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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