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2 cases related to recent oncology update
Milind Arolker
Brain metastases
• Prognostication
•Whole Brain RadioTherapy• Surgery +/- WBRT vs. RadioSurgery +/- WBRT• Dexamethasone – when and when not
For metastases – what factors that might confer a worser outcome
Grade 4 malignant astrocytoma – aka GBM
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
Relationship between the factors
Worst prognosis
Best prognosis
Gaspar, Int J Radiat Onc Biol Phys,1997 & validated in 2000
70 or less: unable to carry outnormal activity, work/job
Class 1
Class 2
Class 350%
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
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
Brain metastases
• Prognostication
•Whole Brain RadioTherapy• Surgery +/- WBRT vs. RadioSurgery +/- WBRT• Dexamethasone – when and when not
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?
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…
WBRT vs BSC/OSC in NSCLC
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
Brain metastases
• Prognostication
•Whole Brain RadioTherapy• Surgery +/- WBRT vs. RadioSurgery +/- WBRT• Dexamethasone – when and when not
WHAT IS RADIOSURGERY?
Done in a single visitHighly conformalMinimal dose to surrounding normal brain
The delivery of a single, high dose of radiation to individual metastases
Ideally suited to brain metsCan be used in eloquent areasOne visit (even for multiple targets)Less toxicity compared to WBRTUp to 3cm lesions. Can’t be done for mets bigger than this because of risk of toxicity to surrounding tissueCan be fitted around other treatments with little difficulty
“does this count as ‘surgery’ on the cremation form?”
aka Stereo-tactic radiosurgery
Headgear!
Day 0
2 months
5 months
2 months
Grade 1 Grade 2 Grade 3 Grade 4
Fatigue 14 (35%) 1 (2%) 1 (2%) 0
Skin soreness 3 (7%) 0 0 0
Hair Loss 12 (30%) 0 0 0
Anorexia 3 (7%) 0 0 0
Taste Change 4 (10%) 0 0 0
Weakness 0 0 1 (2%) 0
Sensory Change 0 1 (2%) 0 0
Cognitive Impairment 1 (2%) 0 0 0
Headache 3 (7%) 0 0 0
Dizziness 3 (7%) 1 (2%) 0 0
Memory 2 (5%) 0 0 0
Seizure 0 4 (10%) 1 (2%) 0
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 requirementsBetter preservation of KPS
RADIOSURGERY ALONE WITH WBRT ON RELAPSE?
Many patients may be spared toxicity of WBRTAllows rapid introduction of systemic therapy or treatment of primaryDelays use of WBRT so late effects less of an issueConcern would be the more rapid development of other brain mets and a possible adverse effect on neurological function / performance status
Brain metastases
• Prognostication
•Whole Brain RadioTherapy• Surgery +/- WBRT vs. RadioSurgery +/- WBRT• Dexamethasone – when and when not
Prophylactic WBRT
• Accelerates cognitive impairment
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
SRS NOW FUNDED BY NHS ENGLAND
Approval from both site-specific and CNS MDTKPS ≥ 70Diagnosis of cancer establishedPrimary absent or controllablePressure symptoms best relieved by surgery excludedTotal volume < 20 cm3
Patient’s life expectancy from extracranial disease is expected to be greater than 6 months
Brain metastases
• Prognostication
•Whole Brain RadioTherapy• Surgery +/- WBRT vs. RadioSurgery +/- WBRT• Dexamethasone – when and when not
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
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
2nd Case
• 67 female odynophagia and dysphagia (Riddlesden)• 15/10/13 CT T3 N0 Junctional adenoca oes• 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
• 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
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
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
Intraluminal brachytherapy
Good for• Slow/oozing bleeding• Maintaining your patient’s
swallow
Not worth doing if
• Complete obstruction• If cancer involves airway – RT
will result in fistulation (CI)
Signs of complete upper GI obstruction?
Fistula: “ an abnormal connection or passageway between two epithelium-
lined organs or vessels”
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
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
• “Clin oncs/RT will make things worse before they get better…”
• In the immediate days– Inflammation:
Diarrhoea, cystitis, sacral neuropathy
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