Complex Case

Gamma Knife® Treatment for Multiple Brain Metastases

A 50-year-old woman presented at NYU Langone with multiple brain metastases from breast cancer.

Until then, she had been treated elsewhere. The cancer was first diagnosed in 1998 as early invasive left breast cancer that was ER-, PR- and Her2-positive. The patient underwent a lumpectomy and received radiotherapy. A local recurrence was found in 2004, at which point she had a bilateral mastectomy, and was treated with radiotherapy to the left chest wall and supraclavicular lymph nodes, as well as with chemotherapy.

In 2011, metastatic cancer was found in the left parotid gland, and a total parotidectomy was performed. A short while later, cancer was found in the vertebral spine, and this lesion was treated with radiotherapy. At the end of 2012 she presented with dizziness, leading to the detection of miliary brain metastases. These tumors were treated with whole-brain radiotherapy. While serial MRI indicated a good response to the treatment at the time, in mid-2013 26 small, asymptomatic tumors were found in her brain.

Axial images at the time of stereotactic radiosurgery (a,b,c) in a woman with metastatic breast cancer, recurrent after prior whole brain radiation therapy. 13 tumors were targeted at each of two sessions; total of 26 tumors.Axial images at the time of stereotactic radiosurgery in a woman with metastatic breast cancer, recurrent after prior whole-brain radiation therapy. Thirteen tumors were targeted at each of two sessions, a total of 26 tumors.

It was at this point that the woman was referred to Douglas Kondziolka, MD, the director of NYU Langone’s Center for Advanced Radiosurgery and vice chair of clinical research for the Department of Neurosurgery and Radiation Oncology. Consulting on the case was Silvia Formenti, MD, chair of the Department of Radiation Oncology at NYU Langone’s Perlmutter Cancer Center. The two physicians agreed that stereotactic Gamma Knife® radiosurgery was the best treatment approach. “Having to treat that many new tumors is a complex challenge to which conventional medicine has no answers,” says Dr. Kondziolka. “But Gamma Knife® radiosurgery is precise and fast enough to allow treating several tumors in the same day.” The treatment plan aimed for complete eradication of the brain disease, followed by systemic care to reduce the chances of new tumors arising, with the goal of long-term survival rather than simple palliation.

Using the Gamma Knife®, Dr. Kondziolka targeted 13 of the patient's brain tumors in one day, and the remaining 13 in a second day a week later. The patient suffered no significant discomfort and enjoyed a travel vacation afterwards.

case2_2bImaging at four months shows the tumor response. At eight months, the appearance was unchanged with no new tumors.

Imaging in the following months indicated that of the 26 tumors, 25 had resolved completely, and the last one, a larger right cerebellar tumor, was reduced to a small remnant. After seven months, the patient has had no additional brain tumors, and remains in excellent neurological condition, leading an active life.