sro tutorial palliative care 04.05.2012 palliative radiotherapy · 2018-02-22 · sro tutorial...
TRANSCRIPT
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie Inselspital
SRO Tutorial Palliative Care
04052012
Palliative Radiotherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 2
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Many thanks tohellip
bull Introduction Palliative Care
ndashKamilla Kruumlger
ndashDr Steffen Eychmuumlller Palliative care unit
bull Introduction Pain therapy
ndashPD Konrad Streitberger Pain service
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 3
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Importance of palliative radiotherapy in a radiation
oncology department
bull Importance of (palliative) radiotherapy in the treatment of
cancer patients
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 4
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radiotherapy 50 of patients
Palliative
25
curative
26
Courtesy of D Aebersold
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brainstorming
bull Differences between curative and palliative radiotherapy
bull What aspects have to be considered
bull Aimsindications of palliative radiotherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 6
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Aims
ndashReduction of existing symptoms
ndashPrevention of immanent symptoms
bull Important
bull Consider
ndashPerformance status
ndashLife expectancy
ndashToxicity
ndashDuration of palliation
bull Quality of life What is important for the patient
bull Not too long (hypofractionation) little toxicity
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Pain
ndashBone
ndashSoft tissue
bull Neurologic compression
ndashSpinal cord
ndashPeripheral nerves
ndashBrain
bull Haemorrhage
bull Symptoms caused by obstruction
ndashAirways dyspnoea
ndashSwallowing route dysphagia
ndashVenous flow superiorinferior cava syndrome
ndashUrinary tract urinary retention renal failure
bull Cosmesis odour in tumours infiltrating the skin
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 8
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Cancer J 2010
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 9
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Cancer J 2010
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 10
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Oorschot Sem Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 12
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cancer 2010
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 13
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastases
bull What tumours
bull Does RT work
bull Causal and symptomatic effect (anti-tumour anti-
inflammatory)
bull How do you treat them Why Studies on fractionation
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
RT of bone metastases -
fractionation
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lievens RO 2000
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lievens RO 2000
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 17
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Konski Semin Oncol 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Konski Semin Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 19
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Overall
response
rate
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Complete
response
rate
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 21
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Retreat
ment
rate
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 22
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull EBRT significant palliation of painful bone metastasis in
50-80 of patients complete pain relief in up to 13 of
patients (Chow JCO 2007)
bull Optimal fractionation RT technique combination with other
treatment options
bull Systematic review combined with expert opinions
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Uncomplicated bone
metastasis
Single vs multiple
fractions
bull Pain relief
equivalent
bull Long term toxicity
equivalent
bull Single fraction
optimal patient and
caregiver
convenience
bull Retreatment rate
20 vs 8
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 24
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Repeat treatment of painful spinal metastasis
bull Pain relief in 46-80
bull Cave dose to spinal cord
bull Dosefractionation unclear
bull Recommendation prospective trial
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Comparable fracture risk Chow Clin Oncol 2012
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Comparable risk of
spinal cord
compression
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SBRT of spinal metastasis
bull Mostly retrospective single-institution series
bull Recommendation prospective trial
bull Not primary treatment for spinal met causing spinal cord
compression
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 28
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 29
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
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Lutz Chow Hartsell Konski Cancer 2007
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Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
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bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
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Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
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Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 2
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Many thanks tohellip
bull Introduction Palliative Care
ndashKamilla Kruumlger
ndashDr Steffen Eychmuumlller Palliative care unit
bull Introduction Pain therapy
ndashPD Konrad Streitberger Pain service
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 3
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Importance of palliative radiotherapy in a radiation
oncology department
bull Importance of (palliative) radiotherapy in the treatment of
cancer patients
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 4
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radiotherapy 50 of patients
Palliative
25
curative
26
Courtesy of D Aebersold
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 5
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brainstorming
bull Differences between curative and palliative radiotherapy
bull What aspects have to be considered
bull Aimsindications of palliative radiotherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 6
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Aims
ndashReduction of existing symptoms
ndashPrevention of immanent symptoms
bull Important
bull Consider
ndashPerformance status
ndashLife expectancy
ndashToxicity
ndashDuration of palliation
bull Quality of life What is important for the patient
bull Not too long (hypofractionation) little toxicity
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 7
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Pain
ndashBone
ndashSoft tissue
bull Neurologic compression
ndashSpinal cord
ndashPeripheral nerves
ndashBrain
bull Haemorrhage
bull Symptoms caused by obstruction
ndashAirways dyspnoea
ndashSwallowing route dysphagia
ndashVenous flow superiorinferior cava syndrome
ndashUrinary tract urinary retention renal failure
bull Cosmesis odour in tumours infiltrating the skin
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 8
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Cancer J 2010
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 9
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Cancer J 2010
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 10
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Oorschot Sem Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 11
