Two weeks after my craniotomy Ian and I met with the Princess Margaret Brain Mets Clinic. I was given the choice between Whole Brain Radiation (WBR) and Gamma Knife Radio Surgery. Both are reasonable options, each with distinctive pros and cons. Typically a craniotomy is paired with radiation because they cannot removed adjacent tissue, to ensure clean margins. Radiation is used cleanup any microscopic cancer cells not visible by a CT or MRI scan.
GAMMA-KNIFE is a one time focused treatment on a specific location in the brain. There are very little side effects with this treatment. There a risk of brain swelling six months after the procedure which can be resolved with drugs or another surgery. In my case, Gamma-Knife would be used to treat the cavity where the metastasis was removed. As such, any rogue mets that may have spread throughout my brain, would not be be treated.
WBR is low level radiation that treats your entire brain. The treatment takes place over a number of days and has a higher side effect profile. WBR can effect your cognitive abilities and there is hair loss. As your entire brain is radiated, any rogue cancer cells that may have spread though out your brain get zapped. Whole brain radiation can only be done once in your life time, although I was told that they do sometimes break that rule.
I have triple negative breast cancer and my only treatment options, outside of clinical trials, are chemotherapy, surgery and radiation. Most chemotherapy does not breach a blood brain barrier that protects your brain. Up to this point our treatment strategy has been a Whack-A-Mole approach. When a metastasis shows up on a scan we try to whack it on the head. Sometimes it works, sometimes it doesn’t. When it doesn’t we just keep whacking until we run out of things to wack with. When my scans are clear I get a treatment holiday. Our goal is to maximize my quality of life for as long as possible. Keeping the Wack-A-Mole strategy in mind, it made the most sense to go for a treatment that targeted the area of the metastasis. As Gamma Knife has the least amount of side effects, I will have the freedom to live the best possible life in the time that I have. This way I will also have WBR in my back pocket, if at some point I get multiple brain mets.
A rundown of my Gamma-Knife Surgery:
Friday before the Gamma-Knife Radio Surgery – MRI:
A detailed scan of the tumour bed that was left over from the craniotomy.
6:30 am – Day of Surgery:
We arrive at PMH and are taken to a curtained in space with a reclining hospital chair.
7:00 am – Frame Attachment:
They put me in a wheel chair and I am moved into a bigger room. A nurse and two doctors are set up to screw a light weight metal frame to my head. One of the doctors puts on my head a clear plastic box that houses and locates the light weight metal frame. They freeze one of the pin holes and screw the first pin into my skull. The freezing stings a bit, not unlike getting your mouth frozen at the dentist. To my surprise fastening the pins to my skull is fairly painless. The doctor continues to freeze and screw the remaining pins. They remove the plastic section of the frame and I am wheeled back to my reclining chair. The nurse tells me I am not allowed to go anywhere without assistance. “EVEN THE BATHROOM!” she laughs as I groan.
8:00 am – Locating the Tumour Cavity:
I am wheeled to the CT scanner where the light weight frame I am wearing is fastened to the CT scanner bed. This scan is used to locate the tumour bed/cavity relative to the metal frame screwed to my head. Getting fastened to the scanner was a bit awkward but the scan itself is fairly quick and painless.
8:30 am to 12:30 pm – I Wait and the Doctor’s Plan:
The doctors review the scans to make sure that no new metastasis have popped up over the weekend. They use both the MRI from Friday and the CT scan to devise a treatment plan. Ian and I play a fingernail biting, action packed game of Killer Bunnies to pass the time. The nurse comes and hooks me up to an IV steroids to prevent my brain from swelling. I ask for a lorazepam because I’m not sure how I’m going to cope with being strapped down in a confined space.
A doctor confirms that there are no new metastasis and the treatment will be 2 hours long. I am second in line and the procedure should start around noon. Ian goes to the cafeteria and gets sandwiches. I have to break it into pieces to get it into my mouth because the frame has a bar that makes eating really complicated. Ian laughs and tells me that I look like a crazed squirrel. I take a pain killer because I am starting to get a bit of a headache.
12:30 to 2:30 pm – Gamma-Knife:
I get wheeled into the treatment room where the technician takes my i-pod and hooks it up to the audio system in the machine. Instead of music I have chosen to listen to a David Sedaris audio book in hopes that it will be both distracting and entertaining. The mild headache I had earlier has combined with discomfort from the pins. The freezing has started to wear off and unfortunately the pain reliever I took earlier has not set in.
I lie down on the Gamma-knife bed/tray. The machine looks a lot like an MRI or CT scanner except instead of entering a doughnut its more like a cup. The technicians attaches the light weight frame to the machine and adjusts my head into a semi-comfortable position. My head is completely suspended by the pins that I can now feel and I am very very uncomfortable. The technician tells me that the machine can be stopped at any point if I need a break.
I close my eyes and the bed/tray moves into place. The procedure itself is completely painless but the pins are a bit uncomfortable. I try to relax and hope that my pain killers will set in soon. They do and thanks to lorazepam I drift in and out of sleep for the entire procedure. Before I know it the technician is telling me that there is two minutes left. They detach me from the bed and move me back into my curtained off space in the waiting area.
2:30 to 3:00 pm – Frame Removal:
This the worst part of the day. The doctor warns me that the screw removal it is going to feel like they are driving the pins deeper into my head. This is extremely uncomfortable and a bit painful. After all four screws are removed I start to have a massive headache. It is similar to the pain you get when you eat something cold, except it encompasses my entire head. The nurse quickly hooks me up to an IV pain reliever and tells me it will get worse before it gets better. It takes about 30 minutes for the pain to completely subside. At this point the nurse comes in and gives me discharge papers. She lets me know that when the pain is manageable I’m free to go home.
That afternoon I’m a bit tired. There is no hair loss or burns to my skin. The only side effects are from the steroids. I’m a bit emotionally all over the place. The insomnia and insatiable hunger has returned. The next day I feel completely like myself and am back to my daily routine.