Whole Brain Radiation (PCI)

Whole brain radiation is being routinely administered to patients after craniotomy for excision of a cerebral metastasis in an attempt to destroy any residual cancer cells at the surgical site. However, the deleterious effects of whole brain radiation, such as dementia and other irreversible neurotoxicities, can become evident.

This raises the question as to whether elective postoperative whole brain radiation should be administered to patients after excision of a solitary brain metastasis. Current clinical practice, at a number of leading cancer centers, use a more focused radiation field that includes only 2-3cm beyond the periphery of the tumor site.

Many metastatic brain lesions are now being treated with stereotactic radiosurgery. In fact, some feel radiosurgery is the treatment of choice for most brain metastases. There are a number of radiation treatments for therapy (Stereotatic, Gamma-Knife, Cyber-Knife, Brachyradiation and IMRT to name a few). These treatments are focal and not diffuse.

Unlike surgery, few lesions are inaccessible to radiosurgical treatment because of their location in the brain. Also, their generally small size and relative lack of invasion into adjacent brain tissue make brain metastases ideal candidates for radiosurgery. Multiple lesions may be treated as long as they are small.

The risk of neurotoxicity from whole brain radiation is not insignificant and this approach is not indicated in patients with a solitary brain metastasis. Observation or focal radiation is a better choice in solitary metastasis patients.

Whole brain radiation can induce neurological deterioration, dementia or both. Those at increased risk for long-term radiation effects are adults over 50 years of age. However, whole brain radiation therapy has been recognized to cause considerable permanent side effects mainly in patients over 60 years of age. The side effects from whole brain radiation therapy affect up to 90% of patients in this age group. Focal radiation to the local tumor bed has been applied to patients to avoid these complications.

Aggressive treatment like surgical resection and focal radiation to the local tumor bed in patients with limited or no systemic disease can yield long-term survival. In some patients, delayed deleterious side effects of whole brain radiation therapy are particularly tragic. Within 6 months to 2 years patients can develop progressive dementia, ataxia and urinary incontinence, causing severe disability and in some, death. Delayed radiation injuries result in increased tissue pressure from edema, vascular injury leading to infarction, damage to endothelial cells and fibrinoid necrosis of small arteries and arterioles.

Previous studies on this protocol were thought to have been on the difference between surgical excision of brain tumor alone vs. surgical excision & whole brain radiation. It was a study of whole brain radiation of a brain tumor alone vs. whole brain radiation & surgical excision. The increased success had been the surgery.

Those studies convincingly showed there was no survival benefit or prolonged independence in patients who received postoperative whole brain radiation therapy. The efficacy of postoperative radiotherapy after complete surgical resection had not been established. It never mentioned the incidence of dementia, alopecia, nausea, fatigue or any other numerous side effects associated with whole brain radiation. The most interesting part of thes studies were the patients who lived the longest. Patients in the observation group who avoided neurologic deaths had an improvement in survival, justifying the recommendation that whole brain radiation therapy is not indicated following surgical resection of a solitary brain metastasis.

Had fatigue, memory loss and other adverse effects of whole brain radiation been considered, and had quality of life been measured, it might be less clear that whole brain radiation is the right choice for all patients. These patients do not remain functionally independent longer, nor do they live longer than those that have surgery alone. The standard for proving the value (improving overall survival) of whole brain radiation fell short of this criteria.

The UCLA Metastatic Brain Tumor Program treats metastatic disease focally so as to spare normal brain tissue and function. Focal treatment allows retreatment of local and new recurrences (whole brain radiation is once and done, cannot be used again). UCLA is equipped with X-knife and Novalis to treat tumors of all sizes and shapes. For patients with a large number of small brain metastases (more than 5), they offer whole brain radiotherapy.

http://neurosurgery.ucla.edu/

The results of a study at the University of Pittsburgh School of Medicine reported that treating four or more brain tumors in a single radiosurgery session resulted in improved survival compared to whole brain radiation therapy alone. Patients underwent Gamma-Knife radiosurgery and the results indicate that treating four or more brain tumors with radiosurgery is safe and effective and translates into a survival benefit for patients.

