a/prof martin borg adelaide radiotherapy centre martin borg adelaide radiotherapy centre palliative...

ROLE OF RADIOTHERAPY

IN PALLIATIVE CARE

A/Prof Martin Borg

Adelaide Radiotherapy Centre

PALLIATIVE RT

Introduction

Essential role

1. Maintain quality of life

2. Relive symptoms

3. Prevent complications

4. Maintain dignity

Minimise treatment

Minimise inconvenience

Minimise investigations pre-/during/post-RT

Informed consent – palliative not curative

PALLIATIVE RT

Introduction

Low TD

1. Lower no of higher doses/# (hypofractionation)

2. Shorter overall treatment time

3. Low risk of (tolerable) SE

4. Minimise no of attendances

5. Rapid + effective response (during RT to 4/52)

6. May be repeated

7. Any site and age

PALLIATIVE RT

Side-Effects

Generally very well tolerated

Low TD

Usually temporary + short-lived

Site dependent

Dose + technique (SABR, VMAT, 3-D, 2-D, CT sim)

dependent

Advise patients/family/care givers beforehand (IC)

1. Intent (palliative)

2. Management (often simple measures)

PALLIATIVE RT

Local

1. Airways obstruction

2. SVCO

3. Haemoptysis

Distant

1. Cerebral, PNS, choroidal

2. Bone

3. Liver

4. Cutaneous

PALLIATIVE RT

Airways Obstruction

80% only suitable for palliative RT

Effective palliation >50%

Commence within 2/52 if atelectasis

PALLIATIVE RT

AIRWAYS OBSTRUCTION

Main Symptoms % with Palliation % CR

Cough 56 37

Haemoptysis 86 84

Chest pain 80 74

Anorexia 64 58

Depression 57 55

Anxiety 66 62

MRC 1991

PALLIATIVE RT

EBRT

6-10 MV photons

Parallel opposed

fields

20 Gy in 5 #

16 Gy in 2 #

10 Gy in 1 #

48 Gy in 4 #

(SRT/SABR)

PALLIATIVE RT

PALLIATIVE RT

HDR 15-20 Gy @ 1cm

1. Retreatment

2. Limited disease

3. No extra-bronchial extension

4. PD on EBRT

Convenient

Short treatment time

Single insertion

?more rapid response

PALLIATIVE RT

SVCO Primary or secondary CA

Diagnosis

1. percutaneous FNA under CT guidance

2. transcarinal biopsy at endoscopy

Avoid biopsy under GA if large mediastinal mass

Often associated with thrombus

Death unusual

PALLIATIVE RT

SVCO

Conventional or palliative doses produce = RR

75% improve symptomatically

Treat in supine position if stable

Elevate head

20-30 Gy in 5-10 #

Steroids

Avoid diuretics

PALLIATIVE RT

PALLIATIVE RT

PALLIATIVE RT

SABR

Selected cases

1. small tumours (1’ or 2’)

2. well defined

3. separate from critical NT

Radical dose – 48 Gy in 4 #

Superior outcomes

Solitary 2’

1’ RCC

PALLIATIVE RT

Cerebral Metastases

Very distressing to patients and care givers

Median OS 3/12

1. 4/12 if 1-3 2’ (79%)

2. 3/12 if >4 2’ (21%)

PALLIATIVE RT

Cerebral Metastases

Headache + impaired cognition most

common symptoms

Most common 1’ site: lung or breast 1’

Melanoma caries the highest risk

SCLC or NSCLC

PALLIATIVE RT

Cerebral Metastases

Steroids

Response within 24 hours

Improve neurological function

Do not effect OS (2/12)

Do not effect duration of response to RT

Indicative of nature of response to RT

PALLIATIVE RT

Cerebral Metastases

80% improvement in headaches

80% reduction in frequency of seizures

Minimum improvement in motor deficits

↑ med S: 27/52 vs 5/52

↑ OS: 5/12 vs 3/12

PALLIATIVE RT

Cerebral Metastases

Med S > 12/12 in selected cases

Solitary lesion (MRI)

