Palliative RT. Jiraporn Setakornnukul, M.D. Radiation Oncology Division Siriraj Hospital, Mahidol University

Transcription

1 Palliative RT Jiraporn Setakornnukul, M.D. Radiation Oncology Division Siriraj Hospital, Mahidol University

2 Scope Brain metastasis Metastasis epidural spinal cord compression SVC obstruction Bone pain Others Airway obstruction Active bleeding eg. vaginal bleeding, hemophysis Impending blindness

3 Palliative care WHO An approach that improves the QOL of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual

4 Brain metastasis

5 Introduction Systemic malignancies: brain metastases 10-30% Most often cause of death due to CNS disease Incidence of brain metastasis Lung cancer 50% Breast cancer 15-20% Malignant melanoma 10% Colorectal cancer 5% Others primary cancer 10-15%

6 Pathogenesis Most common mechanism is hematogenous spread Usually located at gray white junction Distribution of metastases Cerebral hemispheres : approximately 80 % Cerebellum : 15 % Brainstem : 5 % Different primary tumors different areas of brain Pelvic and GI tumors: posterior fossa SCLC: distributed in all regions of the brain Arch Neurol. 1988;45(7):741

7 Clinical manifestation Major from gradually expanding tumor mass and its associated edema cause symptoms Less commonly intratumoral hemorrhage, obstructive hydrocephalus, or embolization by tumor cells

8 Clinical manifestation Headache: 40-50% Worse with bending or raise intrathoracic pressure Nausea and vomiting 40% Focal neurologic dysfunction: 20-40% Most common: Hemiparesis Cognitive dysfunction: 30-35% memory problems and mood or personality changes Seizures: 10-20%

9 Imaging Contrast-enhanced MRI

10 Imaging Contrast enhanced CT

11 Imaging Radiographic features brain metastases Multiple lesions Localization at the junction of grey and white matter Circumscribed margins Large amounts of vasogenic edema compared to the size of the lesion Principles and Practice of Oncology, Davita VT p.2523

12 Treatment brain metastasis Specific treatment: local brain Radiotherapy Conventional whole brain RT: Standard treatment Stereotactic radiotherapy (SRS) Surgical resection Symptomatic treatment Prevent and control cerebral edema Prevent seizure Treatment of systemic malignancy

13 When do we need surgery? Benefit from surgery Rapid relief of symptoms resulting from the mass effect of a large tumor Histologic diagnosis Unknown primary Questionable diagnosis by imaging Improve local control of brain metastases in favorable group

14 Prognostic index (RPA) Int J Radiat Oncol Biol Phys. 1997;37(4):745

15 Management Whole brain RT standard of treatment Limited 1-3 brain metastasis Surgical resection WBRT with SRS boost Initial SRS, omit WBRT? Multiple (> 4) brain metastases

16 Whole brain RT WBRT and appropriated steroid use are still standard treatment of brain metastasis Average Median survival of brain metastasis Without treatment : approximately 1 month With corticosteroids use : 2 months With WBRT : 3-4 months APRIL F. EICHLER,The Oncologist 2007;12:

17 Whole brain RT Most common WBRT regimen uses 30 Gy in ten 3 Gy fractions Response rates after WBRT complete or partial responses more than 60% Deepak Khuntia, J Clin Oncol 24:

18 Management Brain metastasis Known case of cancer or brain metastasis of unknown origin Evaluation of prognostic RPA: age, performance status, primary control and extracranial disease RPA class I-II 1-3 lesions > 3 lesions RPA class III

19 Management Brain metastasis RPA class I-II 1-3 lesions : Surgery + Postop. WBRT WBRT + SRS boost SRS alone WBRT alone > 3 lesions : WBRT alone WBRT + SRS RPA class III WBRT

20 Radiation Technique

21 Stereotactic Radiosurgery

22 Metastasis epidural spinal cord compression

23 Introduction Compression of the dural sac and its contents (spinal cord or cauda equina) by an extradural tumor mass Common neurological complication of CA Important Pain Potentially irreversible loss of neurologic function

24 Epidemiology Most cases with metastasize to the spinal column Most common cancer prostate cancer, breast cancer, lung cancer Location of the site of compression proportional to the relative bone mass and blood flow cervical spine 15% thoracic spine 60% lumbosacral spine 25% Multiple sites of MESCC are seen in 20 35% Lancet Neurol 2008; 7:

