BRAIN METASTASIS

In many patients with brain metastases, the primary therapeutic aim is symptom palliation and maintenance of neurologic function, but in a subgroup, long-term survival is possible. Local control in the brain, and absent or controlled extracranial sites of disease are prerequisites for favorable survival. 

Stereotactic radiosurgery (SRS) is a focal, highly precise treatment option with a long track record. Its clinical development and implementation by several pioneering institutions eventually rendered possible cooperative group randomized trials. A systematic review of those studies and other landmark studies was undertaken. 

Most clinicians are aware of the potential benefits of SRS such as a short treatment time, a high probability of treated-lesion control and, when adhering to typical dose/volume recommendations, a low normal tissue complication probability. 

However, SRS as sole first-line treatment carries a risk of failure in non-treated brain regions, which has resulted in controversy around when to add whole-brain radiotherapy (WBRT). SRS might also be prescribed as salvage treatment in patients relapsing despite previous SRS and/or WBRT. An optimal balance between intracranial control and side effects requires continued research efforts.

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Klatskin tumour

A fifty-four years old Marwari patient from Assam presented with progressive jaundice and intermittent episodes of abdominal pain for three months. CT scan of abdomen showed a small (1.5 x 1.5 cm) mass in the bifurcation of common bile duct which is causing biliary tract obstruction and hence jaundice. Portal nodes were not enlarged and there was no lesion in the liver parenchyma. At presentation, serum bilirubin level was high (14.7 mg/dl). Endoscopic biopsy and brushing cytology was adenocarcinoma and clinic-radiological diagnosis was ‘Klatskin tumour’. 

Metallic stenting was done to relieve jaundice and after stenting serum bilirubin level came down rapidly. PET scan showed increased uptake in the biliary duct region mass without any sign of metastasis. He was evaluated and planned for treatment with robotic radiosurgery. He was treated using robotic radiosurgery (CyberKnife) with high precision radiotherapy technique after fiducial placement (gold seeds) near the tumour. After one year, the patient had no obvious complain, liver function (no jaundice) was normal and CT scan evaluation showed completed resolution of the mass.  

Klatskin tumour is an uncommon tumour that arises from the bifurcation of common bile duct in the abdomen (duct that drains bile from liver). Patients usually present with progressive (increasing) persistent jaundice followed by pain in the upper abdomen. Surgical excision is the mainstay of treatment. However, surgery is not possible in majority of the patients owing to the location of the tumour, high jaundice and medical condition. Chemotherapy may not be an optimal option in majority of the patients as they present with high jaundice. Majority of such patients with poor medical condition are treated with only supportive care and prognosis is dismal (survival for a few months only).

Patients with metallic stent have relief from jaundice but unfortunately in a few weeks time, the stent gets blocked with tumour growth. Patients again present with high jaundice and have severely impaired quality of life. They complain of severe itching of entire body, loss of appetite and succumb due to impaired liver function from high jaundice/obstruction. The treatment is to have a longer ‘jaundice-free period’ which in turn improves quality of life and possibly survival function as well.  

Stereotactic body radiation therapy’s high dose radiation ‘sterilizes’ the metallic stent and bile duct region. It is assumed that with radiation therapy, blockage of bile duct and stent is delayed and patients have longer jaundice-free period.In Klatskin tumour, CyberKnife allows to deliver high dose of radiation in a short duration to the target without significant morbidity. 

Article by Dr.Debnarayan Dutta

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Renal cell carcinoma

Patients with metastatic renal cell carcinoma (RCC) to the brain have a very poor prognosis of three months if left untreated. SRS is an effective treatment modality in numerous patients. This case exemplifies the utility of stereotactic radiosurgery (SRS) in prolonging survival and maintaining quality of life in a patient with RCC. This 64-year-old female patient initially presented to her primary care physician 22 months after a left nephrectomy for RCC with complaints of mild, intermittent headaches and difficulty with balance. An MRI revealed five cerebellar lesions suspicious for intracranial metastasis. The patient's first GKRS treatment targeted four lesions with 22 Gy at the 50% isodose line. She underwent a total of seven GKRS treatments over the next 60 months for recurrent metastases to the brain. 72 months and 12 months have now passed since her brain metastases were first discovered and since her last GKRS treatment, respectively, and this woman is alive with considerable quality of life and no evidence of metastatic reoccurrence. This case shows that repeated GKRS treatments, with minimal surgical intervention, can effectively treat multiple intracranial lesions in select patients, prolonging survival and avoiding iatrogenic neurocognitive decline while maintaining a high quality of life.

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choroidal haemangioma (eye lesion)

Master ShreeVaishnav – Kerala, India 
Radiation therapy is one of the most important tools to combat cancer. However, conventional radiation therapy is long course (usually 6 to 7 weeks) treatment and may have severe acute side effects including skin and mucosal reactions, diarrhea, feeding difficulties and others. Higher dose radiation is also not possible to deliver due to limitations related to toxicities. CyberKnife is a precise radiation therapy technique by which high dose radiation therapy can be delivered only to the tumor and minimal dose to the normal structures. CyberKnife treatment is a short course treatment (usually only one to 5 days) and have no or minimal side effects. Many tumors which are ‘resistant’ to conventional radiation are ‘sensitive’ to high dose radiation delivered by CyberKnife. “CyberKnife has unique system that it can track moving tumors and treat them with immaculate accuracy”. Tumors in moving organs such as lung and liver can be treated most effectively CyberKnife. Dr Debnarayan Dutta, Consultant in Radiation Oncology at Apollo Speciality Hospital, Chennai commented “there are few tumors which were thought to be not treatable are now being treated successfully with CyberKnife”.

Master ShreeVaishnav, a 6 year old boy from Kerala suffering with choroidal haemangioma (eye lesion) had vision loss in both the eyes, he was referred from Sankar Netralaya for treatment. He was treated with CyberKnife and at 2 months follow up evaluation his vision had dramatically improved. “We are thankful to Dr Dutta for giving vision back to my son” told ShreeVaishnav’s father who was elated about CyberKnife. “CyberKnife has opened a modern and effective option for these diseases and we are happy with the result” said Dr Prativa Mishra, eye specialist involved in ShreeVaishnav’s treatment.

CyberKnife is a revolution in cancer treatment; it provides effective, short course, minimal toxic and high dose treatment in brain, lung, liver, pancreas, prostate, head and neck and many other tumors.

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