› Forums › General Melanoma Community › MRI results – size of the Gamma Knife treated lesions
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cancersnewnormal.
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- February 28, 2017 at 4:36 pm
Hello!
My husband had first Gamma Knife surgery in late October – 11 lesions were treated ( various sizes from 1 mm to 2.6 cm)
MRI has been performed in 2 month after the treatment – in late December. Results were very good – almost all lesions decreased in size and no new growth found.
The next MRI ( in February ) revealed 3 new lesions and changes in size of the previously treated lesions.
Some of the previously treated lesions increased in size by 1-3 mm.
I was told that the leasions that were previously treated can't be treated again.
Does anyone had similar results after the Gamma Knife procedures?
Does the increased in size leasions indicate that they are not "dead" and continue to grow or it could be result of the immuno- targeted therapy that he is receiving at the same time?
What is usually done for the lesions that were treated , decreased in size and then started growing again?
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- March 3, 2017 at 6:11 pm
Gamma treated lesions can appear to show "growth" in the months following, particularly if immunotherapy is being done at the same time. Some of the size increase is swelling, and some of it is just a matter of where the imaging slices landed. 1mm is very very tiny. Imaging slices for a typical follow up brain MRI are 2mm apart…. If the slices weren't EXACTLY aligned (which would be near impossible to do) with the prevous scan, the tumor may appear larger, but it may simply be that more of the tumor was captured than on the previous slice covering that space. Does that make sense? Think of the slices like cutting up a ham. If each slice is 2mm thick, there will be spaces in the middle of the meat that cannot be seen. Anything from 1mm-2mm could be "hidden" in that 2mm slice. If you could miraculously "uncut" that same ham, and then slice it up into 2mm slices again… you may discover some of those "hidden" bits that were lost in the meat on the first round of cutting.
"Growth" or "no growth" of prevsiously treated lesions aside…… NEW metastasis is not great news. Those new mets will require another session of gamma. You mentioned immuno-targeted therapy. What is he on, and when did he begin? Anti-pd1 drugs can be effective on brain mets, but may take a few infusions before you'd note a stoppage of new metastasis.
Prior to Keytruda, I was cropping up brain lesions like a movie theater popcorn machine! I had one round of gamma following my first infusion, then did not see another brain met until 13 months later. That little bugger was gamma zapped (round 10!) in early Feb 2016, and my brain MRI yesterday shows no new lesions… just a few little tid bits of scar tissue here and there from some of the previously fried little mets. I did have a second tumor surgically removed in April 2015, when the Keytruda had caused it to swell and spew edema like crazy. The post op pathology showed that there were a few live melanoma cells still active in the "mess of yuck" (my neurosurgeon's words) that was removed. It is possible that your hubs could have a few pesky little cells refusing to give up the fight, despite their having been gamma zapped. However, until there is more solid evidence of actual growth, versus the other potential scenarios, I wouldn't go jumping into brain surgery just yet.
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- March 6, 2017 at 6:38 pm
Hi Niki!
thank you very much for your reply.
my husband had his first craniotomy in October last year to remove the largest lesion of almost 3 cm. At that time he had 9 more in the brains and several in lungs.
He had Gamma Knife procedure 3 weeks after surgery.
after that the oncologist started him on the Taff /Mek combo
the MRI in December showed very good results – all brain lesions reduced in size. CT scan in January also
showed positive reaction to the medicine – may of the lung lesions reduced in size and no new growth.
the problem with the combo was that he was developing high fever and chills almost every week and had to take breaks.
so in February the oncologist prescribed Keytruda and we had his first infusion.
Thr second MRI that I was referring to in my original post was done in February as well – just a couple days before Keytruda. It revealed 3 new lesions, so we are scheduled for second Gamma Knife procedure in two days.
We are reading your story and hoping that his results will be similar.
he feels good – working – he is in IT and hoping for the best.
