Transcript Bone Metastases-- External beam therapy achieves pain

Palliative
Radiation
Heidi McKellar MD
ETMC Cancer Institute
Indications for Palliative Radiation
Pain control
Bone mets
Nerve compression
Superior Vena Cava Syndrome
Spinal Cord Compression
Bleeding
Hemoptysis (lung cancer)
Rectal
Bladder
Gynecological
Brain Mets
Whole Brain
Stereotactic (Cyberknife)
Obstructive Relief
Airway/Bronchus
Esophagus
Subcutaneous met
Lung Primary
Renal Cell
Kaposi’s sarcoma
Palliative Radiation
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Assess Patient
Simulate: Fluoroscopy vs CT
Is a clinical set up with anatomy possible?
Treatment then follows
CT simulator
Conventional Simulator
Linear Accelerator
Pain
• Bone mets most common cause of pain in a
cancer patient
• Due to nerve ending stimulation, periosteal
stretching, or growth into nerves and
surrounding soft tissues
• Pain may be intermittant, or constant; related to
activity; worse at particular times of day
• Plain x-rays may show a lytic lesion or fracture
• Bone scan may be + if lesions are sclerotic or
blastic
• MRI may or may not contribute to the diagnosis
Is Fracture Imminent?
• Important; especially if weight bearing
bone
• Lytic lesions > 50% of diameter
• Lesions >50% of cortex
• Lesions > 2.5cm in length
• Pain after radiation therapy and initial pain
relief
Orthopedic consultation
• Indicated if fracture pending
• Fracture may be direct result of radiation
for pain relief as the entire bone was held
together by disease…response left
absence of bone resulting in fracture
• Higher risk in very responsive tumors:
small cell, lymphoma, etc
• Pinning may preceed radiation when
appropriate
Lytic Lesion Impending Fracture
Post-operative
• Patient received
30Gy/10fx
Effective Radiation Schedules
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800cGy /1 fraction
2000cGy/5 fx
3000cGy/10fx
Weigh long term risks of large fraction size
against projected life length.
• 3000cGy will give the longest pain control
if potential for extended life
• Fractionation usually irrevelant
Bone Metastases-- External beam therapy achieves pain relief in
>75% of patients with healing and reossification occurring in 6585% of lytic lesions in non-fractured bone. Pain relief may begin
within the first few treatments and peaks by 4 weeks following XRT
completion. A standard radiation prescription in the US is 300 cGy x
10 fractions; however, data exists to support a single large fraction (
800 cGy x 1) for extremity lesions, especially in patients with
expected survival < 3 months. Note: surgical fixation prior to XRT is
indicated for large lesions, when >50% of the cortex is replaced by
tumor, or when fracture has occurred in a weight-bearing bone.
Wide Spread Bone Mets
• Common for breast and prostate cancer
• If patient has adequate marrow reserves
and no cord compression may consider
systemic radiation with Strontium or
Quadramet
• These are preferentially taken up in the
bones
Quadramet Indications
• Radionuclide therapy with Strontium 89 or Samarium
153 is indicated for multiple sites of painful bone
metastases, typically breast or prostate cancer.
• Peak analgesic effect occurs 3-6 weeks following
treatment.
• Side effects are hematological with decreased blood
counts in 10-30% of patients. Worsening of pain, "pain
flare", may occur following administration and prior to
pain relief.
• Radionuclide therapy can be combined with external
beam radiation and can be given more than once.
Spinal Cord Compression
• Presents with as:
– Collapsed vertebral body
– Soft tissue mass in the spinal canal
Symptoms
Pain in the back
Inability to ambulate
Urinary obstruction
Numbness/tingling in extremities
Epidural Metastases and Spinal
Cord Compression -• External Beam Radiation is the primary definitive
treatment in conjunction with a short-course of steroids.
• The standard U.S. prescription is 300 cGy x 10 fractions;
although shorter courses can be used if needed (e.g.
400 cGy x 5).
• Results of treatment are directly related to the
neurological status at the time treatment starts.
• Ambulatory patients at the start of treatment generally
remain ambulatory, while non-ambulatory patients are
unlikely to have return of weight-bearing function.
• Indications for surgery include no tissue diagnosis,
spinal instability, bone fragments causing cord damage
and progression during/after XRT.
Signs:
• Muscle weakness
• Sensory level: 70% are in the T-spine
• Change in bowel habits/ inability to empty
bladder can present as low abdominal
pain
• MRI gold standard for diagnosis
Cord compression
Treament
• Dexamethasone to relieve swelling
immediately: Usually 10mg IV followed by
4mg IV/PO q 6 hr
• Radiation: 2000/5 fx or 3000/10
• Neurosurgical intervention considered for
radio-resistant disease or solitary lesion or
recurrence after radiation
Superior Vena Cava Syndrome
• Usually from
lymphoma or lung
cancer
• Presents with venous
congestion: puffy
flushed face,
distended neck veins,
SOB, collaterals on
the chest
SVC syndrome
SVC Treatment
• Steroids
• Radiation
• Chemo if responsive cell type: small cell or
lymphoma
• Short course XRT 300 or 400 x 3 followed
by immediate chemo
Brain Mets
• May be presentation
• Often appears like stroke
• May be asymptomatic and found during
staging
• CT (usually at staging pick-up)
• MRI fore sensitive
• Neurosurgery consult if no primary
Treatment
• Steroids relieve edema: dramatic
improvement
• Standard 30/10: neuro-toxicity is real;
memory loss, concentration, and cognition
can all be affected especially if the patient
lives greater than 6 months post-treatment
Modern Radiation
• Reduce fraction size if longevity a
possibility: 30/12 or 3750 in 15
• Consider stereotactic boost with
Cyberknife or Novalis, particularly if brain
met solitary or only sight of mets
systemically
Cyberknife
• Cyberknife indications
solitary mets or
following standard
radiation
Brain Metastases -• Palliative Radiation, either whole-brain external
beam radiation or, for small lesions, stereotactic
radiosurgery (AKA Gamma Knife), can relieve
symptoms and prolong survival.
• The standard US prescription is 300 cGy x 10
fractions; although shorter courses can be used
(e.g. 400 cGy x 5).
• Surgery is indicated for good prognosis patients
with a single accessible lesion or for refractory
neurology symptoms (e.g. seizures).
Brain Mets from Lung cancer
• Other Indications: The following are all
appropriate for consideration of palliative
radiation:
• Obstruction: vascular (SVC syndrome),
esophagus, airway, rectum, biliary tract
• Pain: adrenal metastases-flank pain, nerve
impingement
• Bleeding: stomach, esophagus, head/neck
cancer, bladder, cervix
• Ulceration/fungation