Excision + RT

1. Solitary lesion

2. No meningeal involvement

3. Good PS

4. Stable or absent neurological disease

PALLIATIVE RT

Cerebral Metastases

RTOG (1980; 2-D)

20 Gy in 5 # vs 30 Gy in 6 or 10 # vs 40 Gy in 20 #

No difference in (unselected patients)

1. Improvement in neurological deficits

2. Duration of improvement

3. Time to progression

4. OS

PALLIATIVE RT

Cerebral Metastases Lancet 2016, Mulvenna et al (QUARTZ Trial, AUS/UK)

RPCT, NSCLC (most RPA class 3: <20% alive @ 12/52)

WBRT vs dexamethasone

QALYs: no difference

OS: no difference

Median OS benefit achieved @ 6/52

Improved outcome if:

1. KPS > 70

2. age <60 yr

3. controlled 1’

Figure 2

Components of quality-adjusted life-years (QALY)

Figure 3

Forrest plot of overall survival by patient characteristics

PALLIATIVE RT

Cerebral Metastases

2-D (PO) or 3-D

Cast

LA

6 MV photons

Standard baseline

20 Gy in 5 #

30 Gy in 10 #

Retreatment

25 Gy in 10 #

PALLIATIVE RT

Cerebral Metastases

Radiosurgery (SRS/T)

Effective for solitary subcortical and deep lesions

Single dose of 20-30 Gy

Superior LC but similar OS - higher incidence of new

brain lesions (SRS vs WBRT; Chougle et al)

Aoyama et al, Chang et al, Kocher et al, Brown et al

(2006-2015: SRS vs SRS + WBRT): sup LC + same OS

MRI scan

SRT

Cerebral

Metastases

SRT

Multiple

Cerebral 2’

48 Gy / 4 #

Solitary

2’

SRT

SRT

Cerebral

2’

PALLIATIVE RT

Choroidal Metastases Lung or breast cancer

Effective with minimal SE (vs BT)

Reasonable survival if effective systemic therapy (usually breast 1’)

Diplopia and occasional proptosis

Urgent RT if symptomatic

20 Gy in 5 # to IL eye

Avoid CL eye

30 Gy in 10 # if solitary 2’ or if DFI > 3 yrs

NHL SRM

VMAT

36 Gy in

18#

PALLIATIVE RT

Spinal Cord Compression

Medical Emergency

5% of patients with bone 2’

Ambulation: critical prognostic factor

1. Med S 8-9/12 if ambulatory

2. Med S 1/12 if not ambulatory

T spine most common site

MRI or CT-myelogram (CI to former)

PALLIATIVE RT

Spinal Cord Compression Surgery

1. 1 RPCT reported superior outcome (Finlay et al)

2. No histological diagnosis

3. Tumours traditionally slow to respond to RT (sarcoma, RCC)

4. Fracture-dislocation

5. Acute onset paraplegia

6. Poor response to steroids

7. Neurological deterioration during RT

8. Prior high dose RT

PALLIATIVE RT

Spinal CC

Surgery

Posterior laminectomy is

CI if lesion arises from VB

1. Unstable spine

2. Kyphoscoliosis in pre-

pubertal children

Excision of VB via

bilateral approach

PALLIATIVE RT

Spinal Cord Compression

Dexamethasone

Stat dose: 8-16 mg IV,

Daily: dose of 8 mg (4mg mane + noon)

Gradual weaning of dose

1. Alleviates pain

2. Improves neurological deficits

3. May predict RT response

PALLIATIVE RT

Spinal Cord Compression

RT 1. 60% respond to RT alone

2. 20% progress during RT

3. 20% not referred because of very poor PS, missed/delayed diagnosis or poor knowledge of RT