http://www.upmc.com/home.htm

As reported in MD Anderson's OncoLog, in the past the only treatment for multiple metastases was whole brain radiation, which on its own had little effect on survival. There are now a variety of effective treatment modalities for people who have fewer than four tumors. Dr. Jeffrey Weinberg at the Department of Neurosurgery at MD Anderson has said "with a small, finite number of tumors, it may be better to treat the individual brain tumors themselves rather than the whole brain." Anderson is equipped with Linac Linear Accelerator. The critical idea is to focally treat all tumors.

http://www2.mdanderson.org/depts/oncolog/pdfs-issues/05/oncolog1-05.pdf

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23 replies. Join the discussion

Hi there, WBR and PCi are two very different things, WBR is done when tumors are present and PCI is done to prevent any LC cells to grow into tumors. The dose for each is very different.

GOd bless you, Kerstin

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I had WBR after removal of my brain mets. Brain surg wanted it over 1 week Radio oncol change it to 2 weeks because he thought the amount of Rads could not be tolerated over one week.. I asked brain surg about the side effects after 18 months and the fact that they were not really considered because most of the WBR patients were gone by then and he agreed. I asked why was I not informed of that. His reply was what good would that have done. They did disclose that the amount of Rad I was to receive would most likely cause some kinda blood cancer within 10 years, SWEET. But they also mentioned by then they might have made great strides in cancer research. The Brain surg said until a better plan to battle lung mets to the brain was proven they would continue to use WBR.
I like this one about statistics.
Sometimes people use statistics like a drunkard uses a lamp post. More for support than illumination. God bless us all.
Bobby & Buddy the dog

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WBR has just about destroyed my husband. He had tiny mets from NSCLC to the bone and brain and was sent to Radiation after his brain mets were found on an MRI. The radiation oncologist told us that the " standard" treatment would be 10 sessions of WBR and that the biggest side effect would be hair loss. HA. Not true. My husband can no longer walk without support, use the bathroom, speak clearly, remember that he even has cancer, sleeps all the time, has no appetite or enthusiasm. I am distressed that they just pass people from one department to another and just follow the " standard" procedures. If the side effects of this procedure were given to us in advance, in detail, we would have opted out. His Oncologist said that he would just bounce back and feel better than ever. This is the Mayo Clinic, folks. After a few treatments I asked one of the technicians if they had Cyberknife technology sh said that they did not. So I will tell you what your Dr. may not: be VERY careful to learn all you can before choosing WBR.

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WBR is administered prophylactically to patients after craniotomy for excision of a cerebral metastasis in an attempt to destroy any residual cancer cells that may be in the brain to prevent them from growing into tumors. PCI is used prophylactically to prevent any cells to grow into tumors in the brain. The amount of dosage is questionable. If you get a rad onc who is aggressive, it may be a moot point. The institutions I presented have taken the 'focal' concept of radiation treatment for up to five brain mets, not just a solitary brain met.

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Professional liability in the field of radiation oncology may result from inadequate explanation to the patient of the intent, risks, side effects and expected results of radiation treatment. A patient must always be fully informed whenever risky protocols are followed. It is "vital" that the radiation oncologist coordinate the radiation treatments with surgeons so as to ensure that any treatments follow accepted protocol. Inappropriate technique or dosage may subject a patient to increased risk of side effects and complications.

In the past, patients who were candidates for whole brain radiation were selected because they were thought to have limited survival times of less than 1-2 years and other technology did not exist. Today, many physicians question the use of whole brain radiation in most cases as one-session radiosurgery treatment can be repeated for original tumors or used for additional tumors with little or no side effects from radiation to healthy tissues. Increasingly, major studies and research have shown that the benefits of radiosurgery can be as effective as whole brain radiation without the side effects.

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Hello, I knew very well what I was getting myself into doing PCI, I had spent hours upon hours doing research on and off line on PCI, and yes often the bad outweight the good in these studies that are older than my teeange boys, but I am glad that I did it and other than sometimes telling you something that I had told you 2 weeks ago, I have no other side effects, as of yet.
God bless you, Kerstin

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Until the new millenium, the only treatment for patients with confirmed radiation-induced necrosis was pentoxifyline or heparin therapy, and it was almost always unsuccessful. Hyperbaric Oxygen Therapy (HBOT) is now a useful therapeutic option for patients with confirmed symptomatic radiation necrosis. Duke University and the University of Cincinnati had clinical trials in the late '90s on this matter. I've received numerous emails from radiation necrosis patients who had HBOT, both from these clinical trials and otherwise, and the good news is, it works (for most patients).

