Oncology (General Cancer)/Leptomeningeal Carcinomatosis
Hi Dr. Higby,
My 46 yr old wife has stage 4 HER-2+ breast cancer. She was initially diagnosed in Dec. 2008, responded well to treatment initially(including bilateral mastectomy in 2010) and had no evidence of disease until June 2012 when a single brain met was removed surgically from the temporal lobe. Then in 11/12, a single met was found in the frontal lobe and treated with cyberknife. Lately she had been complaining of facial numbness only on her right side, and leg weakness only on her right side. A brain MRI revealed another tumor, and additional tests were done, including a spinal tap, which showed LC. From all I read, this of course seems very serious. An ommaya reservoir was put in on Friday, and here is the oncologist's treatment plan, which was put in place between him, the radiation oncologist, and surgeon:
1)Begin treating twice a week with methotrexate this week for at least 2 weeks, then once per week thereafter.
2)Whole brain radiation beginning next week. It will be for 5 days a week for 4 weeks.
3)Begin TDM-1 treatment after WBR.
I have some questions regarding this and as always, appreciate your knowledge and honesty.
1) My wife has struggled with whether it is worth doing all of this. The oncologist has told me that breast cancer reacts better to the methotrexate than other cancers. Is this true?
2)Do you agree with this treatment plan? Is it possibly too aggressive at this stage? The nurse at the oncologist office said frankly they hope to buy her time, and then maybe another drug will come out.
3) What is her prognosis based on your experience? I have seen maybe 6 months, but the oncologist said if she gets a good response, she could live several years. have you seen that kind of outcome?
4) Will the side effects from the methotrexate and WBR be expected to be bad? I know everyone is different, but how are they generally tolerated?
Thanks for your response in advance. I know you don't have all her info, but sometimes I feel her oncologist tries to protect her too much and just hope he truly feels she will get a response, as he says he expects she will.
I've seen some good results in this situation but they are never permanent. She might buy a few months at best. This would be my treatment plan at this stage, if the patient was not demented or otherwise debilitated. It is true that topical methotrexate works pretty well on breast cancer, but the other advantage is that unlike many other cancer drugs, it doesn't damage the brain. Thiotepa and high dose cytosine arabinoside are also effective, but I'd agree with starting with methotrexate. I'd be surprised if she lives longer than a year, but it has happened. The side effects are not terrible; Methotrexate may give some meningial symptoms ( headache, light sensitivity) and the radiation might give some nausea, hair loss, scalp itch, etc. But people recover. In the long run there may be a higher risk of Alzheimer's like symptoms, but if she lives long enough to experience those, she'll be fortunate. All in all, if she's 46 and has had a nice long first remission, I'd consider the therapy. Your doctor may want to consider following the treatment with examestane and everolimus, a combination that works pretty well in this type of cancer. I would be on the fence about this, but I'd probably offer it after the completion of the radiation.