RT = S+RT

1. Ambulatory patients

2. Paretic patients who respond to steroids

Within 24 hours

1. 67% walk if RT commenced before onset of paraplegia

2. Poor outcome: paraesthesia, loss of bowel/bladder F

PALLIATIVE RT

Spinal Cord Compression

RT

No difference between 20 Gy in 5 #, 30 Gy in 10 #, 40-45 Gy in 20-25 #

Single 8 Gy # if for pain only

Single PA field prescribed to 5-6 cm (CT spine) or 8-10 cm (LS spine) or VMAT

PO lateral fields in C spine (OP) or VMAT

4-6 MV photons

PALLIATIVE RT

Spinal Cord Compression

Other Measures

Informed consent

Psychosocial support and counseling

1. Social and occupational issues

2. Family and friends

Physiotherapy

Stockings (DVT)

Skin care

PALLIATIVE RT

Other Neurological Complications

Cauda equina syndrome

Peripheral neuropathy (nerve entrapment)

Cranial nerve palsy

Plexopahty (e.g. brachial or LS/psoas)

MRI/CT scan

Urgent RT

PALLIATIVE RT

Bone Metastases Pain and impaired mobility in 65-75%

1. Bone destruction

2. Tumour growth

2nd commonest cause of pathological # (OP)

Life expectancy

1. Prostate 29.3/12

2. Breast 22.6/12

3. Renal 11.8/12

4. Lung 3.6/12

> 20% of patients

PALLIATIVE RT

Bone Metastases Surgery (prophylactic fixation/impending #)

1. Expected to survive > 6/52

2. > 50% diaphysis

3. > 50% cortex

4. > 2.5 cm in femoral neck or IT region

5. Lytic, permeative 2’ in other high stress regions

6. Lesser trochanter, subtrochanteric or supracondylar regions

7. Locally tender lesions

8. Inadequate pain relief despite adequate RT

PALLIATIVE RT

Bone Metastases

RT

Pain relief in 80-90% within 2/52

Frequently need re-treatment

65-85% healing/ossification of lytic lesions in

unfractured bone

EBRT or RN

PALLIATIVE RT

Bone Metastases

EBRT

VMAT or single localised field or HBI

6 MV photons (SXRT or electrons; e.g. ribs)

20 Gy in 5 # or 8 Gy in 1 # or 48 Gy in 4#

Respect TD of spinal cord, lung, other OAR

Appropriate shielding or technique (VMAT)

1. Uninvolved NT

2. Avoid fall-off on skin (perineum)

Solitary 2’

STS Pelvis

30 Gy in 3#

PALLIATIVE RT

Bone Metastases

HBI 80% have pain in > 1 site

34% have pain in > 3 sites

Single 6-8 Gy

Shorter life-expectancy

Multiple symptomatic lesions in one half

Check CBE (prior CT)

Very well tolerated out-patient treatment

1. LDR

2. Pre-med (ondansetron 8 mg D1-3 + dexamethasone 8mg D1 + lorazepam 1 mg D1)

Bone Metastases

Radionuclide Therapy

Patients with multiple blastic (sclerotic) 2’

Exhausted EBRT

Discontinue calcium-containing drugs x 2/52

1. Strontium

2. Samarium

3. Radium-223 (Nakamura K, et al; Nishon Rinsho,

2014): ↑OS (not on PBS; ongoing trial)

PALLIATIVE RT

Bone Metastases

Radionuclide Therapy

Selection criteria

1. > 1 painful site

2. WBC > 3.0; Pl > 60

3. Life expectancy > 3/12

4. No change in systemic therapy for 30/7

PALLIATIVE RT

Bone Metastases

Strontium 89

1. Selective uptake by sclerotic bone 2’

2. 4 mCi

3. Beta (electron) emitter

4. 4 ml IV injection

5. Monitor CBE

PALLIATIVE RT

Bone Metastases

Strontium 89

37-91% RR (lower if extensive or lytic 2’)

