Laser thermocoagulation - A novel treatment for brain metastases regrowing after radiosurgery

Keywords: brain metastasis, recurrent disease, gamma knife, laser interstitial thermocoagulation, outcome

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     Stereotactic radiosurgery (SRS) as treatment for new or recurrent brain metastases has become commonplace because multiple lesions can be treated in sick patients very effectively with minimal morbidity. Limited options are available however if lesions regrow after SRS, especially if the patient has already had, or wishes to avoid whole brain radiation therapy (WBRT).
     Our purpose was to define outcomes after laser interstitial thermocoagulation therapy for brain metastases.
     Of our 6 patients, the lesions treated were located in the frontal lobe (3), cerebellar peduncle (2) and parietal periventricular region (1).
     We report on a series of 6 patients who had previously undergone SRS for brain metastases (NSCLCa x3, melanoma x2, ovarian x1) whose lesions were demonstrated by gadolinium-enhanced MRI to be regrowing. In each case, due to the presence of a deep symptomatic lesion failing medical management including steroids, the patients were offered conventional surgical biopsy followed by intra-operative MR-guided laser interstitial thermocoagulation therapy (LITT) using the Visualase laser system.
       No patients developed new neurological deficits post-operatively and all were able to be discharged post-operative day #1. 5 out of the 6 patients successfully weaned off steroids within one month of their LITT procedure with gradual improvement in symptomatology over the next 2 months. Histology demonstrated adverse radiation effect (ARE) in all 5 patients. 6 month follow-up imaging in these 5 patients showed significant decrease in lesion size, enhancement and FLAIR signal abnormality. The single patient who was unable to wean off steroids had histology showing regrowing tumor and subsequently underwent craniotomy for continued lesion growth.
     This was a retrospective series.
     LITT is a novel surgical treatment that may play a role in the treatment of lesions that radiographically appear to be regrowing after SRS.
     Given the technical limitations of the technology at this time, it may be more appropriate for use in the treatment of biopsy proven ARE. Further experience is required to determine if it can be used safely in regrowing tumors.


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