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 12
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cancer 2010
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 13
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastases
bull What tumours
bull Does RT work
bull Causal and symptomatic effect (anti-tumour anti-
inflammatory)
bull How do you treat them Why Studies on fractionation
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 14
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
RT of bone metastases -
fractionation
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 15
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lievens RO 2000
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 16
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lievens RO 2000
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 17
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Konski Semin Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 18
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Konski Semin Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 19
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Overall
response
rate
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 20
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Complete
response
rate
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 21
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Retreat
ment
rate
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 22
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull EBRT significant palliation of painful bone metastasis in
50-80 of patients complete pain relief in up to 13 of
patients (Chow JCO 2007)
bull Optimal fractionation RT technique combination with other
treatment options
bull Systematic review combined with expert opinions
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 23
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Uncomplicated bone
metastasis
Single vs multiple
fractions
bull Pain relief
equivalent
bull Long term toxicity
equivalent
bull Single fraction
optimal patient and
caregiver
convenience
bull Retreatment rate
20 vs 8
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 24
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Repeat treatment of painful spinal metastasis
bull Pain relief in 46-80
bull Cave dose to spinal cord
bull Dosefractionation unclear
bull Recommendation prospective trial
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 25
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Comparable fracture risk Chow Clin Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 26
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Comparable risk of
spinal cord
compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 27
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SBRT of spinal metastasis
bull Mostly retrospective single-institution series
bull Recommendation prospective trial
bull Not primary treatment for spinal met causing spinal cord
compression
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 28
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 29
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 30
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 31
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 75
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Randomisierte Studien
Homs Lancet 2004
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bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Thanks
Questions
Discussion
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References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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bull Importance of palliative radiotherapy in a radiation
oncology department
bull Importance of (palliative) radiotherapy in the treatment of
cancer patients
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radiotherapy 50 of patients
Palliative
25
curative
26
Courtesy of D Aebersold
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brainstorming
bull Differences between curative and palliative radiotherapy
bull What aspects have to be considered
bull Aimsindications of palliative radiotherapy
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Aims
ndashReduction of existing symptoms
ndashPrevention of immanent symptoms
bull Important
bull Consider
ndashPerformance status
ndashLife expectancy
ndashToxicity
ndashDuration of palliation
bull Quality of life What is important for the patient
bull Not too long (hypofractionation) little toxicity
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Pain
ndashBone
ndashSoft tissue
bull Neurologic compression
ndashSpinal cord
ndashPeripheral nerves
ndashBrain
bull Haemorrhage
bull Symptoms caused by obstruction
ndashAirways dyspnoea
ndashSwallowing route dysphagia
ndashVenous flow superiorinferior cava syndrome
ndashUrinary tract urinary retention renal failure
bull Cosmesis odour in tumours infiltrating the skin
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 8
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Lutz Cancer J 2010
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 9
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Lutz Cancer J 2010
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 10
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Van Oorschot Sem Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 11
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Cancer 2010
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Bone metastases
bull What tumours
bull Does RT work
bull Causal and symptomatic effect (anti-tumour anti-
inflammatory)
bull How do you treat them Why Studies on fractionation
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RT of bone metastases -
fractionation
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Lievens RO 2000
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Lievens RO 2000
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Konski Semin Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 18
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Konski Semin Oncol 2005
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Chow Clin Oncol 2012
Overall
response
rate
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 20
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Chow Clin Oncol 2012
Complete
response
rate
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Chow Clin Oncol 2012
Retreat
ment
rate
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull EBRT significant palliation of painful bone metastasis in
50-80 of patients complete pain relief in up to 13 of
patients (Chow JCO 2007)
bull Optimal fractionation RT technique combination with other
treatment options
bull Systematic review combined with expert opinions
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 23
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Uncomplicated bone
metastasis
Single vs multiple
fractions
bull Pain relief
equivalent
bull Long term toxicity
equivalent
bull Single fraction
optimal patient and
caregiver
convenience
bull Retreatment rate
20 vs 8
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Repeat treatment of painful spinal metastasis
bull Pain relief in 46-80
bull Cave dose to spinal cord
bull Dosefractionation unclear
bull Recommendation prospective trial
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Comparable fracture risk Chow Clin Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 26
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Comparable risk of
spinal cord
compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 27
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SBRT of spinal metastasis
bull Mostly retrospective single-institution series
bull Recommendation prospective trial
