29 year old woman with a painful bone metastasis

Transcription

1 29 year old woman with a painful bone metastasis Joanna Yang, MD Faculty Mentors: Zachary Kohutek, MD, PhD, and T. Jonathan Yang, MD Memorial Sloan Kettering Cancer Center, New York, NY

2 Case Presentation 29F with stage IV ER+/PR+/HER2- breast cancer s/p multiple lines of systemic therapy, most recently capecitabine 3 weeks prior to presentation, she noted new pain in the right lateral hip, bandlike, with associated difficulty ambulating No pain in left hip or elsewhere; no weakness or paresthesias

3 Case Presentation Not taking pain medications due to personal preference Presented to medical oncologist for evaluation and was referred for consideration of palliative RT

4 History and Physical PMHx: - past RT to brain x 5 and left CW PSHx: - liver cyst resection - bilateral mastectomy - craniotomy and resection of brain metastases x 2 - TAH-BSO FamHx: - no cancer SHx: - never smoker - works as receptionist Meds: lidocaine patch All: none

5 History and Physical PERFORMANCE STATUS: KPS 70 Gen: chronically ill appearing, sitting in chair in no acute distress HEENT: pupils equally round and reactive to light, extraocular movements intact, moist mucous membranes Lymph Nodes: no supraclavicular lymphadenopathy CV: regular rate and rhythm, no rubs, or gallops Pulm: lungs clear to auscultation bilaterally, no wheezes, rhonchi, or rales Abd: soft, non-tender, non-distended, normoactive bowel sounds Ext: full range of motion, no edema, calves symmetric and nontender Neuro: A&Ox3, no focal deficits, strength 4/5 in right lower extremity, limited by pain, 5/5 otherwise Skin: no rashes.

6 Imaging PET/CT: FDG avid osseous metastases in C4, T5, L2, left posterior iliac bone, right posterior iliac bone, and left posterior acetabulum

7 PET/CT

8 PET/CT

9 PET/CT

10 PET/CT

11 PET/CT

12 Pathology Original pathology (at diagnosis): - invasive ductal carcinoma, moderately to poorly differentiated, with lymphovascular invasion - ER 99% +/PR 60% +/HER2 1+ (negative) Right 7 th rib bone metastasis pathology (at diagnosis): - metastatic compatible with spread from breast primary - ER 50% +/ PR 1% +/HER2 0 (negative) * Right posterior iliac metastasis was not biopsied

13 Palliative RT for Bone Metastases Bone metastases are often the first finding of metastatic disease with an incidence of up to 84% in some types of cancer Major symptom is pain, either acute or chronic Palliative RT can be delivered via many different treatment dose schedules RT is very effective with partial response up to 80% and complete response up to 33% August 18, 2016

14 RTOG RTOG evaluated 8Gy in 1 fraction vs. 30Gy in 10 fractions in patients with painful bone metastases and expected median survival of at least 3 months Complete and partial response rates were 15% and 50% in the 8Gy arm 18% and 48% in the 30Gy arm 8Gy arm had lower incidence of grade 2-4 acute toxicities (10% compared to 17%) but higher rates of retreatment (18% compared to 9%) August 18, 2016

15 Fractionation Schemes Metaanalyses have shown overall response rates for pain to be 58-62% with single fraction and 59% with multiple fraction Complete response rates were also similar at 23-34% and 24-32%, respectively Likelihood for retreatment was 2.5 hold higher in single fraction patients Pathological fracture rate may be higher in patients receiving single fraction, but this is debated August 18, 2016

16 Treatment Considerations Location of the metastasis far from OARs Prior treatment to the area none Field size medium Convenience for patient patient worked near hospital

17 ASTRO Consensus Guidelines 30Gy/10fx = 24Gy/6fx = 20Gy/5fx = 8Gy/1fx Single fraction has higher retreatment rate but optimizes patient and caregiver convenience No data that 8Gy/1fx provides inferior pain relief or produces unacceptable rates of long term side effects rert for peripheral bone lesions Whenever possible, patients should be included in prospective randomized trials to further define appropriate use of RT in setting of recurrent cancer symptoms

