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The Role of Palliative Radiotherapy for Patients with Cancer. John Childs Radiation Oncologist Auckland District Health Board 20 th June 2012. Principles of Pallative Treatment with Radiotherapy. Ensure metastasis is cause of symptoms Account for needs and performance status of patient - PowerPoint PPT Presentation
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The Role of Palliative Radiotherapy for
Patients with Cancer
John ChildsRadiation OncologistAuckland District Health Board20th June 2012
Principles of Pallative Treatment with Radiotherapy
Ensure metastasis is cause of symptomsAccount for needs and performance status of
patientEstablish clear outcome goalCommunicate expected outcomeEnsure minimal radiation side effectsAccount for treatment complexity
Bone MetastasesCommon cause of pain and other symptomsBone metastases in 85% of people dying from
lung, breast and breast cancerLess common thyroid, melanoma, kidney and
bowel cancer (3% to 15%)Haematologic malignancy can be significant
cause of bone pain (Myeloma and Lymphoma)
Bone Metastases: Prognosis
Median survival is usually short despite advances in system therapyLung cancer 6 monthsBreast and prostate (with bone metastases only) 2
to 4 yearsIndications for radiotherapy
Pain, difficulty with ambulation and immobility, hypercalcaemia, pathologic fractures, neurologic deficits, anxiety, depression, spinal cord or nerve root compression, and general deterioration of quality of life
Clinical Features: Bone Metastases
Slowly progressive Insidious pain Often well localizedPain may be worse at nightWorsen with weight bearing or ambulationMay radiate to other areas (does not necessarily
indicate nerve impingement because radicular pain can also be caused by spasm of muscles that originate or insert near the area of disease)
Bone Metastases: Goal of Radiotherapy
Pain reliefComplete 50% to 60%Overall 80% to 90%
Preservation of functionMaintain structural integrityMaintain quality of life
Early interventionMinimise side effects of analgesics
Bone Metastases: Radiotherapy Schedules
Various RT fractionation schedules 30 Gy in 10 fractions 20 Gy in five fractions single-fraction of 8 Gy
Single fraction using 8 Gy Equal palliation Improved patient convenience and cost effectiveness
compared Retreatment was necessary in approximately 20
percent
Bone Metastases: Radiotherapy Schedules
The EvidenceThree randomised trials comparing fractionated RT with single 8Gy
Dutch multicenter 8Gy vs. 24Gy/6 Pain relief 69% and 72% Median time to response 3 weeks Retreatment 25% vs. 7%
RTOG 8Gy vs. 30Gy/10 Pain relief 66% Retreatment 18% v. 9%
British 8Gy vs. 20Gy vs. 30Gy 78% response rate Median time to response 1 month
Bone Metastases: SurgerySurgical fixation Prior to EBRT to decrease pain and facilitate
rehabilitation in symptomatic bone metastases causing
Fixation pathologic fracture involving the long bones or other weigh- bearing bones
Prophylactic fixation to prevent pathologic fractures prior to EBRT.
Inoperable fractures: EBRT may achieve pain relief alone
Bone Metastases: Other Approaches
Stereotactic radiotherapy (SBRT): especially spinal and paraspinal tumours
Radiopharmaceuticals: eg: strontium-89 [89Sr], samarium- 153
Bisphosphonates: Good evidence for breast and multiple myeloma. Current trials for prostate cancer.
Hemibody Irradiation
Cerebral Metastases
Very common site of metastases (autopsy studies 10% to 30%)
Common primary sites are lung, breast and melanoma
Increasing incidence in other cancers following chemotherapy
Increased detection with MRI scanning
Prognostic Assessment
Performance statusControl of primaryAge < 65 years
I (Karnofsky Performance score [KPS] ≥70, controlled primary, age <65 years, brain metastasis only) 7.1 month
II (not meeting requirements of classes I or III) 4.2 months
III (KPS <70) 2.3 monthsRTOG studies
CorticosteroidsUsual dose 4mg to 16mg dailyGive with concurrent RanitidineUsually improvement of PFS over first 7 daysReduce dose over 4 weeksAsymptomatic patients with limited oedema:
reserve for neurologic symptoms
Management
Whole Brain RadiotherapySurgical resectionRadiosurgery boostPost operative RTStereotactic radiotherapy
Favourable Prognosis
Surgery: Single metastasis in a surgically accessible location Limited number of metastases.