bull Not primary treatment for spinal met causing spinal cord
compression
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 28
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 29
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 30
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 31
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
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Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
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Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
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Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
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Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
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Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Radiotherapy 50 of patients
Palliative
25
curative
26
Courtesy of D Aebersold
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brainstorming
bull Differences between curative and palliative radiotherapy
bull What aspects have to be considered
bull Aimsindications of palliative radiotherapy
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Aims
ndashReduction of existing symptoms
ndashPrevention of immanent symptoms
bull Important
bull Consider
ndashPerformance status
ndashLife expectancy
ndashToxicity
ndashDuration of palliation
bull Quality of life What is important for the patient
bull Not too long (hypofractionation) little toxicity
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Pain
ndashBone
ndashSoft tissue
bull Neurologic compression
ndashSpinal cord
ndashPeripheral nerves
ndashBrain
bull Haemorrhage
bull Symptoms caused by obstruction
ndashAirways dyspnoea
ndashSwallowing route dysphagia
ndashVenous flow superiorinferior cava syndrome
ndashUrinary tract urinary retention renal failure
bull Cosmesis odour in tumours infiltrating the skin
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Lutz Cancer J 2010
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Lutz Cancer J 2010
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Van Oorschot Sem Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cancer 2010
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastases
bull What tumours
bull Does RT work
bull Causal and symptomatic effect (anti-tumour anti-
inflammatory)
bull How do you treat them Why Studies on fractionation
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
RT of bone metastases -
fractionation
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Lievens RO 2000
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Lievens RO 2000
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Konski Semin Oncol 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Konski Semin Oncol 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Overall
response
rate
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Complete
response
rate
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Retreat
ment
rate
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull EBRT significant palliation of painful bone metastasis in
50-80 of patients complete pain relief in up to 13 of
patients (Chow JCO 2007)
bull Optimal fractionation RT technique combination with other
treatment options
bull Systematic review combined with expert opinions
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 23
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Uncomplicated bone
metastasis
Single vs multiple
fractions
bull Pain relief
equivalent
bull Long term toxicity
equivalent
bull Single fraction
optimal patient and
caregiver
convenience
bull Retreatment rate
20 vs 8
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 24
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Repeat treatment of painful spinal metastasis
bull Pain relief in 46-80
bull Cave dose to spinal cord
bull Dosefractionation unclear
bull Recommendation prospective trial
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Comparable fracture risk Chow Clin Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 26
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Comparable risk of
spinal cord
compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 27
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SBRT of spinal metastasis
bull Mostly retrospective single-institution series
bull Recommendation prospective trial
bull Not primary treatment for spinal met causing spinal cord
compression
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 28
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 29
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 30
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 31
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
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Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
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Lutz
Cancer
2007
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Lutz Chow Hartsell Konski Cancer 2007
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Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
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Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Brainstorming
bull Differences between curative and palliative radiotherapy
bull What aspects have to be considered
bull Aimsindications of palliative radiotherapy
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Aims
ndashReduction of existing symptoms
ndashPrevention of immanent symptoms
bull Important
bull Consider
ndashPerformance status
ndashLife expectancy
ndashToxicity
ndashDuration of palliation
bull Quality of life What is important for the patient
bull Not too long (hypofractionation) little toxicity
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 7
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Pain
ndashBone
ndashSoft tissue
bull Neurologic compression
ndashSpinal cord
ndashPeripheral nerves
ndashBrain
bull Haemorrhage
bull Symptoms caused by obstruction
ndashAirways dyspnoea
ndashSwallowing route dysphagia
ndashVenous flow superiorinferior cava syndrome
ndashUrinary tract urinary retention renal failure
bull Cosmesis odour in tumours infiltrating the skin
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Lutz Cancer J 2010
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Lutz Cancer J 2010
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Van Oorschot Sem Oncol 2011
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Cancer 2010
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Bone metastases
bull What tumours
bull Does RT work
bull Causal and symptomatic effect (anti-tumour anti-
inflammatory)
bull How do you treat them Why Studies on fractionation
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
RT of bone metastases -
fractionation
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Lievens RO 2000
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Lievens RO 2000
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Konski Semin Oncol 2005
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Konski Semin Oncol 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Overall
response
rate
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Complete
response
rate
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Retreat
ment
rate
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull EBRT significant palliation of painful bone metastasis in
50-80 of patients complete pain relief in up to 13 of
patients (Chow JCO 2007)
bull Optimal fractionation RT technique combination with other
treatment options
bull Systematic review combined with expert opinions
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 23
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Uncomplicated bone
metastasis
Single vs multiple
fractions
