ROLE OF RADIOTHERAPY
IN PALLIATIVE CARE
A/Prof Martin Borg
Adelaide Radiotherapy Centre
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
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
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)
PALLIATIVE RT
Local
1. Airways obstruction
2. SVCO
3. Haemoptysis
Distant
1. Cerebral, PNS, choroidal
2. Bone
3. Liver
4. Cutaneous
PALLIATIVE RT
Airways Obstruction
80% only suitable for palliative RT
Effective palliation >50%
Commence within 2/52 if atelectasis
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
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)
PALLIATIVE RT
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
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
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
PALLIATIVE RT
PALLIATIVE RT
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
Solitary 2’
1’ RCC
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%)
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
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
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
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
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
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’
Figure 2
Components of quality-adjusted life-years (QALY)
Figure 3
Forrest plot of overall survival by patient characteristics
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 #
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
SRT
Cerebral
Metastases
SRT
Multiple
Cerebral 2’
48 Gy / 4 #
Solitary
2’
SRT
SRT
Cerebral
2’
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
NHL SRM
VMAT
36 Gy in
18#
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)
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
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
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
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
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
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
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
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
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
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
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)
Solitary 2’
STS Pelvis
30 Gy in 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)
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
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
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
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
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.
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
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
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)
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
PALLIATIVE RT
PALLIATIVE RT
PALLIATIVE RT
Bone Metastases
Other Measures
CT/Hormonal T (Stampede trial)
Bisphosphonates
Analgesics
External supports (braces, walkers)
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
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
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
PALLIATIVE RT
Fungating Tumours
90% RR
1. Bleeding
2. Cosmesis
3. Pain
4. Odour
5. Infection
PALLIATIVE RT
Lymphatic Obstruction
Effective
Pelvic/para-aortic, groin, axilla
1. Oedema
2. Pain
3. Immobility
4. Impaired micturition (penile/scrotal oedema)
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)