Case 4: SRS Versus Whole Brain Radiation Therapy

EXPERT PERSPECTIVE VIRTUAL TUMOR BOARD

Benjamin P. Levy, MD:Anshu, this patient, as I recall, had 2 brain METS [metastases]. Clearly, management of brain METS has evolved. We have data now that targeted therapies may cross the blood-brain barrier and may circumvent the need for radiation. We have some soft data on immunotherapy. Maybe it crosses the blood-brain barrier? What is your role in managing this? How you manage them—SRS [stereotactic radiosurgery], CyberKnife. Walk us through that.

Anshu K. Jain, MD: Sure. We often will look at this on a patient-by-patient basis. In the up-front setting, if the patient has brain METS on diagnosis, and certainly I think when you’re looking at a case where you’re dealing with 3 or fewer METS, we typically like to at least have an evaluation for surgical resection. I think that if they could come out, that’s the best way to go.

I think that the paradigm has really changed, moving away from whole brain radiation therapy, even in the setting of up to 3 METS. We typically favor up-front stereotactic radiosurgery [SRS] for these patients. In experienced hands, this can be done fairly quickly. It results in fairly predictable and low rates of toxicity. Also, I think it allows us to keep those options, in terms of any type of cross-brain barrier activity that a systemic therapy may have. I think we like to think about it more in terms of helping to prevent relapse as opposed to treating existing METS.

Benjamin P. Levy, MD:Yeah. How often do you surveil the brain after you have completed radiosurgery? Do you talk to your medical oncologist? We’ve done the radiation, or our SRS every 3 months, every 6 months. How often do you monitor the patient?

Anshu K. Jain, MDDuring year 1, we like to do every 3 months with MRI [magnetic resonance imaging] surveillance. That seems to be what practice patterns typically bear out—about every 3 months. Some practitioners will get a post-SRS MRI of the brain at 6 weeks and then have that as a baseline to assess from in the future.

Transcript edited for clarity.