18 ASTRO Consensus Guidelines Surgery, radionuclides, bisophosphonates, kyphoplasty/vertebroplasty Surgery and kyphoplast/vertebroplasty do not obviate need for postop RT; optimal dosing unknown but 30Gy/10fx most commonly used Systemic radiopharmaceuticals and bisphosphonates do not obviate need for RT

19 Treatment Details Our patient received 300cGy x 10 fractions using conventional APPA technique GTV was contoured with a 1.5cm expansion to PTV PTV was expanded.5cm to block edge August 18, 2016

20 Pain Flare after Palliative RT Pain flare is defined as a temporal worsening of pain in the treated site Incidence of 30-40%, possibly related to release of inflammatory cytokines Recent double-blind, randomized phase 3 trial in Canada suggests that dex may reduce incidence of pain flare (35% in placebo group vs 26% in dex group) 2 grade 3 and 1 grade 4 biochemical hyperglycemic events occurred in dex group August 18, 2016

21 Follow-up At 4 week follow-up visit, pain was improved and patient was able to ambulate She did not experience a pain flare after RT She was planning to restart chemotherapy No plans for repeat imaging of the irradiated site at this time August 18, 2016

22 Optimal Follow-Up Imaging Optimal frequency and modality of disease monitoring in patients with advanced cancer are unknown Recent population-based analysis suggested 38% of elderly women with metastatic breast cancer were extreme users of disease-monitoring tests extreme user defined as 4 or more imaging tests per year extreme users tended to have 50% higher total health care costs They also had higher health care costs in the last year of life No association between more frequent disease monitoring and OS August 18, 2016

23 References 1. Accordino MK, Wright JD, Vasan S, Neugut AI, Hillyer GC, Hu JC, Hershman DL. Use and costs of disease monitoring in women with metastatic breast cancer. J Clin Oncol 2016 May 9. Epub ahead of print. 2. Chow E, Harris K, Fan G, Tsao M, Sze WM. Palliative radiotherapy trials for bone metastases: a systematic review. J Clin Oncol 2007 Apr 10;25(11): Chow E, Meyer RM, Ding K, Nabid A, Chabot P, Wong P, Ahmed S, Kuk J, Dar AR, Mahmud A, Fairchild A, Wilson CF, Wu JS, Dennis K, Brundage M, DeAngelis C, Wong RK. Dexamethasone in the prophylaxis of radiation-induced pain flare after palliative radiotherapy for bone metastases: a double-blind, randomised placebo-controlled, phase 3 trial. Lancet Oncol 2015 Nov;16(15): Hartsell WF, Scott CB, Bruner DW, Scarantino CW, Ivker RA, Roach M 3 rd, Suh JH, Demas WF, Movsas B, Petersen IA, Konski AA, Cleeland CS, Janjan NA. DeSilvio M. Randomized trial of short versus long-course radiotherapy for palliation of painful bone metastases. J Natl Cancer Insti 2005 Jun 1;97(11): Lutz S, Berk L, Chang E, Chow E, Hahn C, Hoskin P, Howell D, Konski A, Kachnic L, Lo S, Sahgal A, Silveramn L, vongunten C, Mendel E, Vassil A, Bruner DW, Hartsell W; American Society of Radiation Oncology (ASTRO). Palliative radiotherapy for bone metastases: an ASTRO evidence-based guideline. Int J Radiat Oncol Biol Phys 2011 Mar 15;79(4): Sze WM, Shelley MD, Heid I, Wilt TJ, Mason MD. Palliation of metastatic bone pain: single fraction versus multifraction radiotherapy a systematic review of randomised trials. Clin Oncol(R Coll Radiol) 2003 Sep;15(6): Tong D, Gillick L, Hendrickson FR. The palliation of symptomatic osseous metastases: final results of the Study by the Radiation Therapy Oncology Group. Cancer 1982 Sep 1;50(5): Wu JS, Wong R, Johnston M, Bezjak A, Whelan T; Cancer Care Ontario Practice Guidelines Initiative Supportive Care Group. Meta-analysis of dose-fractionation radiotherapy trials for the palliation of painful bone metastases. Int J Radiat Oncol Biol Phys 2003 Mar 1;55(3): August 18, 2016