2 cases related to recent oncology update

Milind Arolker

Brain metastases

• Prognostication

•Whole Brain RadioTherapy• Surgery +/- WBRT vs. RadioSurgery +/- WBRT• Dexamethasone – when and when not

For metastases – what factors that might confer a worser outcome

Grade 4 malignant astrocytoma – aka GBM

Prognostication in patients with brain metastases (NB not primary brain)

• Age (65)• Performance status: KPS 70 = self-caring; BUT

unable to carry on normal activity or do work• Primary – treated vs. untreated• Mets in brain only vs. mets at other sites• Tumour histology or type

Relationship between the factors

Worst prognosis

Best prognosis

Gaspar, Int J Radiat Onc Biol Phys,1997 & validated in 2000

70 or less: unable to carry outnormal activity, work/job

Class 1

Class 2

Class 350%

Case DK

• 84 yo married retired headmaster. • 6/12 history of +ve visual phenomena (floaters,

hallucinations), leading to increasing reading difficulties, and daytime somnolence

• June 2013 - Dx of right occipital and left frontal mets on CT. Histology unavailable. MDT: best supportive care. 4 mg maintenance dose of dexamethasone

• February 2014 – Admitted for symptom control

Case DK

• Initial difficulty was unilateral, ankle/foot oedema with cellulitis and venous ulceration

• Sourcing better recliner for his height• After 2/52, increasing cognitive impairment:

word finding difficulties, confusion, physically restless

• Died 1035 hrs last week

Brain metastases

• Prognostication

•Whole Brain RadioTherapy• Surgery +/- WBRT vs. RadioSurgery +/- WBRT• Dexamethasone – when and when not

WBRT for brain metastases

• Often 5 doses over one week• May reduce steroid requirements in longer

term• BUT acutely: fatigue, hair loss, scalp soreness,

raised i.c.p (steroids increase). Potentially significant late toxicity

• What does it offer over best supportive care?

WBRT vs BSC/OSC in NSCLC

Needs 534 patients to be an adequately powered study

Before recruitment started in 2007, nobody had thought to compare these…

WBRT vs BSC/OSC in NSCLC

Surgery for brain mets

• When immediate relief from pressure effects is required (and pt well enough!)

• Offers tissue diagnosis – 11% of lesions may be another pathological process

• Usually for a solitary lesion in a ‘non-eloquent’ area of the brain

Brain metastases

• Prognostication

•Whole Brain RadioTherapy• Surgery +/- WBRT vs. RadioSurgery +/- WBRT• Dexamethasone – when and when not

WHAT IS RADIOSURGERY?

Done in a single visitHighly conformalMinimal dose to surrounding normal brain

The delivery of a single, high dose of radiation to individual metastases

Ideally suited to brain metsCan be used in eloquent areasOne visit (even for multiple targets)Less toxicity compared to WBRTUp to 3cm lesions. Can’t be done for mets bigger than this because of risk of toxicity to surrounding tissueCan be fitted around other treatments with little difficulty

“does this count as ‘surgery’ on the cremation form?”

aka Stereo-tactic radiosurgery

Headgear!

Day 0

2 months

5 months

2 months

Grade 1 Grade 2 Grade 3 Grade 4

Fatigue 14 (35%) 1 (2%) 1 (2%) 0

Skin soreness 3 (7%) 0 0 0

Hair Loss 12 (30%) 0 0 0

Anorexia 3 (7%) 0 0 0

Taste Change 4 (10%) 0 0 0

Weakness 0 0 1 (2%) 0

Sensory Change 0 1 (2%) 0 0

Cognitive Impairment 1 (2%) 0 0 0

Headache 3 (7%) 0 0 0

Dizziness 3 (7%) 1 (2%) 0 0

Memory 2 (5%) 0 0 0

Seizure 0 4 (10%) 1 (2%) 0

WBRT VS WBRT + RADIOSURGERY

Survival benefit only clearly shown for single mets (ie similar to surgery)Improved local control when used with more mets- 2 to 3 - (survival then related to systemic disease)Reduced steroid requirementsBetter preservation of KPS

RADIOSURGERY ALONE WITH WBRT ON RELAPSE?