The most common condition treated at some HBOT centers is tissue injury caused by brain radiation therapy for cancer. Wound healing requires oxygen delivery to the injured tissues. Radiation damaged tissue has lost blood supply and is oxygen deprived. Chronic radiation complications result from scarring and narrowing of the blood vessels within the area which has received the treatment. Hyperbaric Oxygen Therapy provides a better healing environment and leads to the growth of new blood vessels in a process called re-vascularization. It also fights infection by direct bacteriocidal effects.

Some sources:
http://www.oncolink.com/treatment/article.cfm?c=5&s=33&id=51
http://anesthesia.duhs.duke.edu/divisions/hyperbarics.html
http://www.spinalrehab.com.au/Updates/Hyperbaric%20Oxygen%20treatments %20can%20help%20patients%20with%20radiation-induced%20brain%20injuries .htm
http://www.hbot.com/BrainRadiation.html

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Glad things went well for you. PCI, as I understand it, is much better than Whole Brain Radiation which they gave to my husband.

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One school of thought from scientists at Brookhaven National Labs, believes that platinum compounds (cisplatin/carboplatin) could lower the central nervous system's resistance/tolerance and make it more sensitive to radiation, making any side effects more pronounced. What can make it more harmful, giving chemo and radiation treatments at the same time doubles the toxic dosage.

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Thanks for posting the opening article. My husband is being asked to do PCI and we are so on the fence about this! We just can't decide, and that in itself might ultimately be the decision. He's 53, went back to work 2 weeks after finishing the chemo & radiation, and can't get around the idea of what is the point of surviving if its with diminished capacity from potential PCI brain damage? Are there any statistics showing how many sclc-limited individuals who undergo PCI end up with what THEY subjectively consider neurlogogical deficits from it? Also, we are troubled by the statistics showing no benefit in longevity in the group that did the PCI. Does anyone know if longevity was measured by both limited and extensive individuals participating in these studies? Anyway to know the results for just sclc-limited participants? If the cancer is just going to come back and kill you in another form (e.g. as bone, endo cancer), what really is the point of PCI if it doesn't make you live longer? Not dying from brain cancer doesn't seem compelling enough to undergo the risk without more information. Any info. appreciated.

Louise

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In studying the science of cell function analysis, the unique situation about SCLC is it's intrinsically "sensitive" to chemotherapy. It is one of the very few forms of carcinoma for which chemotherapy has some positive effect on survival. NSCLC is intrinsically "resistant" to chemotherapy. What this means is that surgery and chemotherapy (the "right" chemotherapy the first time around) works much better for SCLC, while surgery and radiation therapy would work better for NSCLC.

However, SCLC is also very aggressive, tends to metastasize readily and grow rapidly. Recurrences are much more difficult to treat. Brain mets are common, hence the use of prophylactic whole brain radiation (PCI). Patients who are candidates for this are selected because they are thought to have "limited" survival times of less than 1-2 years, before the effects of radiation necrosis would show up.

A study led by a lung cancer surgeon at Jefferson Medical College suggests that oncologists should take more advantage of laboratory tests that have the potential to help determine a lung cancer patient's resistance to chemotherapy drugs. All too often, patients with NSCLC are given standard chemotherapy drugs after surgery in a "hit or miss" fashion, without doctors knowing which drugs might have better chances than others to help treat the tumor. Steps should be taken to validate such resistance tests in clinical trials.

Reporting recently in the Journal of Thoracic and Cardiovascular Surgery, Thomas d'Amato, M.D., Ph.D., assistant professor of surgery at Jefferson Medical College of Thomas Jefferson University in Philadelphia, and his colleagues analyzed data on 4,571 non-small cell lung cancer tumors' resistance to four pairs of chemotherapy agents, each of which included a standard platinum-based drug: carboplatin and paclitaxel (taxol), cisplatin and navelbine, cisplatin and docetaxel and cisplatin and gemcitabine.

d’Amato, Thomas A. Adjuvant Chemotherapy and the Role of Chemoresistance Testing for Stage I Non-Small Cell Lung Cancer. Thorac Surg Clin 17 (2007) 287–299.

