Question: Dear Doctors


XXXXX's metastatic breast cancer was detected nearly three years ago in Apr 2012.

Radiation doctor asked for MRI and MRS spectroscopy to be done for Mangla. We got it done on 1.5.15 and the reports are attached herewith. Also attached is an excel summary of three sheets made by me 1) all MRIs till now 2) MRS 3) Seizures, radiation brain ( SRS) and medication connected with brain .

The reports seem to be alarming.

A) MRI summary would show increasing sizes of lesion from even before SRS that was done on 1.10.14 as per MRI dated 28.09.14, 10.12.14, 02.02.15 and 01.05.15
a) left high frontal size increasing 16 X 15 mm, 19 X 15 mm, 27 X 16 mm and now 3.4 X 1.6 cm respectively
b) left occipital lobe along left tentorium cerebelli fluctuating 19 X 21 X 12 mm, , 12(TR) X 21(AP) X 11(CC) MM, no size shown to now 4.3 X 2.9 cm
Surprisingly MRI report is showing such a major increase from mm to cm as only a mild increase.
These details are given in my MRI summary in excel sheet.

It seems that the Oct 14 SRS did not finish these two lesions at all and MRI spectroscopy confirms their being consistent with metastasis, ie malignant in nature, as also areas with Radiation necrosis exist.

If it so then is it that it was required to stop their growth at initial stages itself ? What now ?

B) Moreover now MRI is also showing Mass Effect, effacement as also shift of midline septum , all of them further worsening the situation with increasing edema bringing on and off effect on limb movement , memory mood understanding and ability to do activities.
What can be done about it now ?

D) Details of Seizures, Radiation and brain medicines viz. Dexona, Levepil and Frisium are given in my excel sheet on it along with dates, nature, doses and duration.
Are these not sufficient to be able to control the deteriorating mental state and well being ?

E ) Lately from 24.02.15 to 17.03.15 Radiation of primary location being left breast was done, the only other place showing last though started with liver, lymph nodes etc also in 3.5.12 , the first PET CT. Latest PET CT report dated 12.02.15 is attached herewith. .
Could this be a cause of such rapid changes in the brain leading to increased growth of metastatic disease ?
.Rest of the body position yet to be known after PET CT when it is done later on after the last one done on 12.02.15.

F ) Medicines taken till now sequentially,for other than brain prescribed by medical onco are as follows:
Under systematic treatment - Andryamycin, Cytoxan, Taxol, Taxotere, Arimidex (Horm), Zeloda, Navelbine, Femara (Horm), Aromasin (Horm) and now continuing Nolvadex (Tamoxifen)(Horm).

she is also ER/PR and HER2 positive

Under Targeted Therapy - Herclon, Canmab, Tykerb and Canmab still continuing as on date starting from as long back as 22.08.12 totalling to nearly 40 viles other than Tykerb.


Your valuable advice is required to see the things down the line and proceed.
MRI Magnetic Resonance Imaging
Cracinoma Breast with Brain Metastasis
XXXX

Fri 03.05.13 SRS- Stereotactic Radio Surgery
10.05.13 30.05.13 WBR - Whole Brain Radiation
01.10.14 SRS- Stereotactic Radio Surgery

S No Date Location Size Lesion Particulars Doctor
1 02.05.13 Superficial cortical/ subcortical location 2 X 1.7 cm slightly hyperintense hetrogeneous enhancement Dr Bhuvnesh Guglani
Superficial cortical/ subcortical location 1.7 X 1.3 cm slightly hyperintense hetrogeneous enhancement
adjoining left ventricle mild compression
anterior interhemisphere fissure with minimal rightward shift
right cerebellum in vermian region 3 mm suspicious enhancing focus
2 04.08.13 Left frontal parafacine region hyperintense signals on T2W1 Dr XXXXXXX Chand
with nodular eccentric hypointense foci
Gliotic areas
3 08.01.14 Left anteriomedial occipital lobe along left tentorium cerebelli 7 X 4 mm Dr XXXXXXX Marwah
surrounding Edema, metastasis
Left high frontal lobe no discrete lesion White matter edema
Bilateral periventricular white matter Chronic ischemic changes
4 19.06.14 Left anteriomedial occipital lobe along left tentorium cerebelli 19.8 (TR) X 18.4 (AP) X 11.3 (CC) mm well defined hetrogeneously enhancing lesion Dr XXXXXXX K XXXXXXX
underlying tentorium cerebelli mild enhancement
Perilesional mild vasogenic white matter edema
Left high fronal subcortical deep white matter subcentimeteric area of gliosis, arcuate/partial ring like enhancement adjacent to it
5 28.09.14 Left anteriomedial occipital lobe along left tentorium cerebelli 17 (TR) X 21 (AP) X 12 (CC) mm well defined hetrogeneously enhancing lesion Dr XXXXXXX Goel
underlying tentorium cerebelli mild enhancement
Perilesional mild vasogenic white matter edema
Left high fronal subcortical deep white matter 16 X 15 mm with moderate perilesional edema
6 10.12.14 Left anteriomedial occipital lobe along left tentorium cerebelli 12 (TR) X 21 (AP) X 11 (CC) mm well defined hetrogeneously enhancing lesion Dr XXXXXXX Chand
underlying tentorium cerebelli mild enhancement
Perilesional mild vasogenic white matter edema
Left high fronal subcortical deep white matter 19 X 15 mm with moderate perilesional edema
7 02.02.15 Left occipital lobe along left tentorium cerebelli ill defined hetrogeneously enhancing lesion Dr Pravesh XXXXXXX
underlying tentorium cerebelli mild enhancement
Perilesional mild vasogenic white matter edema
Left high fronal subcortical deep white matter 27 X 16 mm with moderate perilesional edema
8 01.05.15 Left Temporo-occipital lobe along left tentorium cerebelli 4.3 X 2.9 cm ill defined hetrogeneously enhancing lesion Dr XXXXXXX K XXXXXXX
underlying tentorium cerebelli mild enhancement
Perilesional mild vasogenic white matter edema
Mass Effect Mass effect with compression
Posterior horn of left lateral ventricle Effacement
Ipsilateral basal cisterns Effacement
midline septum 3.0 mm Mild shift towards right
Left high frontoparietal deep cerebral white matter 3.4 X 1.6 cm with moderate perilesional edema
Necrosis peripheral irregular enhancement with central area of necrosis

Hi, thanks for your prompt revert. Have a few follow up questions:

1. how effective would the surgery be in terns of its pros and cons and keeping in mind the survival rates and post operative quality of life.

2. do you suggest any surgeons/hospitals in delhi/ncr who can successfully carry out this operation.

3. In terms of the current reports what are your views on whether the current developpments are due to increase in dead tissues or due to malignent cancer tumors and what are the ways to detect and diffentiate bwtween the two.

4. Radiation of the primary area in the breat was done in February 2015. Is there any linkage betwwen the treatment and the sudden spurt in activity in the brain.

5. The general condition at the moment is ok with sporadic loss of memory and fatigue. What would be the trigger points to go for surgery at this stage.

Thanks