25 Pathophysiology 2 ways to spinal cord compression Indirect route of initial haematogenous metastasis to vertebral body (85%) Paravertebral tumor directly into spinal canal through intervertebral foramen (15%) commonly associated with lymphomas and neuroblastomas Lancet Neurol 2008; 7:

26 Clinical manifestations Bone pain 83-95% : earliest symptom Muscle weakness 35-75% Sensory loss 50-70% : examined spinal sensory level is typically 1-5 levels below the actual level of cord compression Bowel or bladder dysfunction 50-60% Ataxia of gait due to involvement of the spinocerebellar tracts Lancet Neurol 2008; 7: Neurologic Complications of Cancer, FA Davis, Philadelphia 1995

27 Diagnosis imaging MRI Method of choice for the diagnosis of MESCC Accuracy 95% sensitivity 44-93% specificity 90-98% J Clin Oncol 23: Magn Reson Imaging 1988; 6:

28 Diagnosis imaging Plain film False negative 10-17% might not detect paraspinal masses CT myelography Equivalent sensitivity and specificity with MRI Sensitivity 71-97% Specificity % Better in case with laterally located lesions J Clin Oncol 23:

29 Treatment: Goals of treatment ESCC Pain control Avoidance of complications Preservation or improvement of neurologic function

30 Treatment: General principles Immediate administration of glucocorticoids in all patients Followed by surgery, external beam radiation therapy (EBRT), or stereotactic body radiotherapy (SBRT) Systemic therapy may be beneficial in patients with chemosensitive tumors.

31 Treatment: Symptomatic treatment Pain management Bedrest Prevention of constipation Anticoagulation

32 Definite treatment: indication for surgery Spinal instability or bony compression Single site of cord compression Neurologic progression during or after RT Unknown primary site Radioresistant tumors J Clin Oncol 23:

33 Assessing spinal stability Spine Oncology Study Group, an international group of 30 spine oncology experts highest ranked factors predictive of spinal instability subluxation/translation progression of deformity bilateral facet destruction character of neurologic changes (with motion) Anatomic areas of greatest concern occipitocervical junction cervicothoracic junction Int J Oncol 2011; 38:5 Spine (Phila Pa 1976) 2010; 35:E1221

34 Definite treatment: indication for surgery Single site of cord compression Single area of spinal compression Excluded: totally paraplegia > 48 hr compressed only cauda equina or nerve root J Clin Oncol 23: Lancet 2005; 366:

35 Ability to walk Surgical plus RT All/walk entry (50/34) Combined ambulatory rate 84% (42/50) 57% (29/51) Retained ability to walk 122 days 13 days Walk at entry 94% (32/34) 74% (26/35) Retained ability to walk 153 days 54 days Unable to walk at entry 62% (10/16) 19% (3/16) Retained ability to walk 59 days 0 days RT alone All/walk entry (51/35) Post operative complication Range 0-54% Vertebral body resection 10-54% Laminectomy 0-10% J Clin Oncol 23: Lancet 2005; 366:

36 Definite treatment: indication for RT RT for patients without bony compression or spinal instability RT following decompression surgery RT for patients with subclinical cord compression

37 Efficacy of RT: improved neurological Fn One-third of nonambulatory patients from paraparesis regain the ability to walk 2-6% of paraplegic patients regain the ability to walk Patients who require a urinary catheter before therapy, 20-40% will become catheter free Int J Radiat Oncol Biol Phys 1995; 32:959.

