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ROLE OF RADIOTHERAPY IN PALLIATIVE CARE A/Prof Martin Borg Adelaide Radiotherapy Centre

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Page 1: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

ROLE OF RADIOTHERAPY

IN PALLIATIVE CARE

A/Prof Martin Borg

Adelaide Radiotherapy Centre

Page 2: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 3: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 4: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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)

Page 5: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

PALLIATIVE RT

Local

1. Airways obstruction

2. SVCO

3. Haemoptysis

Distant

1. Cerebral, PNS, choroidal

2. Bone

3. Liver

4. Cutaneous

Page 6: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

PALLIATIVE RT

Airways Obstruction

80% only suitable for palliative RT

Effective palliation >50%

Commence within 2/52 if atelectasis

Page 7: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 8: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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)

Page 9: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

PALLIATIVE RT

Page 10: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3
Page 11: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3
Page 12: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 13: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 14: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 15: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

PALLIATIVE RT

Page 16: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

PALLIATIVE RT

Page 17: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 18: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

Solitary 2’

1’ RCC

Page 19: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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%)

Page 20: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 21: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 22: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 23: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 24: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3
Page 25: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3
Page 26: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 27: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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’

Page 28: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

Figure 2

Components of quality-adjusted life-years (QALY)

Page 29: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

Figure 3

Forrest plot of overall survival by patient characteristics

Page 30: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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 #

Page 31: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 32: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

SRT

Cerebral

Metastases

Page 33: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

SRT

Multiple

Cerebral 2’

48 Gy / 4 #

Page 34: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

Solitary

2’

SRT

Page 35: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

SRT

Cerebral

2’

Page 36: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 37: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3
Page 38: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

NHL SRM

VMAT

36 Gy in

18#

Page 39: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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)

Page 40: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3
Page 41: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3
Page 42: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3
Page 43: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3
Page 44: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3
Page 45: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 46: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 47: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 48: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 49: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 50: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 51: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 52: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3
Page 53: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 54: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 55: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 56: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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)

Page 57: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

Solitary 2’

STS Pelvis

30 Gy in 3#

Page 58: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 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)

Page 59: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 60: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 61: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 62: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 63: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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.

Page 64: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 65: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 66: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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)

Page 67: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 68: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3
Page 69: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

PALLIATIVE RT

Page 70: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

PALLIATIVE RT

Page 71: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

PALLIATIVE RT

Bone Metastases

Other Measures

CT/Hormonal T (Stampede trial)

Bisphosphonates

Analgesics

External supports (braces, walkers)

Page 72: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3
Page 73: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3
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Page 83: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 84: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

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Page 86: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

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

Page 87: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3
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Page 89: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

PALLIATIVE RT

Fungating Tumours

90% RR

1. Bleeding

2. Cosmesis

3. Pain

4. Odour

5. Infection

Page 90: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3
Page 91: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3

PALLIATIVE RT

Lymphatic Obstruction

Effective

Pelvic/para-aortic, groin, axilla

1. Oedema

2. Pain

3. Immobility

4. Impaired micturition (penile/scrotal oedema)

Page 92: A/Prof Martin Borg Adelaide Radiotherapy Centre Martin Borg Adelaide Radiotherapy Centre PALLIATIVE RT Introduction Essential role 1. Maintain quality of life 2. Relive symptoms 3
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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)