4. “New-onset neurologic symptoms in a known cancer patient should
always be presumed to be from brain metastasis until proven otherwise.”
5. MRI is more sensitive than CT detects a
lesion as small as a dot (2mm).
6.
7.
8. MR Spectroscopy
Intratumoural choline peak with no choline elevation in the peritumoural
oedema any tumour necrosis results in a lipid peak, NAA depleted
9.
10. DEXAMETHASONE – Preferred
➢ No mineralocorticoid activity ( no fluid retention)
➢ Lower risk of infection and cognitive impairment than other GC.
➢ Effects seen within 24hrs – 48 hrs
➢ Load at 16mg – severe // 8mg moderate….4mg/day…over a period of 4
weeks.*
Vecht CJ et al. Neurology 1994;44(4):675–680.
19. Int J Radiat Oncol Biol Phys. 2017;99:1179-1189., Neurosurgery. 2016;79:279-285
20. EORTC 22952-26001, MDACC, JSROG, JLGK0901, Alliance N0574.
As WBRT offers no survival benefit over SRS and worse neurocognitive outcomes, in
patients with reasonably good PS and with up to 4 intact brain metastases SRS is
recommended.
22. Int J Radiat Oncol Biol Phys. 2016;95:1142-1148.
MDACC/Mount Sinai, NY
23. Based on this prospective Study,, the task force conditionally recommends SRS to
patients with 5 to 10 intact brain metastases who have a ECOG-PS ≤ 2.
24.
25.
26. A total of 30 Gy in 10 fractions or 37.5 Gy in 15 fractions continue
to remain the standards for a vast majority of patients.
(24% CR and 35% PR).
27. • SIB/Sequential/Delayed
• Mostly Retrospective
• Dose/Fr:
• 30Gy/10 fr with sequential 20/10 fr
• 33Gy/15fr with SIB 43.5 Gy/15 fr
• 40Gy/20 fr with SIB 56 Gy/20 fr
28.
29. ➢ Leukoencephalopathy and brain atrophy, leading to
neurocognitive deterioration and dementia
➢ Normal pressure hydrocephalus, causing cognitive, gait and
bladder dysfunction
➢ Neuroendocrine dysfunction, most commonly hypothyroidism
➢ Cerebrovascular disease etc
Concerns of WBRT
30. Lynch M. Journal of Oncology Pharmacy Practice. 2019;25(3):657-662.
31. TRIAL DESIGN Outcome
RTOG 0933 PH II- HA-WBRT 7% Cognitive Decline in
Avoidance Arm vs 30% in
historical arm
RTOG 0614 Phase III
Memantine
22% relative decline
reduction in Cognitive
Decline
NRG-CC001 Phase III
HA-WBRT+Memantine
26% relative decline
reduction in Cognitive
Decline
How to reduce Neurocognitive Decline
32. Dmax and D100% < 16 Gy and 9Gy
HA-WBRT is not Suitable for:
• Within 5 mm
• KPS<70
• Life expectancy < 4 mo
• Leptomeningeal disease
33.
34. Mulvenna et al, Lancet, 2016.
Best Supportive Care (QUARTZ-A non inferiority Trial)
35.
36. For such patients multidisciplinary and patient-centered decision making with
close MRI surveillance is recommended to determine whether local therapy
may be safely deferred.
