Stereotactic Radiosurgery

Marty fitted with metal frame for stereotactic radio surgery.

After a melanoma tumor was found in my brain on March 9, 2017, and removed by a neurosurgeon, I met with my oncologist to plan for post-operation treatment. I was expecting a recommendation of recently developed immunotherapy treatments.

Instead my oncologist said, “I’ve taken the liberty to consult with a radiation oncologist. We reviewed your pre- and post-surgery MRIs and he says that he can treat the tissue around the tumor with radiation to lessen the risk that a tumor will regrow at that site … Would you like to go ahead and make an appointment to talk to him?”

This seemed unlike my doctor, who normally takes time to discuss options before recommendations. “No, I’d prefer to talk about immunotherapy treatment before we talk about radiation,” I replied.

In response to my interview-like questions, he related four main alternatives for people in my situation with metastatic melanoma of the brain that has been surgically removed:

1. Without further treatment, 5% of patients will not experience recurrence of tumors in the brain, but 95% will experience recurrence.

2. Patients treated with radiation will be less likely to experience recurrence at the same site, but are not likely to have better survival, because the cancer will usually recur elsewhere in the brain.

3. Patients treated with immunotherapy are less likely to experience recurrence and more likely to have improved survival.

4. Treating with both radiation and immunotherapy is likely to increase side effects such as swelling and headaches more than treating with either separately. This is usually manageable with additional compounds.

Our interview was shortened because of the lateness of the hour, and we parted with an agreement to wait two weeks and then review another MRI before proceeding with option 3, treatment with immunotherapy. I felt very unsettled — we hadn’t covered the options very well, and ended with what seemed like a premature conclusion.

After a couple of restless nights, I decided to continue this discussion on treatment planning via email messaging built into the MyChart website. I wrote: “What does the data say about outcomes for people who have both radiation and immunotherapy?”  He replied: “While we do not yet have experimental results to confirm our theory, our group, and other groups, believe that radiation helps immunotherapy work better.”

I estimated that the risk of additional side effects from combining treatments is outweighed by synergy from radiation plus immunotherapy—and this idea put my mind at ease. We met with the radiation oncologist and found him to be both reassuring and informative.

We set about organizing the plan and schedule for starting both treatments without delay.

The two departments at Providence worked together to start treatment the next week. On Monday afternoon, April 17, I reported to the infusion center for the first time. Blood was drawn, and lab results received to verify that I was healthy enough to take immunotherapy. The IV took only 30 minutes to deliver a dose and the whole process felt relaxed. No adverse side effects were noted.

Current radiation treatment uses stereotactic radiosurgery where radiation from many sources in three-dimensional space around the head is focused on a small sphere of treatment area. The location of the treatment area is carefully measured using a current MRI and administered while the patient’s head is immobilized in a metal cage.  The radiating machine is called a Gamma Knife, which emits gamma rays from radioactive decay of cobalt 60. Since no knife, nor cutting, is involved, I prefer the term stereotactic radiosurgery.

Early Tuesday morning, April 18, we arrived at the Gamma Knife office on the Garden Floor at Providence Cancer Center. After dressing down, I received a dose of Xanax to reduce anxiety, and a current MRI. The hardest thing was placement of the metal frame, which was attached to my cranium with small metal screws. Despite injections of Lidocaine, I experienced sharp pains when the screws were tightened. With the mask in place I was wheeled to the Gamma Knife machine and when my head was placed inside, it seemed more confining than the MRI. The radiation was a 40-minute, silent experience, which put me to sleep and had no noticeable physical effect. I was able take a cup of coffee and a sweet treat, dress, and walk to the cafeteria for breakfast.

Following the short drive home, I retired for a long, refreshing afternoon nap. I had a mild sensation of pressure in my head for a couple of days, and took Tylenol and coffee to relieve this sensation. We were advised that unpleasant side effects or dangerous side effects are unlikely with the radiation, and if they do occur they will be associated with the infusion on the second or third round.

In summary, if all goes as planned, I’m set for the next year of immunotherapy treatment, which will stimulate my immune system to eradicate the melanoma tumors in both my head and chest. This has been the case for many people including my favorite cancer blogger.