Wednesday, 24 August 2016

First MRI and follow-up

My father is due on Tuesday for the first follow-up after radiation and two rounds of monthly 5/23 high dose TMZ.

No MRI was taken after radiation but prior to monthly TMZ. I asked the NO if it wouldn't be a good idea to have an MRI taken one month after the RT, but she said it was too early to see the effects of the radiation, and besides it simply wasn't their way of doing things.

So this will be the first MRI to compare to the post-op scan taken the day after surgical resection of the tumors.
Since he's MGMT unmethylated I suspect the TMZ will not have had that much of an effect, and thus the question: What to do if the scan shows progression or recurrence?

Continue the monthly TMZ or suggest something else - carboplatin, irinotecan, re-operation if possible, try the german clinics, something else?
I guess CCNU wouldn't really be any better, since it works the same way as TMZ?
What would be the least bad/unpromising "salvage therapy" - Stephen?

I had a quick check on clinical trials in Sweden but nothing targeting recurrent tumors.

Father's profile:
* EGFR positive/staining (but unknown if EGFRvIII mutated or not)
* IDH1 R132 negative/unmutated.
* Weak p53 staining (likely unmutated p53)
* No loss of 1p or 19q.
* MGMT unmethylated (9% methylation)



  1. There is a Gamma knife center at Karolinska University Hospital in Stockholm, if the tumor is <4cm diameter. Re-irradiation plus PD-1 antibody (nivolumab or pembrolizumab) could potentially arouse a powerful immune response.

    That combined with very low dose daily TMZ, propranolol and etodolac (or other COX-2 inhibitor) might be even better.

    If there are no trials in Sweden, low dose Avastin could also be considered, but I wouldn't rely on that alone. Gamma knife (or other forms of radiosurgery) plus low dose Avastin, plus anti PD-1, and if you have lots of money, vaccine therapy in Germany, might be your best bet. I wouldn't put much faith in CCNU if the tumor has unmethylated MGMT. I'm not a big fan of the other salvage chemos either.

    1. We met the oncologist today and she was very positive, saying that she thinks the tumor shows shrinkage and suggested continuation of TMZ 5/23.

      I asked if she could show a few images, and the MRI taken a few days ago showed a brightly lit tumor border which gives me a quite uneasy feeling.

      I have however no idea what a 'good' scan should look like, other than the less contrast enhancement, the better?

      The radiologist's interpretation said that "no clear progression can be seen" and also mentioned "central areas show necrosis". However, there was some mixup in the images, so he had compared the current MRI with the pre-resection scan, not the post-op scan.

      I asked the oncologist if she could order a new interpretation of the images as compared to the post-op scan and also to send a copy of the images on CD, which she would do.

      It will probably take a week or two before we get the images and the new interpretation, which means father will start the third round of 5/23 TMZ.

      Any thoughts on the MRI feedback above?

      Thanks, Peter