CR 0-43%

Onset of pain relief at 10-20/7

Maximum relief at 6/52*

Median duration of pain relief 12/52

Avoid if extensive CT

PALLIATIVE RT

* use EBRT 1st for painful site

Bone Metastases

Strontium 89

Side-effects

1. Flair attack (10-20%, x 2-4 days)*

2. Transient 30-40% decrease in CBE at 4-8/52

3. RA isotope (but very minimal exposure)

4. Cost (mostly covered by Medicare)

PALLIATIVE RT

* ? better RR; treat with NSAID. Use EBRT 1st for if SCC, etc.

PALLIATIVE RT

Bone Metastases

Radionuclide Therapy

Contra-indications

1. Pathological #

2. SCC, cauda equina syndrome, nerve root

compression

3. Index lesion with inadequate uptake on WBBS

4. Lesion with significant extraosseous component

5. Large areas of one destruction/ large tumour mass

PALLIATIVE RT

Bone Metastases

Radionuclide Therapy Contra-indications (cont)

6. Inadequate CBE

7. Poor renal function

8. Poor hepatic function

9. Life expectancy < 6/52

10. Urinary incontinence

11. Hypercalcaemia

12. Pregnancy

PALLIATIVE RT

Bone Metastases

Multiple Symptomatic Lesions

1. Sequential lower + upper HBI (best results)

2. HBI (superior to local field RT alone)

3. Sr 89 (superior to local field RT alone)

4. Local field RT + Sr 89 (inferior to HBI)

PALLIATIVE RT

Stereotactic Body Radiotherapy A. Characteristics

1. Secure immobilisation

2. Accurate positioning from Planning CT Scan to treatment

3. Utilisation of multiple beams to reduce RT dose to NT

4. Accurate tracking of surrounding organ motion

5. Image guidance + T surrogates (implanted FM + BL)

6. Ablative dose + fractionation scheme + mm accuracy

B. Candidate requirements

1. Well-circumscribed lesions

2. Minimal cord compression

3. Inoperable lesions

4. Lesions that do not require open spinal stabilisation

Available at ARC

PALLIATIVE RT

PALLIATIVE RT

PALLIATIVE RT

Bone Metastases

Other Measures

CT/Hormonal T (Stampede trial)

Bisphosphonates

Analgesics

External supports (braces, walkers)

PALLIATIVE RT

Hepatic Metastases

21 Gy in 7 # (RTOG)

1. Med S 4/12

2. 80% RR

55-95% R: malaise, N/V, sweats, pain

0.5% CR

0% RT hepatitis (TD 28-30 Gy @ 2 Gy/#)

No added benefit to misnidazole

PALLIATIVE RT

Hepatic Metastases

TROG – 10 Gy in 2 #, D1+2

4 mg Dexamethasone

Prognostic factors

1. Karnosky performance status

2. Primary site (lung 1’ adverse PF)

3. Presence of extrahepatic metastases

4. Extent of hepatic metastases

PALLIATIVE RT

Haemorrhage

Very effective in any site

Bronchial, cerebral, fungating tumours,

cutaneous, GI and GU

EBRT or IC BT

Hypofractionated RT + small fields

> 90 % RR

Within 1/52

PALLIATIVE RT

Fungating Tumours

90% RR

1. Bleeding

2. Cosmesis

3. Pain

4. Odour

5. Infection

PALLIATIVE RT

Lymphatic Obstruction

Effective

Pelvic/para-aortic, groin, axilla

1. Oedema

2. Pain

3. Immobility

4. Impaired micturition (penile/scrotal oedema)

PALLIATIVE RT

Conclusions

Palliative RT

1. Effective locally

2. Expedient - one short course

3. Minimal + often temporary toxicity

4. Non-invasive

5. Relatively cheap

6. Multidisciplinary approach (Med Onc/PC/S)