Transcript Document

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
70 or less: unable to carry out
normal activity, work/job
Worst prognosis
Best prognosis
Gaspar, Int J Radiat Onc Biol Phys,1997 & validated in 2000
Class 1
Class 2
50%
Class 3
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?
The delivery of a single, high dose of radiation to
individual metastases
• Done in a single visit
• Highly conformal
• Minimal dose to surrounding normal brain
• Ideally suited to brain mets
– Can be used in eloquent areas
– One visit (even for multiple targets)
– Less toxicity compared to WBRT
– Up to 3cm lesions. Can’t be done for mets bigger
than this because of risk of toxicity to surrounding
tissue
– Can be fitted around other treatments with little
difficulty
“does this count as ‘surgery’ on the
cremation form?”
aka Stereo-tactic radiosurgery
Headgear!
Day 0
5 months
2 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 requirements
• Better preservation of KPS
Radiosurgery alone with WBRT on relapse?
• Many patients may be spared toxicity of WBRT
• Allows rapid introduction of systemic therapy or
treatment of primary
• Delays use of WBRT so late effects less of an issue
• Concern 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
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Approval from both site-specific and CNS MDT
KPS ≥ 70
Diagnosis of cancer established
Primary absent or controllable
Pressure symptoms best relieved by surgery excluded
Total 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 epitheliumlined 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