Radiotherapy and Symptoms Management Dr. Bashir Bashir FRCPC Radiation Oncologist CancerCare Manitoba Western Manitoba cancer Centre
Learning objective 1. Diagnosis and symptoms assessment. 2. Role of radiotherapy in management of Cancer pain. Chest symptoms ( SOB, SVCO, Hemoptysis). Spinal cord compression. Brain metastasis symptoms. Other symptoms. 3. Post Radiation follow up
What are the common symptoms of metastatic cancer? To bone: pain and fracture. To lung: SOB, SVCO, pain, dysphagia, odynophagia. To brain: headaches, Seizure, and unsteadiness. To spine: pain, weakness, paralysis, cord compression. To liver: biochemical abn, Jaundice, Pain. Encephalopathy. To Lymph Nodes: edema, pain. Organs anatomy and physiology related symptoms.
Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
Types of pain
1. Assessment of the pain History Physical Examination 2. Discussion with patient/family the goals of care, hopes, expectations, anticipated course of illness. This will influence consideration of investigations and interventions 3. Investigations X-Ray, bone scan, CT, MRI, etc - if they will affect approach to care 4. Treatments pharmacological and nonpharmacological; interventional analgesia. 5. Ongoing reassessment and review of options, goals, expectations, etc.
By the Clock WHO cancer pain ladder
By the Clock OPIOIDS Most commonly use: Morphine Hydromorphone Dermal fentanyl Oxycodone Methadone
Adjuvants General / Non-specific corticosteroids Neuropathic Pain gabapentin antidepressants Bone Pain bisphosphonates
incidence Metastatic cancer to bone metastatic disease is the most common cancer involving the skeletal system anatomic distribution vertebra: 70% pelvis: 40% femur: 25% skull: 15% upper extremity: 10% >80% of pts will develop Mets at some point of disease course.
irradiation local field irradiation pain relief > 80% of patients experience at least partial relief Some patients will experience increase pain during radiotherapy course. most patients begin to experience relief 7 10 days after start of therapy.
Radiation schedule RTOG (Tong. Cancer 50:893. 1982) randomized 759 patients to a variety of dose schedules (270 cgy x 15, 300 cgy x 10, 300 cgy x 5, 400 cgy x 5, and 500 cgy x 5) and found no difference in response. Royal Marsden (Price. Radiother Oncol 6:247. 1986) randomized 288 patients to 800 cgy x 1 or 300 cgy x 10 no differences in regard to response rate, rapidity of response. however, substantially more single-fraction patients needed to be re-irradiated to the same site
Dose of XRT to Bone Mets Pts KPS, location of Mets, associated soft tissue. 800cGy/1, 2000cGy/5, 3000cGy/10, same pain control. Re irradiation dose calculation to avoid normal tissue damage. No chemotherapy If there risk of # surgery fixation 1 st. If surgery done give time for wound healing.
Brain Mets Overview Most common intracranial tumor Occur in 10-30% of all adults with CA Most common sources lung (50%) breast (15-20%) unknown (10%) melanoma (10%) colon/rectum (5%) Most present with multiple brain mets
Symptoms associated with brain metastasis are: Headache (40-50%) Cognitive dysfunction (30-65%) Memory, mood, personality Focal Neurologic Dysfunction (20-40%) Nausea/vomiting (2 ICP) Seizures (10-20%) Altered speech Visual problems Paralysis CVA (5-10%) Papilledema (<10%)
Brain Met Distribution Is this really a solitary metastases? 50% of pts have a single met on CT With MRI likely only 25-33% Disease specific Multiple mets lung, melanoma Sinlge mets breast, colon, renal
Treatment majority of patients are treated with the following : Steroids to reduce the swelling of the brain. Anti seizure medicines to prevent seizure. Radiation therapy to shrink the tumor. Radiosurgery < 4 lesions, < 4cm +- WBRT. Surgery in selected patients ( Single lesion) to remove the tumor from the brain or Diagnosis. Response to treatment depends on a patient's overall condition and the type and extent of the underlying cancer.
Whole Brain XRT Start steroid 1 st, depending on the vasogenic edema amount. WBRT (palliative) Dose depend on KPS, extra cranial dz, age, number of lesion.( RPA status) Different doses: 3000cGy/12 or 10fs, 2000cGy/5 etc WBRT (prophylactic) PCI as in SCLC 2500cGy/10. SRS dose depending on location, size 15-18-24Gy to 3-4cm, 2-3cm, < 2cm.
Prognosis Recursive partitioning analysis (RPA) from 3 RTOG trials with 1200 patients 3 prognosis groups Gaspar et al, IJROBP 1997;37:745
Spinal cord compression Seen is 10% of all cancer pts. Commonly from Prostate, lung & breast Signs and symptoms Back pain Numbness / Paresthesia difficulty with walking / weakness Problems passing urine Problems bowel control Location The most common area for spinal cord metastases are the: middle part of the back or chest (thoracic spine) 70% lower back (lumbar spine) 20% upper back or neck area (cervical spine) 10%
Diagnosis by MRI or CT. Treatment Bed rest(collar to the neck). Steroids Dose controversial Usually recommend 10 mg IV and then 4 mg IV/PO q6h Radiotherapy Surgery unstable spine, unknown primary, good KPS, debulking of tumor, single lesion, limited visceral diz.
Dexamethasone; relieves edema; gets pressure off cord If it is lymphoma in canal this can be extremely effective Consider surgical intervention unknown primary, good KPS, debulking of tumor, single lesion, limited visceral diz. Bone protruding into canal Radio-resistant primary; melanoma, kidney Recurrence after radiation Progressive on radiation.
Most important in outcome, pts ambulatory status. Surgery +RT better than RT alone. In practice not common approach. RT dose 2000cGy/5 or 3000cGy/10. After RT rehabilitation team nursing care and physiotherapy wheelchair access Home care lifting aids.etc.
Symptoms associated with lung Mets: Shortness of breath Cough Pain in the chest Pleural effusion Collapse lung SVCO Diagnosis Chest X-ray /CT chest. Lung Metastasis
Treatment Almost all patients are treated with chemotherapy Radiation therapy may be used in selected patients, when tumor causes bleeding, SVCO, pain, large mass or obstruction of the airways. Surgery in selected patients to remove the tumor from the lungs, e.g. sarcoma, colorectal etc
Palliative XRT 3DCRT most common use. Dose: 2000cGy/5f,3000cGy/10 or 4000cGy/16. 5000cGy/20 planning SBRT in some cases. E.g. 4800cGy/ 6fs
Superior vena cava obstruction Benign and malignant causes Benign Thrombosis (usually catheter related) Fibrosing mediastinitis Goiter Aortic aneurysms Malignant Primary Lymphoma Lung cancer Metastatic Nodal mets
Presentation Typical Result of venous congestion Flushed face Distended neck veins Dyspnea Appearance of collaterals on chest to bypass obstruction Worse lying down
XRT Pts respiratory status, KPS & pathology. Consideration of SVC stent. If pts cannot lying in supine position set up clinically on the treatment unit in a sitting up position 600cGy/2fs Then CT sim Complete in palliative or radical XRT.
Bleeding Hemoptysis Nodes or tumour eroding into airway Bladder Ca Prostate Cervix Rectal All commonly cause bleeding; can use radiation to stop it
Conclusion Radiation useful for palliation of: Bone pain Tumour causing pain by mass. Obstruction Bleeding Brain mets Spinal cord compression Short courses of radiation used
Questions