Many patients may be spared toxicity of WBRTAllows rapid introduction of systemic therapy or treatment of primaryDelays use of WBRT so late effects less of an issueConcern would be the more rapid development of other brain mets and a possible adverse effect on neurological function / performance status

Brain metastases

• Prognostication

•Whole Brain RadioTherapy• Surgery +/- WBRT vs. RadioSurgery +/- WBRT• Dexamethasone – when and when not

Prophylactic WBRT

• Accelerates cognitive impairment

Some take-home messages for patients with brain metastases

• Many patients will still require best supportive care

• WBRT alone is used less than before• Stereotactic radiosurgery (SRS) alone produces

good local control of treated lesions• SRS vs SRS + WBRT: WBRT produces better local

control and less new mets but same PS, OS and ?more toxicity

• Delaying WBRT increases need for salvage but spares many (~30-50%) the need to ever have it

SRS NOW FUNDED BY NHS ENGLAND

Approval from both site-specific and CNS MDTKPS ≥ 70Diagnosis of cancer establishedPrimary absent or controllablePressure symptoms best relieved by surgery excludedTotal volume < 20 cm3

Patient’s life expectancy from extracranial disease is expected to be greater than 6 months

Brain metastases

• Prognostication

•Whole Brain RadioTherapy• Surgery +/- WBRT vs. RadioSurgery +/- WBRT• Dexamethasone – when and when not

16 mg isn’t always appropriate

• i.e. not needed for a single solitary metastases giving rise to mild headache. – Within 4/52, patient WILL get steroid side effects

• Try 8 mg and ALWAYS include a reduction plan where possible, resorting to prednisolone if stopping at 500 mcg problematic

• No evidence for dosing more frequently than omne mane

What about a seizure from brain mets?

• Give enough dex for 1/52 to decrease intracranial pressure

• Also give levetiracetam (– see case report (2013) for highlighting subcut use)– Keppra far less cross-reactive with other drugs

compared with phenytoin

2nd Case

• 67 female odynophagia and dysphagia (Riddlesden)• 15/10/13 CT T3 N0 Junctional adenoca oes• PHx COPD, 15-12/day. Lives with brother who has

MS, daughter and grandson• 30Gy in 10# palliative RT (external beam) Completed

3.12.13• Jan 10 2014: single fraction intraluminal

brachytherapy 8 Gy. Symptoms: dysphagia score 1, Odynophagia on-going

• 29.01 F ^ from 75 to 100, as taking 45 mg total for odynophagia

• 14.02 “pain levels improving no discomfort when eating”

• Admitted to IPU (6/52 post ILB)– Trial of 6 mg dex om– Agreed to titration of background analgesia to F

125

External beam vs intraluminal brachytherpay

High dose palliative radiotherapy is generally given to patients with upper GI cancer if they have co-morbidities that preclude chemo

Ambulatory radiotherapy clinic

• Phone the clinical oncology registrar on-call for access to an all-in-one-day simulation and treatment

• Patient needs to be fit enough to attend, and be able to lie still. Check if had previous EBRT

• Think of this ‘boost’ of brachytherapy as delaying need for a stent/alternative to stenting

Intraluminal brachytherapy

Good for• Slow/oozing bleeding• Maintaining your patient’s

swallow

Not worth doing if

• Complete obstruction• If cancer involves airway – RT

will result in fistulation (CI)

Signs of complete upper GI obstruction?

Fistula: “ an abnormal connection or passageway between two epithelium-

lined organs or vessels”

When to ring gastro for a stent?

• Think of stenting as “end-stage” for oesophagus Ca

• No clear benefit (morbidity/mortality) if RT used post-stent

• Unclear if RT has a role in stent-associated pain

• If cancer involves airway

RT for lower GI/pelvic signs

• Good for– Pain– Bleeding– Discharge

• Can be external beam or intraluminal

• Not advised for – Obstruction, as RT will

worsen this

• “Clin oncs/RT will make things worse before they get better…”

• In the immediate days– Inflammation:

Diarrhoea, cystitis, sacral neuropathy

RT for lower GI/pelvic signs

• Good for– Pain– Bleeding– Discharge

• Can be external beam or intraluminal

• Not advised for – Obstruction, as RT will

worsen this

• Longer term side effects– Weeks/months

• Altered bowel habit• Urinary urgency

– Months/years• Strictures