bull Pain relief
equivalent
bull Long term toxicity
equivalent
bull Single fraction
optimal patient and
caregiver
convenience
bull Retreatment rate
20 vs 8
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 24
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Repeat treatment of painful spinal metastasis
bull Pain relief in 46-80
bull Cave dose to spinal cord
bull Dosefractionation unclear
bull Recommendation prospective trial
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 25
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Comparable fracture risk Chow Clin Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 26
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Comparable risk of
spinal cord
compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 27
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SBRT of spinal metastasis
bull Mostly retrospective single-institution series
bull Recommendation prospective trial
bull Not primary treatment for spinal met causing spinal cord
compression
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 28
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 29
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 30
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 31
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 6
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Aims
ndashReduction of existing symptoms
ndashPrevention of immanent symptoms
bull Important
bull Consider
ndashPerformance status
ndashLife expectancy
ndashToxicity
ndashDuration of palliation
bull Quality of life What is important for the patient
bull Not too long (hypofractionation) little toxicity
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 7
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Pain
ndashBone
ndashSoft tissue
bull Neurologic compression
ndashSpinal cord
ndashPeripheral nerves
ndashBrain
bull Haemorrhage
bull Symptoms caused by obstruction
ndashAirways dyspnoea
ndashSwallowing route dysphagia
ndashVenous flow superiorinferior cava syndrome
ndashUrinary tract urinary retention renal failure
bull Cosmesis odour in tumours infiltrating the skin
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 8
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Cancer J 2010
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 9
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Cancer J 2010
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 10
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Oorschot Sem Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 11
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 12
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cancer 2010
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 13
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastases
bull What tumours
bull Does RT work
bull Causal and symptomatic effect (anti-tumour anti-
inflammatory)
bull How do you treat them Why Studies on fractionation
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 14
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
RT of bone metastases -
fractionation
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 15
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lievens RO 2000
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 16
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lievens RO 2000
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 17
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Konski Semin Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 18
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Konski Semin Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 19
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Overall
response
rate
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 20
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Complete
response
rate
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 21
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Retreat
ment
rate
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 22
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull EBRT significant palliation of painful bone metastasis in
50-80 of patients complete pain relief in up to 13 of
patients (Chow JCO 2007)
bull Optimal fractionation RT technique combination with other
treatment options
bull Systematic review combined with expert opinions
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 23
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Uncomplicated bone
metastasis
Single vs multiple
fractions
bull Pain relief
equivalent
bull Long term toxicity
equivalent
bull Single fraction
optimal patient and
caregiver
convenience
bull Retreatment rate
20 vs 8
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 24
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Repeat treatment of painful spinal metastasis
bull Pain relief in 46-80
bull Cave dose to spinal cord
bull Dosefractionation unclear
bull Recommendation prospective trial
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 25
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Comparable fracture risk Chow Clin Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 26
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Comparable risk of
spinal cord
compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 27
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SBRT of spinal metastasis
bull Mostly retrospective single-institution series
bull Recommendation prospective trial
bull Not primary treatment for spinal met causing spinal cord
compression
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 28
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 29
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 30
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 31
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
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Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
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Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 7
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Pain
ndashBone
ndashSoft tissue
bull Neurologic compression
ndashSpinal cord
ndashPeripheral nerves
ndashBrain
bull Haemorrhage
bull Symptoms caused by obstruction
ndashAirways dyspnoea
ndashSwallowing route dysphagia
ndashVenous flow superiorinferior cava syndrome
ndashUrinary tract urinary retention renal failure
bull Cosmesis odour in tumours infiltrating the skin
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 8
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Cancer J 2010
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 9
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Cancer J 2010
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 10
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Oorschot Sem Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 11
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 12
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cancer 2010
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 13
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastases
bull What tumours
bull Does RT work
bull Causal and symptomatic effect (anti-tumour anti-
inflammatory)
bull How do you treat them Why Studies on fractionation
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 14
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
RT of bone metastases -
fractionation
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 15
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lievens RO 2000
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 16
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lievens RO 2000
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 17
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Konski Semin Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 18