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Hi,

Thanks again for the great research you have done on this subject.. I am wondering if you have come across any statistics on PCI in individuals under 60 (in their 50's), showing the percentage who sustain white matter brain damage and the like from undergoing PCI? Is 90% neurological damage for individuals over 60 due to WBR still a good statistic? Also, any distinction between PCI and WBR? We are very concerned about having my husband do this as he already has been treated with cisplatin + etoposide a month ago (plus radiation to chest tumor). Please go ahead & email me off board if you have any information. can't locate the statistics we need online. Thanks so much!

Louise

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Cisplatin + etoposide has been one of the most "tried-and-true" agents for SCLC for many years. It is a classic treatment, going back 25 years. If it is synergistic to the "individual" cancer patient, it works.

Both WBR and PCI are administered "prophylactically" to patients. The amount of dosage is questionable and still is debatable. If you get an aggressive radiation oncologist, there may not be much or any difference.

Some of the url addresses of sites that give information on radiation treatment are listed below. Many have gone dead, changed, revised, etc. One of my favorites had been the Armed Forces Institute of Pathology website, but they had done some major revisions of their site and have changed their locations of much material. You may get some ideas from these sites:

http://www.irsa.org/radiation_injury.html
http://www.emedicine.com/neuro/topic330.htm
http://www.aboutcancer.com/brain_radiation_comps_aminoff.htm
http://spinwarp.ucsd.edu/NeuroWeb/Text/br-840.htm
http://jco.ascopubs.org/cgi/content/abstract/12/3/627
http://www.cancer.gov/clinicaltrials/results/stereotactic-radiosurgery 0806
http://www.radiologyinfo.org/en/info.cfm?pg=thera-brain&bhsh=1024&bhsw =1280&bhqs=1
http://www2.mdanderson.org/depts/oncolog/articles/05/1-jan/1-05-1.html
http://www.medpagetoday.com/Radiology/GeneralRadiology/tb/3486
http://knowledge.bcmets.org/index.php/Whole_Brain_Radiation

One item that may help in making an informed decision is reading information about Hyperbaric Oxygen Therapy (HBOT) for radiation-induced necrosis. If symptoms should occur after PCI or WBR, there is at least something that can be done about it. I've received many emails over the years from patients receiving this treatment, confirming the positive effects of the treatment for any incidious side effects of radiation treatments. You may want to look into it.

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Hi,
I had to let you know that my husband had a full body PET and CT scans done with contrast a week ago, and the results are in. They showed that the cancer was completely gone (sclc-ld, treated with cisplatin + etoposide 4 rounds, plus 30+ radiation to chest, left central tumor). We are just thrilled beyond belief!!!! The oncologist isn't suggesting PCI at this point-instead, he is going to start him in about 3 weeks on 'maintenance oral etoposide.' I'm hoping that this puts the PCi option permanently off the shelf-after reviewing all the articles on PCI, considering my husband is in his early 50's and wants to continue working, the possibility of side effects from PCI would be devastating, and he truly doesn't want to risk impairment. Of course, we are praying we remain lucky...!I think etoposide as maintenance may be something new, but will keep you posted on what develops. We will be back to see the oncolgist in 3 weeks to begin, and will report his suggestions then. Thanks so much for all the information!

Louise

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My mother has just passed after almost a year battling lung cancer. My sisters and I are convinced that WBRT played a key role in her quick demise. But, how do we separate this impact from the impact of the metastasis of the cancer to the brain?

She was weak but fully ambulatory before the start of WBRT. Within a few days of the start of WBRT, she became less mobile and cognitive thinking was impaired. After a week of WBRT, my mother could not walk without assistance, feed herself, or sign her name!

We had been told that WBRT would "kick her in the butt" (e.g. make her super-fatigued). Otherwise, we were told that it could result in some memory loss, hair loss, and maybe some nausea. We could not get anyone to discuss more permanent side effects.

