/2 weeks and at the half-way point was almost back to breathing normally. With the exception of a sore throat, he tolerated the treatment well and was more or less back to his normal activities within a month of finishing therapy.
In Contrast With ... SLOWER RESPONSE OF SYMPTOMS WITH RADIORESISTANT TUMORSPatient is a 88 y/o female with a history of metastatic melanoma to the distal esophagus. She was initially treated with chemotherapy and radiation in early 2008 and had a partial response to therapy. However, in early 2010 she complained of ongoing upper abdominal pain and upper endoscopy revealed recurrent melanoma in the esophagus. Despite aggressive antacid (prescription strength) therapy the patient was still fairly debilitated by the pain. We decided to offer re-irradation to the esophagus and stomach using a highly conformal approach. Within a few weeks of finishing treatment the patient was pain free. Her energy level returned as did her appetite. Post-treatment PET/CT showed complete resolution of her recurrent melanoma. Both patient and family are exceedingly happy that she has returned back to "normal".
Case of the Month - July 2010BODY RADIOSURGERY FOR LIVER METASTASES
This is a case of a 50 year-old female initially diagnosed with locally advanced lung cancer in early 2008. She was treated with a combination of chemotherapy and radiation and then was followed. Unfortunately, she developed a liver metastasis 4 months after her initial diagnosis with lung cancer and presented to Sharp Memorial for treatment recommendations. Since the patient was without evidence of disease elsewhere in the body the decision was to proceed with stereotactic body radiosurgery to the solitary lesion in the left lobe of the liver. She was treated on the Novalis linear accelerator at that Memorial facility over a 2 week period of time. Five fractions were delivered every other day. The scan on the left shows the radiated lesion several months after treatment—it is no longer metabolically active. That is, the tumor is gone. Body radiosurgery for liver lesions, either primary liver cancer or metastases from various other primary sources, is becoming more and more accepted as an alternative to surgical resection or interventional radiologic approaches such as radiofrequency ablation or chemoembolization. Depending on the size and number of lesions, radiosurgery can treat with a very high control rate, well over 90% in many published series. Case of the Month - June 2010SALVAGE RADIOTHERAPY AFTER SURGERYThis is a case of a 56 year-old female with a history of non-small cell lung cancer initially treated with a pneumonectomy (removal of the left lung). She did well for some time and was monitored closely when she was found to have an abnormal scan, seen on left. Note the increased metabolism in orange, adjacent to the surgical clips (in white). The patient underwent a biopsy which confirmed recurrent tumor at the bronchial stump. She was seen by an XRO physician who decided to treat the recurrence using a 3-dimensional conformal approach, which minimizes dose of radiation to the adjacent lung and vascular tissue. This was critical given the fact that the patient only had one lung. Strict constraints were placed on the plan but in the end the tumor and adjacent lymph nodes were treated over 7 weeks’ time. The results after 3 months are seen in the scan on the right. The patient is now over one year out from her radiotherapy and is alive and well.
Case of the Month - April 2010STEREOTACTIC BODY RADIOSURGERY—A NEW OPTION IN EARLY-STAGE LUNG CANCERIn the past, patients with small, early-stage lung cancers were felt to be best treated by surgery. In some cases patients were not candidates for surgery and were left with standard, daily radiation therapy given over 6 weeks. Local control and cure rates with this approach, however, have been disappointing. Promising data from contemporary studies have shown that small lung cancers treated with high-dose, highly-focused radiation delivered over 1 to 2 weeks (in one to five daily fractions) can have outcomes equal to those seen following surgery. This case is from an 86-year-old woman initially sent to us with early stage breast cancer. In the process of setting up the patient for her left breast radiation we found a lung mass, which is illustrated quite clearly on the pre-treatment PET scan on the left. The mass was biopsied and it came back positive for non-small cell lung cancer.
Given the patient’s age the decision was made to forego surgery and proceed with stereotactic body radiosurgery. A gold maker was placed in the middle of the tumor for purposes of tracking the movement of the mass during respiration and careful planning was done by our physics staff to ensure that all of the tumor was covered by our radiation beam. The patient then returned to our department on four consecutive days and she was treated for approximately 20 minutes each day directly to the tumor mass. The scan on the right was taken three months after her treatment. The mass is gone and the patient remains without cough, fevers, chest pain or fevers. We will continue to follow her with PET scans every 3 months. Clearly this new technique to treat lung cancer is powerful and very effective. Your physicians at XRO are experienced in this technique and can offer this treatment at most of their affiliated treatment centers. March 2010 RE-IRRADIATION: HOPE FOR PREVIOUSLY TREATED PATIENTSWhen training to become a radiation oncologist one is taught that, in general, tissues cannot be re-treated. Basically, it was “one shot” to get rid of a tumor and then other options, like salvage surgery or chemotherapy, had to be employed. More and more data in modern literature speak to the contrary, however. In this case, a young male treated several years ago with primary nasopharyngeal cancer had a radiographic recurrence on PET scan. Despite the proximity of the tumor to critical structures such as the brain, optic chiasm, and brainstem, stereotactic techniques on our Novalis linear accelerator allow us to re-irradiate small areas safely and effectively. Note the PET scan at the time of recurrence (on left) and
This patient was treated in only 5 days as opposed to his initial course of therapy which took almost 7 weeks of daily therapy. He remains asymptomatic from a tumor standpoint and will continue to see his physician every couple of months for examination and regular surveillance scans. This case is an excellent example of the precision and efficacy of radiosurgery in a re-irradiation setting. Such technology is currently available at our Palomar, Memorial, and Grossmont sites and will soon be available at the new cancer center in Chula Vista. Brian P. Volpp, M.D.,MPH Meet Our Physicians
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