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Konski Semin Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 19
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Overall
response
rate
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 20
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Complete
response
rate
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 21
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Retreat
ment
rate
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 22
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull EBRT significant palliation of painful bone metastasis in
50-80 of patients complete pain relief in up to 13 of
patients (Chow JCO 2007)
bull Optimal fractionation RT technique combination with other
treatment options
bull Systematic review combined with expert opinions
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 23
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Uncomplicated bone
metastasis
Single vs multiple
fractions
bull Pain relief
equivalent
bull Long term toxicity
equivalent
bull Single fraction
optimal patient and
caregiver
convenience
bull Retreatment rate
20 vs 8
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 24
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Repeat treatment of painful spinal metastasis
bull Pain relief in 46-80
bull Cave dose to spinal cord
bull Dosefractionation unclear
bull Recommendation prospective trial
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 25
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Comparable fracture risk Chow Clin Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 26
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Comparable risk of
spinal cord
compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 27
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SBRT of spinal metastasis
bull Mostly retrospective single-institution series
bull Recommendation prospective trial
bull Not primary treatment for spinal met causing spinal cord
compression
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 28
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 29
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 30
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 31
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Randomisierte Studien
Homs Lancet 2004
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bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
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bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Thanks
Questions
Discussion
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References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
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Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
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Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Lutz Cancer J 2010
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Lutz Cancer J 2010
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 10
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Van Oorschot Sem Oncol 2011
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Cancer 2010
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Bone metastases
bull What tumours
bull Does RT work
bull Causal and symptomatic effect (anti-tumour anti-
inflammatory)
bull How do you treat them Why Studies on fractionation
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
RT of bone metastases -
fractionation
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Lievens RO 2000
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Lievens RO 2000
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Konski Semin Oncol 2005
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Konski Semin Oncol 2005
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Chow Clin Oncol 2012
Overall
response
rate
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Chow Clin Oncol 2012
Complete
response
rate
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Chow Clin Oncol 2012
Retreat
ment
rate
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bull EBRT significant palliation of painful bone metastasis in
50-80 of patients complete pain relief in up to 13 of
patients (Chow JCO 2007)
bull Optimal fractionation RT technique combination with other
treatment options
bull Systematic review combined with expert opinions
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Uncomplicated bone
metastasis
Single vs multiple
fractions
bull Pain relief
equivalent
bull Long term toxicity
equivalent
bull Single fraction
optimal patient and
caregiver
convenience
bull Retreatment rate
20 vs 8
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Repeat treatment of painful spinal metastasis
bull Pain relief in 46-80
bull Cave dose to spinal cord
bull Dosefractionation unclear
bull Recommendation prospective trial
Lutz IJROBP 2011
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Comparable fracture risk Chow Clin Oncol 2012
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Chow Clin Oncol 2012
Comparable risk of
spinal cord
compression
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SBRT of spinal metastasis
bull Mostly retrospective single-institution series
bull Recommendation prospective trial
bull Not primary treatment for spinal met causing spinal cord
compression
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
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Lutz IJROBP 2011
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Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
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Lutz IJROBP 2011
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bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
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Lutz IJROBP 2011
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bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
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Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
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Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
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Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
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Maranzano Radiother Oncol 2009
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Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
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Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
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Rades IJROBP 2008
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Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
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Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
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Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
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Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
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Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
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Lutz
Cancer
2007
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Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
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Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
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Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
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Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
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Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Randomisierte Studien