Our mother was very worried about WBRT despite agreeing to go through with it. She was worried about the long-term effect on her brain.

Her MRI had shown eight small brain lesions. She had experienced nausea and vomiting, and she had been started on Decadron 4 mg twice a day.

After just eight treatments, she became agitated when placed under the mask. She told the technicians she couldn't breathe and that they were killing her when they made her lie flat. She was panicked because she felt like she was being smothered!

After trying Xanax to relieve the anxiety, my mother could not lie flat or tolerate the mask. She was hospitalized when the dose of Xanax made her stop breathing.

She began to spiral immediately downward. She was totally breathless upon exertion or lying less than 45 degrees in the bed. She began to beg all of us, "Please, help me!" Her memory lapses increased.

When she went into the WBRT, she was not in the dying process, but it was clear that now she was! She began to show increasing periods of apnea. Her chest x-ray showed increased pleural effusion and pneumonitis post-radiation treatment.

Did WBRT hasten my mother's death? We believe it did. My mother kept a daily journal in her treatment, and just three days after the start of WBRT, her entries stopped completely. Her last entry is almost illegible!

We asked for an enhanced MRI, but my mother could not tolerate lying flat. A CT scan of her head didn't show anything. Despite extreme SOB on exertion, my mother's oxygen saturation was always above 90. She felt like she was being smothered.

Any thoughts? We feel now that we should have guided our mother to forego the WBRT---the just use steroids and stay comfortable. The outcome would have been the same possibly, but our mother would have been spared the debilitating side effects of the WBRT. It was just a nightmare!

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When it comes time for us to find out all that happened, many times we may think our thoughts are our own, but more often than not, they emanate from our passed on loved-ones. Your loved-one is there with you, they'll help you to understand. Give them time to learn to communicate with you.

With the many variables of cancer, specific "real person" stories and situations are a blessing to those in need. In sharing with others what is learned, or will be learned, not only does it help with the healing process, but something that is mention may be just the information someone who is just finding out, may be looking for.

Just taking the time to post information experienced and learned is a tribute to your loved-one's memory and not only shows love for her, but for people in general. Take the time to understand, your mother is still there with you, and will help you to understand. Peace and blessings, I empathize with your grief.

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I always follow your posts. I learn so much from them. Thankfully, I have not had mets to the brain but I do have alot of radiation damage to the chest and thoracic spine. I am three years post-treatment with concurrent radiation and chemo(carboplatin-taxol). Would HBOT be helpful to me...Three years out but with a lot of necrosis in the lung that is very susceptible to infection? Is this something I should be questioning my radonc about? Thank you. Babs

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I have finished 3 wks (15 treatments) of WBR. I had a tumor that was affecting my entire left side. I have not had chemo yet. That will start next Tues. So far, so good. Went through some nausea and vomiting. I have always had short term memory loss (as told by my kids) Ha! Ha! Will keep everyone posted as to any changes. God Bless all!!
Eileen

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I was able to find your first referenced article from oncolink.com but cannot locate the one on spinal rehab. It is of interest to me because my thoracic spine was damaged from radiation. I had kyphoplasty to T6 and &7...amazing surgery... but still have pain from other vertebrae. Is there any other way I can access the article? Babs

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The one item I mentioned at the end of one of the above posts is Hyperbaric Oxygen Therapy (HBOT). HBOT is now a useful therapeutic option for patients with confirmed symptomatic radiation necrosis.

I had an appointment to take my wife to Duke University for Hyperbaric Oxygen Therapy for radiation-induced necrosis. But it was way too late. She expired before we could even try.

I've received a number of emails from radiation necrosis patients who had HBOT. One of them was the mother of a patient who went through the Duke clinical trial. The good news is, it works for most of them (if one is not too late in the process of the side effect).

The most common condition treated at some HBOT centers is tissue injury caused by brain radiation therapy for cancer.

http://lungevity.org/l_community/viewtopic.php?t=37475&highlight=hyperbaric +oxygen+therapy

http://health.ucsd.edu/specialties/hyperbaric

http://www.florida-oxygen.com/

http://www.jacobi-hyperbaric.com/html/radiation-hyperbaric.html

http://www.oncolink.com/treatment/article.cfm?c=5&s=33&id=51

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