2 cases related to recent oncology update

1. 2 cases related to recent oncology update MilindArolker

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

3. For metastases – what factors that might confer a worser outcome Grade 4 malignant astrocytoma – aka GBM

4. 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

7. Relationship between the factors 70 or less: unable to carry out normal activity, work/job Worst prognosis Best prognosis Gaspar, Int J RadiatOncBiol Phys,1997 & validated in 2000

8. Class 1 Class 2 50% Class 3

9. 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

10. 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

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

12. 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?

13. 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…

14. WBRT vs BSC/OSC in NSCLC

15. 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

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

17. What is Radiosurgery? Done in a single visit Highly conformal Minimal dose to surrounding normal brain The delivery of a single, high dose of radiation to individual metastases

18. 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

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

20. aka Stereo-tactic radiosurgery

21. Headgear!

22. Day 0 5 months 2 months 2 months

24. 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

25. 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

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

30. Prophylactic WBRT • Accelerates cognitive impairment

31. 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

32. SRS now funded by NHS England 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

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

34. 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

35. 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

36. 2nd Case • 67 female odynophagia and dysphagia (Riddlesden) • 15/10/13 CT T3 N0 Junctionaladenocaoes • 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

37. 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

38. 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

39. 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

40. Intraluminal brachytherapy Good for Not worth doing if Complete obstruction If cancer involves airway – RT will result in fistulation(CI) • Slow/oozing bleeding • Maintaining your patient’s swallow Signs of complete upper GI obstruction?

41. Fistula: “ an abnormal connection or passageway between two epithelium-lined organs or vessels”

42. 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

43. 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 • “Clinoncs/RT will make things worse before they get better…” • In the immediate days • Inflammation: Diarrhoea, cystitis, sacral neuropathy

44. 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