Just recently he started feeling minor spasms in the temple area that radiate to the bottom of the face and last for about a minute. The doctor suspects that these are minor seizures so he prescribed Kepra, I think it might be related to some swelling from the Keytruda .
thanks again for the very detail explanation
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- March 7, 2017 at 4:39 pm
Your hubs and I are riding a similar roller coaster. : ) My first craniotomy was April 2013, to remove the largest lesion…. although mine was only 1.4 cm. The surrounding edema was the real problem! 3 weeks post surgery, and I was in for my first round of gamma! I went onto Ipi after that though… Although I am technically a "BRAF positive", it isn't the type that is generally recognized (V600 E or K). Ipi didn't work. More gamma. Eventually, my doc got involved with some research which allowed for me to be treated with MEK. The other BRAF drugs didn't work on my cells in a dish… sooooo… no real need to try them in my body. The MEK worked, but gave me a horrible rash and was short lived before the brain mets mutated around it again. It did wonders for my lung lesions though! I was able to have the largest (9cm down to 5 after MEK) surgically removed. Then more gamma. Finally, Keytruda gained FDA approved use, and I was able to begin infusions. Hope he has the same good response that I did! Gamma is no fun. Best wishes to him tomorrow!
I had some really odd little "spasm" kind of numbness on the left corner of my mouth, and the tips of three fingers on the left hand. I saw a neuro oncologist for them, but nothing was ever uncovered as to why this happened. It lasted only a minute or so, and I had it happen 3 or 4 times now….. although it's been a good long while since it last occured. Docs opted to boost my Keppra from 500mg x2 daily to 1000mg x2 daily. Thankfully there are no side effects from that, as I have a feeling after two craniotomies and 10 rounds of gamma, the wiring in my brain may have some permanent disruption. ; ) HA!
He's feeling good… That's always good! : ) In IT huh? Well… he can think of those mets like a network virus. the BRAF drugs are like running anti-viral software… but the Keytruda is more like installing a firewall. LOL! ; )
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- March 7, 2017 at 6:38 pm
Hi Niki!
thanks again ! You have a wonderful sense of humor . I guess it is very helpful and a big factor towards successful outcome
why did the doctor decided to surgically remove the lung lesion versus relying on Keytruda to take care of it? Is it because Keytruda was not approved at that time?
Another question:
we were told that if a lesion was treated once by Gamma Knife
it can't be treated again. Only new ones. What is your experience?
and what do you think about WBRT? We are trying to avoid it as long as possible
thanks again
will update you tomorrow
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- March 8, 2017 at 4:20 pm
Yes, I had the lung lesion surgically removed, because Keytruda was not FDA approved and available outside of trials at that point. I couldn't get into the trials, because I was cropping up new brain mets at an "uncontrolled rate". I was fortunate that a surgeon agreed to do the lobectomy. Some won't (and some insurance companies won't pay for it), if the patient is likely to die from the brain metastasis. My oncologist got me into some research on MEK, and was able to shrink the lung lesion (nearly in half) and keep my brain clear of new mets for one month….. soooooo… he was able to convince the surgeon that I'd be ok. I was happy to have it OUT. It ended up making Keytruda's job easier (lower tumor burden) and more rapid.
Yes, I too have been told that once gamma radiated, a lesion can not be gamma zapped a second time. My radiation oncologist explained the "why" to me in detail a few years ago. It made perfect sense at the time… but I've long since set aside the reasoning. It has something to do with the way the radiation destroys the lesion structure, and not risking blasting the broken scar tissue bits around your brain. I consider myself a well educated and reasonably intelligent individual… but this doc went to MIT and Harvard. Top that with the fact that his dad was also a radiation oncologist, and I just can't keep up. ha! I question the hell out of him, but I have to trust him on things like that. :-p
I don't like WBRT. When I first went in for treatment of the brain lesions, I was given the option of WBRT or gamma. We went round and round with questions, and decided that avoiding WBRT was best. Unless I were staring into the face of "no other choice", with 25 plus lesions… I'd stay away from it. The potential long term side effects are terrifying, and because it is a lower dose to each lesion, it is not nearly as effective as targeted radiation. Google Dr. Michael Apuzzo (brilliant man with looooong term experience)… he was the Neurosurgeon in charge of the gamma unit at USC (where I get treatment) until his retirement in 2015. He was adamantly against hitting me with WBRT, unless it was literally a last ditch effort to buy more time, or get me into a trial. That's not to say that it doesn't have its necessary place in treatment… but it is certainly one of the more risky endeavors. I am stunned when I read that people outside of the U.S. do not have gamma as an option if there are more than 4 lesions. It makes me want to slap the worldwide medical community for not having updated the "standard treatment" protocol yet.
