Radiation Therapy for Pain Control DUŠAN MILEUSNIC

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1 Radiation Therapy for Pain Control DUŠAN MILEUSNIC

2 PAIN BIOLOGICAL SENSE Acute Biological alarm function Protection, Defence reaction Pain Chronic Useless pain Emotional, disturbances Psychological changes distress Physical, affection Social isolation

3 EPIDEMIOLOGY Pain % of cancer patients < 50 % in early stages % in terminal stage Solide > hematological malignancies

4 PAIN IN CANCER PATIENTS Tumor related (60-90%) Therapy related (10-25%) Tumor-ass. (5-20%) Until 87% of all tumor patients will suffer from heavy pain in the course of their disease Tumor unrelated (5-10 %)

5 TUMOR RELATED PAIN 1. Infiltration of bone or soft tissue 2. Compression of nerval structures/ plexus 3. Organcapsule pain (liver, spleen) 4. Edema (brain metastases) 5. Necrosis / ulceration

6 POSSIBILITIES OF PAIN CONTROL Pharmacological Cytotoxic agents Radiooncology Pain Control Neuro/Surgery Psychology Physical therapy

7 The desired therapeutic aim of radiotherapy is achieved by tumor cell destruction with minimal destruction of normal tissue

8 RADIOTHERAPY IN TUMOR INDUCED PAIN Destruction of malignant cells Mechanism and influence on central pain modulation Expression of mediators (f.e. bradycinins, prostaglandins) Inhibition of nociceptor stimulation Interruption of abnormal reflex activation ( central sensibilization )

9 EXTERNAL BEAM RADIOTHERAPY FOR CANCER PAIN - efective treatment in persistent pain Orthovoltage unit: x- ray 2. Cobalt 60 unit : gamma rays 3. Linear accelerator LINAC: x rays + electrons

10 PLANNING AND CARRYING OUT OF RADIOTHERAPY Planning of: Treatment volume, single and total dose, treatment time Taking into consideration: Safe improvement of symtoms Avoidance of acute side effects Beginning as soon as possible

11 I. PAIN DUE TO BONE INFILTRATION The most common form of cancer pain, usually due to metastatic involvement. The role of RT in the management of pain due to bone metastases is unquestioned and this indication constitutes cca 15% of the tota number of patients referred to an average RT department.

12 I. PAIN DUE TO BONE INFILTRATION Wide variations in RT techniques - from a large dose given in a single treatment to as many as 20 smaller treatments given over four weeks. Standard palliative treatment for a small volume is 20 Gy in 5 fractions over 5 days. For large volumes 30 Gy in 10 fractions over 12 days is usual regime. Treatment with single fraction of 8-10 Gy is adequate for most situations for speed of effect and to avoid repeated discomfort for patient or need for hospitalisation. Retrospective comparisons found single and multiple fraction course of treatment to be equally effective

13 FRACTIONATION REGIMES Randomized studies for bone metastases: 1x8 Gy vs. 5x4 Gy / 10x3 Gy Pain control n.s. different Risk of fracture higher when 1x8 Gy 1x8 Gy standard dose for uncomplicated bone metastasis ( only 1 day!) 5x4 Gy / 10x 3 Gy when risk of fracture or soft tissue infiltration

14 RADIOTHERAPY FOR PAIN CONTROL 12 wks.after RTX: complete pain control and recalcification Before radiation: Pain Risk of fracture 10 x 3 Gy

15 DISSEMINATED BONE METASTASES 1. Half-Body Irradiation 2. Radionuklides 3. Bisphosphonate

16 BONE METASTASES radioactive nuclids Diffuse oss. metastases, severe pain Radioactive isotopes Phosphor 32 (prostate, breast) % pain reduction after 1 week Strontium 89 (prostate) 75% efficiency approx. 6 weeks after injection Problem: myelotoxicity

17 II. COMPRESSION OF NERVAL STRUCTURES SPINAL CORD COMPRESSION: may be due to to collapse of vertebral body or to pressure from extradural tumor within the spinal canal prodromal pain is a feature in 96% of patients. Emergency surgical decompression followed by postoperative radiation offers the best chance of reversing incipient paraplegia OR Primary radiotherapy + high dose corticosteroids Dose: Gy in 5 10 fractions

18 II. COMPRESSION OF NERVAL STRUCTURES NERVE PLEXUS COMPRESSION: Brachial, lumbar and sacral nerve plexus compression give rise to characteristic pain syndromes. If radiotherapy can induce tumor shrinkage, the pain will be relieved

19 III. ORGANCAPSULE PAIN (LIVER, SPLEEN) Hepatosplenomegaly Hepatic invasion by secondary tumor common cause of right hypochondrial pain - Whole liver radiotherapy: 30 Gy in 15 daily fractions

20 IV. BRAIN EDEMA PRIMARY TUMORS / METASTASES The site of involvement will determine the presenting symptoms and signs. Bulky supratentorial tumors or small deposits adjacent to the ventricles may obstruct the flow of cerebrospinal fluid, leading to symptoms and signs of raised intracranial pressure such as vomiting and headache. In patients with headache due to metastases, radiotherapy obtains complete pain releaf in 52%. If partial relief is included, the response rate rises to 82%. There is no difference in response between regime with 20 Gy in 5 daily fractions and longer schedule such as 40 Gy in 20 daily fractions over 4 weeks. Stereotactic radiosurgery: Gy in 1 fraction

21 V. NECROSIS / ULCERATION Chest wall Eroding by locally advanced breast cancer - Standard regime: 30 Gy in 10 fractions over 12 days - Poor prognosis: 35 Gy in 6 fractions over 18 days 10 Gy x 2 consecutive days Invasion of neighbouring hollow viscera by advanced tumourous of cervix, bladder, bowel or bronchus - Palliative radiotherapy should be used with caution (fistula!)

22 Indications, management and control rates of palliative radiotherapy for pain Primary situation Radiotherapy Control Rate Skeletal metastasis Soft tissue metastasis Brain metastases Spinal cord compression Plexus infiltration 10x3 Gy, 5x4Gy, 1x8 Gy 12 x 3 Gy, 5 x 4Gy Radiosurgery 1x25 Gy, 10x3 Gy 10x3 Gy 20 x 2 Gy 10x3 Gy x 2 Gy 80% 90% 70-90% 50-95% 90%

23 SUMMARY Effective and safe method: >80% good response >20% complete pain relief Early response, reduction of analgesics in 1-2 weeks Many indications Short therapy: 1x8 Gy, 5x4 Gy or 10x3 Gy Long term effect Low side effects

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