Stereotactic RS:metastasis is smaller than 3 cm in a surgically inaccessible location, not suitable/declines more than one small metastasisOther disease stable
WBRT or SRS post surgeryDelay recurrence Impact on survival uncertain
Unfavourable Prognosis
Whole Brain RTImprove neurologic deficits Prevent any further deterioration of neurologic
function. Extent of improvement after WBRT directly related to
the time from diagnosis to radiation therapy: early treatment associated with a better outcome
EfficacyNeurologic symptoms improve in 70%Neurologic deficits improve in 40% to 50%
Dose Schedule
Randomised trials have not shown significant differences with varying dose and fractions
Common schedules are:20Gy in 5 fractions30 GY in 10 fractions40 Gy in 15 fractions
Approach depends on:Anticipated survivalClinical performance status
Stereotactic RadiosurgeryAbility to treat surgically inaccessible areas of
the brain, such as the brainstem Noninvasiveness and suitability for outpatient
treatment Potential to treat multiple lesions Cost-effectiveness compared to neurosurgical
resection
Prophylactic Cranial RadiotherapyLimited stage Small Cell Carcinoma Lung
Cumulative incidence of brain metastases decreased 46%
Absolute decrease in three-year cumulative incidence of brain metastases (33% versus 59%)
Increase in the three-year survival rate from 15.3% to 20.7%
Advanced Stage Small Cell Carcinoma LungBenefits less clear
The benefits of PCI must be balanced against the toxicity and potential impact on quality of life
Complications of Radiation Acute Complications
Nausea/vomitingHair lossSomnolenceChange taste and smell
Late ComplicationsMost patients have a limited survival however with longer survival there is a risk for debilitating late complications.
Leukoencephalopathy and brain atrophy, leading to neurocognitive deterioration and dementia
Radiation necrosis, with symptoms related to the site of necrosis Normal pressure hydrocephalus, causing cognitive, gait and bladder
dysfunction Neuroendocrine dysfunction, most commonly hypothyroidism Cerebrovascular disease
Carcinoma Lung: Superior Venacaval
ObstructionCarcinoma lung most common cause (80%)
Initial investigation and priority of treatment depends on severity of symptoms
Radiotherapy: relief of symptoms 80%
Most patients poor prognosis (<10%-15% survive 2 years)
Carcinoma Lung: superior venacaval
obstructionEmergency management
severe or rapidly progressive symptoms gross facial oedema and cerebral symptoms, or associated stridor
Management High dose corticosteroid considered for palliative radiotherapy
Other techniques ( venous and tracheobronchial stents, endobrachial laser or cryotherapy)
Where there is local expertiseappropriate for selected patients.
Carcinoma Lung Major Airway Obstruction with
Stridor
Severe symptoms require urgent treatment
There are no randomised trialsPalliative radiotherapy: 20Gy in 5
fractions or 30Gy in 10 fractions with high dose corticosteroids (grade c)
Endobronchial therapy is an option (laser and brachytherapy)
One randomised study no advantage over external beam: risk of major haemoptysis
Acute Complications of RadiotherapyOesophagitis: dysphagia and dyspepsiaNon productive coughL’Hermittes syndromeSkin reactionLethargy and malaise
Late complications of Radiotherapy
Pneumonitis (15%)Pulmonary fibrosis (30%)Oesophageal stricture, perforation or fistulae (1% -
2%)Cardiac
pericardial effusion, constrictive pericarditis, cardiomyopathy
Spinal cord myelopathy (usually < 1%)Brachial plexopathy (<1%)