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- March 9, 2017 at 12:56 pm
Hi Niki!
looks like we are approaching your numbers.
the MRI revealed 20 new lesions – very small – under 1 cm. So they treated all of them with Gamma Knife. Will hope that Keytruda will kick in soon.so now we have all together 30 brain lesions and 1 operation bed site.
the Radiologist was thinking about WBRT next time if the progress will continue, but we will not agree.
for Melanoma brain lesions – only Gamma Knife
appears to be effective.
let'shope for the best. The next MRI will be scheduled in 6 weeks
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- March 9, 2017 at 2:36 pm
Yuck! 20 new lesions! Small is good… but getting that many zapped must've taken a lot of time in the gamma unit. That had to be a long day for you both. : ( Hopefully that Keytruda will be his magic elixir, and that popcorn like spread will STOP!
When the lesion numbers get high like that, it gets to be a challenge for the team to map out which ones have already been treated, and whether or not something might be new. My MRI's had to be passed through the gamma team and tumor board for review, so they could check the mapping for previous treatment locations. The radiology reports turn into these two or three page scrolls with itemized lesion locations.
If the radiation oncologist suggests WBRT "next time if the progress continues"….. First and foremost, ask how many lesions are indeed "new", and how they have ensured they aren't looking at treatment related response of already gamma zapped tumors. If the new lesion numbers are high once again… perhaps ask about the possibility of reducing the number of WBRT treatments. What would be the minimal amount before he could be imaged again to see what the response is? Since he cropped up a numerous amount at once, but they were all pretty small….. he may not require the "standard" (gads I hate that word) number of doses of WBRT, to eliminate any microscopic disease. I was getting MRI's 3-4 weeks apart when things were at their worst….. For early 2014: Jan 16th… Feb 25th… March 11th… April 8th… April 17th… May 19th ……. It was getting almost ridiculous. My doc would bring the gamma paperwork into the room along with the results. We all knew I was going to sign them. I started joking with the gamma nurse before MRI's that she needed to reserve my spot for particular dates.
When is his next Keytruda infusion? Is it right away? I know some docs shy away from that… particularly if the patient has been put on steroids to minimize/control any brain lesion swelling after the radiation. But then, there are the docs who are shooting for the potential abscopal benefit of Keytruda combined with the radiation.
Hope he is bouncing back quickly today and you guys can relax a little.
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- March 9, 2017 at 5:50 pm
Hi Niki!
is it possible to talk to you over the phone?
The docs don't want to do MRIs more often than 6 weeks apart. They are saying that we will not see the results of the previous Gamma Knife sooner and it doesn't make sense to do it more frequently.
The oncologist is against WBRT because she explained that the dosage of radiation during WBRT is much smaller than in Gamma Knife and it's not enough to kill the melanoma cells.
so it's killing normal cells and have very little effect on the melanoma cells. In addition I read a lot of feedback about WBRT and melanoma and it looks like it doesn't make any sense to administer it – it will prolong life by may be 90 – 120 days but will do more damage than good.
Radiologists believe in it and don't believe in the immunotherapy for the brain lesions . Oncologists have their own opinion. And we are between them – making our own decisions.
i do have a concern about swelling and Keytruda/steroids controversy. Currently Greg is on 1mg per day – already for 2 month.
if he will need more – we will consult with oncologist to see what she says
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- March 9, 2017 at 10:50 pm
I sent you a message via the "contact" tab on your forum profile page. Let me know if you don't receive it.
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- March 12, 2017 at 6:12 pm
Yeah… hit me with an email at [email protected] ….. I'll send you my number. : )
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