38 Radiation Technique Volume of treatment Superior-inferior To cover 1 level of upper and lower spine, if definite level from MRI Lateral Adequate margin vertebral body Radiation dose Commonly use 30 Gy in 10 Fx

39 Superior Vena Cava Syndrome (SVC) with Malignancy Causes

40 Introduction Syndrome results from any condition that leads to obstruction of blood flow through the SVC Obstruction by invasion or external compression of SVC by adjacent pathologic structure eg, right lung, LN or mediastinal structures thrombosis of blood within the SVC Eur J Cardiothorac Surg 2003; 24:208

41 Introduction Causes of SVC obstruction Malignancy 60-80% NSCLC 50% SCLC 25% Lymphoma Metastasis tumor at mediastinum Benign 20-40% Thrombosis due to using intravascular devices Infection N Engl J Med 2007;356:1862-9

42 Clinical manifestation Facial edema 82% Distended neck veins 63% Distended chest veins 53% Dyspnea 54% Cough 54% Arm edema 46% Symptoms are progressive over several weeks Some cases may improve as collateral circulation develops N Engl J Med 2007;356:1862-9

43 Imaging Chest X-ray CT scan with contrast Most useful image shows level and extent of blockage Sensitivity 92% Specificity 96% Bilateral upper extremity venography Gold standard for diagnosis SVC obstruction esp. thrombus MRI Patients cannot tolerate contrast medium PET-CT For design radiotherapy field

44 Diagnosis Minimal invasive procedures Sputum cytology pleural fluid cytology biopsy SPC More invasive procedures Bronchoscopy Mediastinoscopy video-assisted thoracoscopy thoracotomy Percutaneous transthoracic CT-guided biopsy

45 Management Considered treatment of cancer and relief symptoms of obstruction Current management guidelines stress the importance of accurate histologic diagnosis prior to starting therapy

46 Management by treatment sensitive tumor Chemo-responsive tumor: SCLC, NHL, germ cell tumor Initial chemotherapy is treatment of choice for patients with symptomatic SVC syndrome Rapid clinical response Often achieve long-term remission Int J Radiat Oncol Biol Phys 1995; 33:77 J Clin Oncol 1984; 2:260

47 Management by treatment sensitive tumor Radiation therapy (RT) widely advocated for SVC syndrome who have not been previously irradiated RT complete relief of symptoms of SVC obstruction within two weeks 78% in SCLC and 63% in NSCLC Target: gross disease and adjacent nodal region Dose: lymphoma is recommended conventional Fx SCLC/NSCLC are recommended hypofractionation Clin Oncol (R Coll Radiol) 2002; 14:338

48 Management by severity Endovascular stenting For patients with clinical SVC syndrome who present with stridor due to central airway obstruction or severe laryngeal edema, and those with coma from cerebral edema fatal condition Recommend emergent treatment with endovascular stenting followed by radiation therapy (RT)

49 Supportive treatment Head should be raised to decrease head and neck edema Avoid intramuscular/intravascular injections in arms Glucocorticoids Effective in steroid-responsive malignancies such as lymphoma or thymoma Effective in NSCLC is question, never been study In patients RT, particularly if laryngeal edema, glucocorticoids are commonly prescribed to reduce swelling Diuretics Commonly recommended but mechanism is unclear

50 Bone metastasis

51 Bone metastasis Skeletal involvement is most common in patients with metastatic breast or prostate cancer Bone is a frequent site of metastases in most advanced malignancies Direct complications of bone involvement include severe pain, pathologic fractures, and ESCC Osteolytic metastases can result in life-threatening hypercalcemia

52 Osteolytic VS Osteoblastic Osteolytic: destruction of normal bone Osteoblastic: deposition of new bone based upon the predominant radiologic appearance

53 Bone metastasis Predominantly osteoblastic Prostate Carcinoid Small cell lung cancer Hodgkin lymphoma Medulloblastoma Predominantly osteolytic Renal cell cancer Melanoma Multiple myeloma Non-small cell lung cancer Thyroid cancer Non-Hodgkin lymphoma Mixed osteoblastic and osteolytic Breast cancer Gastrointestinal cancers Squamous cancers at most primary sites

54 Goals of palliative treatment of bone metastases pain relief preservation of function maintenance of skeletal integrity

55 Management bone metastasis Control pain by medication

56 Local field external beam radiation therapy (RT) provide pain relief in 80 to 90 percent of cases complete pain response obtained in 50 to 60 percent Radiation scheme Most common use 30 Gy in 10 fractions 8 Gy single fraction provided equal palliation with improved patient convenience and cost effectiveness compared with fractionated schedules Retreatment about 20%

57 Prevention Pathologic Fracture Surgical fixation may be indicated prior to the institution of radiation therapy for bone metastases involving the long bones or other weight bearing bones to treat or prevent a pathologic fracture

58 Question?