A 62-year-old female patient was diagnosed in 2005 with ovarian carcinoma. She underwent surgery, several lines of antitumoral treatment, and regional fractionated radiotherapy prior to developing metastases to regional lymph nodes as well as peritoneal carcinomatosis (2008). In January 2016, the patient presented with 2-week history of nausea, vomiting, impaired balance and speech, severe swallowing difficulties, and sensory symptoms. The brain MRI demonstrated a large, solitary, 20-mm metastasis in the upper part of the medulla oblongata (M1) without significant perilesional edema, yet compressing the foramina of Luschka and Magendie with signs of mild hydrocephalus []. Corticosteroid therapy was initiated shortly thereafter. Microsurgical removal/debulking of the metastasis were deemed not feasible and 3R was offered after multidisciplinary in-hospital discussion. At the time of GKRS 1 in February 2016, KPS was estimated to be 60 and RPA 3. The corresponding dose fractionation schedule is described in . No tumor volume reduction or V4 decompression was noted between GKRS 1 and GKRS 3. A follow-up MRI at 4 weeks revealed a 54% decrease in the size of M1 (4.8 cm3 at GKRS 1 to 2.2 cm3 at follow-up). V4 volume increased (1.56 cm3 at GKRS 1 to 2 cm3 at follow-up), and the foramina of Luschka and Magendie were less compressed []. There was no evidence of hydrocephalus. The patient's neurological condition also improved dramatically at this time and KPS was estimated to be 70. The dysphagia, nausea, and vomiting disappeared, and she could articulate much better. Nevertheless, no considerable improvement in balance was reported. The patient continued systemic antitumoral treatment. Consecutive, initially monthly and later bimonthly radiological follow-ups until September 2016 (7 months after 3R) showed further volume decrease of M1. However, the patient developed mild radiation-induced perilesional edema (assessed as ARE) 5 months after treatment which slowly progressed until her last MRI at 7 months (September 2016) though without evidence of hydrocephalus. At this time, the patient was experiencing mild facial numbness almost solely limited to her right cheek and the right side of the jaw. The patient was also experiencing some more fatigue and balance impairment than usual although it was difficult to assess whether it was caused by the lesion itself and/or other factors such as aggressive systemic tumor progression, ongoing systemic treatment, and steroids. Nevertheless, despite the presence of perilesional edema, we assessed her neurological status and quality of life in relation to M1 as stable. She died 7 months after completion of 3R-treatment due to aggressive extracranial tumor disease progression.
We report on a 64-year-old woman who initially presented to the emergency department with complaints of chest pain following a motor vehicle crash. A CT incidentally found renal abnormalities, and a postnephrectomy biopsy confirmed renal cell carcinoma. The patient was asymptomatic at that time and remained so for ten months, after which she visited her primary care physician with complaints of mild intermittent headaches and difficulty with balance. An MRI revealed five cerebellar lesions measuring 1.4 × 1.5 × 1.6 cm, 2.0 × 1.5 × 1.7 cm, 0.7 × 0.7 × 0.7 cm, 0.2 × 0.2 × 0.2 cm, and 0.1 × 0.1 × 0.1 cm, as well as extensive vasogenic edema.\nHer treatment team recommended against resection due to the sensitive location of her tumors. GKRS was recommended over WBRT due to concern that avoiding previous radiation fields from treatment for oropharyngeal carcinoma 14 years earlier would not adequately address her relatively caudal metastatic tumors. The patient then underwent her first GKRS treatment at a dose of 22 Gy at the 50% isodose line (Figures and ). On the day of treatment, her Karnofsky Performance Status score was 100. Following GKRS, she was placed on dexamethasone 2 mg daily. Within several weeks she had experienced significant resolution of symptoms.\nOver the next 51 months, she underwent a subsequent six GKRS treatments, all of which treated between one and four metastases. Many of these metastases were in new locations within the cerebellum, while several appeared in the brainstem itself. 49 months after her initial treatment, she underwent a craniotomy to relieve obstructive hydrocephalus with a ventricular shunt placement. An 8.0 mm cerebellar lesion was successfully resected in the same procedure. Around the same time, she underwent SBRT for liver metastases, which was tolerated well.\nThe patient's most recent GKRS treatment occurred 60 months after the first and was suggested when the patient presented with complaints of consistent falls. A CT demonstrated five lesions, four of which were localized to the cerebellum and one limited to the pons. Three of the lesions had increased in size since her previous CT several months earlier. Three lesions were treated with a dose of 20 Gy at the 50% isodose line, one lesion was treated with 18 Gy at the 75% isodose line, and one was treated with 18 Gy at the 55% isodose line. A posttreatment CT demonstrated reduced dimensions of all lesions. Her most recent CT was taken 5 months later and demonstrated reduced or stable sizes of all lesions. 65 months after her initial diagnosis of brain metastasis, the patient began treatment with Votrient 800 mg for her liver metastases, which was tapered down to 400 mg and eventually held completely for after severe GI side effects and elevated liver enzymes.\nOne month prior to this paper, a PET scan was obtained, showing no new evidence of systemic or metastatic disease. At that time, she remained symptom-free with a high quality of life a total of 72 months after her brain metastases were diagnosed.