Homs Lancet 2004
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bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Thanks
Questions
Discussion
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References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
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Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
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Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Lutz Cancer J 2010
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Van Oorschot Sem Oncol 2011
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Cancer 2010
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Bone metastases
bull What tumours
bull Does RT work
bull Causal and symptomatic effect (anti-tumour anti-
inflammatory)
bull How do you treat them Why Studies on fractionation
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RT of bone metastases -
fractionation
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Lievens RO 2000
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Lievens RO 2000
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Konski Semin Oncol 2005
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Konski Semin Oncol 2005
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Chow Clin Oncol 2012
Overall
response
rate
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Chow Clin Oncol 2012
Complete
response
rate
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Chow Clin Oncol 2012
Retreat
ment
rate
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull EBRT significant palliation of painful bone metastasis in
50-80 of patients complete pain relief in up to 13 of
patients (Chow JCO 2007)
bull Optimal fractionation RT technique combination with other
treatment options
bull Systematic review combined with expert opinions
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Uncomplicated bone
metastasis
Single vs multiple
fractions
bull Pain relief
equivalent
bull Long term toxicity
equivalent
bull Single fraction
optimal patient and
caregiver
convenience
bull Retreatment rate
20 vs 8
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Repeat treatment of painful spinal metastasis
bull Pain relief in 46-80
bull Cave dose to spinal cord
bull Dosefractionation unclear
bull Recommendation prospective trial
Lutz IJROBP 2011
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Comparable fracture risk Chow Clin Oncol 2012
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Chow Clin Oncol 2012
Comparable risk of
spinal cord
compression
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SBRT of spinal metastasis
bull Mostly retrospective single-institution series
bull Recommendation prospective trial
bull Not primary treatment for spinal met causing spinal cord
compression
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
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Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 30
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 31
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Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
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Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
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Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
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Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Van Oorschot Sem Oncol 2011
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Cancer 2010
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Bone metastases
bull What tumours
bull Does RT work
bull Causal and symptomatic effect (anti-tumour anti-
inflammatory)
bull How do you treat them Why Studies on fractionation
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
RT of bone metastases -
fractionation
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Lievens RO 2000
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Lievens RO 2000
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Konski Semin Oncol 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Konski Semin Oncol 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Overall
response
rate
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Complete
response
rate
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Retreat
ment
rate
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull EBRT significant palliation of painful bone metastasis in
50-80 of patients complete pain relief in up to 13 of
patients (Chow JCO 2007)
bull Optimal fractionation RT technique combination with other
treatment options
bull Systematic review combined with expert opinions
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 23
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Uncomplicated bone
metastasis
Single vs multiple
fractions
bull Pain relief
equivalent
bull Long term toxicity
equivalent
bull Single fraction
optimal patient and
caregiver
convenience
bull Retreatment rate
20 vs 8
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Repeat treatment of painful spinal metastasis
bull Pain relief in 46-80
bull Cave dose to spinal cord
bull Dosefractionation unclear
bull Recommendation prospective trial
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Comparable fracture risk Chow Clin Oncol 2012
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Comparable risk of
spinal cord
compression
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SBRT of spinal metastasis
bull Mostly retrospective single-institution series
bull Recommendation prospective trial
bull Not primary treatment for spinal met causing spinal cord
compression
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 28
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 30
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 31
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
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Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
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Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
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Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
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Lutz
Cancer
2007
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Lutz Chow Hartsell Konski Cancer 2007
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Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
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Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
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Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Thanks
Questions
Discussion
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References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Cancer 2010
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Bone metastases
bull What tumours
bull Does RT work
bull Causal and symptomatic effect (anti-tumour anti-
inflammatory)
bull How do you treat them Why Studies on fractionation
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RT of bone metastases -
fractionation
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Lievens RO 2000
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Lievens RO 2000
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Konski Semin Oncol 2005
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Konski Semin Oncol 2005
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Chow Clin Oncol 2012
Overall
response
rate
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Chow Clin Oncol 2012
Complete
response
rate
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Chow Clin Oncol 2012
Retreat
ment
rate
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull EBRT significant palliation of painful bone metastasis in
