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Heidi McKellar MD ETMC Cancer Institute

Heidi McKellar MD ETMC Cancer Institute. 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).

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Heidi McKellar MD ETMC Cancer Institute

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  1. Heidi McKellar MDETMC Cancer Institute Palliative Radiation

  2. 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 Indications for Palliative Radiation

  3. Palliative Radiation • Assess Patient • Simulate: Fluoroscopy vs CT • Is a clinical set up with anatomy possible? • Treatment then follows

  4. CT simulator

  5. Conventional Simulator

  6. Linear Accelerator

  7. 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

  8. 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

  9. 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

  10. Lytic Lesion Impending Fracture

  11. Post-operative • Patient received 30Gy/10fx

  12. Effective Radiation Schedules • 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

  13. Bone Metastases-- External beam therapy achieves pain relief in >75% of patients with healing and reossification occurring in 65-85% 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.

  14. 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

  15. 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.

  16. 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

  17. 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.

  18. 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

  19. Cord compression

  20. 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

  21. 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

  22. SVC syndrome

  23. 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

  24. 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

  25. 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

  26. 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

  27. Cyberknife • Cyberknife indications solitary mets or following standard radiation

  28. 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).

  29. Brain Mets from Lung cancer

  30. 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

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