50-80 of patients complete pain relief in up to 13 of
patients (Chow JCO 2007)
bull Optimal fractionation RT technique combination with other
treatment options
bull Systematic review combined with expert opinions
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Uncomplicated bone
metastasis
Single vs multiple
fractions
bull Pain relief
equivalent
bull Long term toxicity
equivalent
bull Single fraction
optimal patient and
caregiver
convenience
bull Retreatment rate
20 vs 8
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Repeat treatment of painful spinal metastasis
bull Pain relief in 46-80
bull Cave dose to spinal cord
bull Dosefractionation unclear
bull Recommendation prospective trial
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Comparable fracture risk Chow Clin Oncol 2012
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Comparable risk of
spinal cord
compression
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SBRT of spinal metastasis
bull Mostly retrospective single-institution series
bull Recommendation prospective trial
bull Not primary treatment for spinal met causing spinal cord
compression
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
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Lutz IJROBP 2011
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Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 31
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Cancer 2010
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Bone metastases
bull What tumours
bull Does RT work
bull Causal and symptomatic effect (anti-tumour anti-
inflammatory)
bull How do you treat them Why Studies on fractionation
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
RT of bone metastases -
fractionation
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Lievens RO 2000
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Lievens RO 2000
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Konski Semin Oncol 2005
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Konski Semin Oncol 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Overall
response
rate
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 20
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Complete
response
rate
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 21
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Retreat
ment
rate
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 22
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull EBRT significant palliation of painful bone metastasis in
50-80 of patients complete pain relief in up to 13 of
patients (Chow JCO 2007)
bull Optimal fractionation RT technique combination with other
treatment options
bull Systematic review combined with expert opinions
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 23
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Uncomplicated bone
metastasis
Single vs multiple
fractions
bull Pain relief
equivalent
bull Long term toxicity
equivalent
bull Single fraction
optimal patient and
caregiver
convenience
bull Retreatment rate
20 vs 8
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 24
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Repeat treatment of painful spinal metastasis
bull Pain relief in 46-80
bull Cave dose to spinal cord
bull Dosefractionation unclear
bull Recommendation prospective trial
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 25
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Comparable fracture risk Chow Clin Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 26
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Comparable risk of
spinal cord
compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 27
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SBRT of spinal metastasis
bull Mostly retrospective single-institution series
bull Recommendation prospective trial
bull Not primary treatment for spinal met causing spinal cord
compression
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 28
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 29
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 30
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 31
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 13
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastases
bull What tumours
bull Does RT work
bull Causal and symptomatic effect (anti-tumour anti-
inflammatory)
bull How do you treat them Why Studies on fractionation
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 14
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
RT of bone metastases -
fractionation
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 15
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lievens RO 2000
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 16
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lievens RO 2000
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 17
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Konski Semin Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 18
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Konski Semin Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 19
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Overall
response
rate
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 20
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Complete
response
rate
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 21
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Retreat
ment
rate
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 22
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull EBRT significant palliation of painful bone metastasis in
50-80 of patients complete pain relief in up to 13 of
patients (Chow JCO 2007)
bull Optimal fractionation RT technique combination with other
treatment options
bull Systematic review combined with expert opinions
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 23
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Uncomplicated bone
metastasis
Single vs multiple
fractions
bull Pain relief
equivalent
bull Long term toxicity
equivalent
bull Single fraction
optimal patient and
caregiver
convenience
bull Retreatment rate
20 vs 8
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 24
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Repeat treatment of painful spinal metastasis
bull Pain relief in 46-80
bull Cave dose to spinal cord
bull Dosefractionation unclear
bull Recommendation prospective trial
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 25
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Comparable fracture risk Chow Clin Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 26
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Comparable risk of
spinal cord
compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 27
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SBRT of spinal metastasis
bull Mostly retrospective single-institution series
bull Recommendation prospective trial
bull Not primary treatment for spinal met causing spinal cord
compression
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 28
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 29
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 30
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 31
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 14
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
RT of bone metastases -
fractionation
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 15
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lievens RO 2000
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 16
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lievens RO 2000
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 17
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Konski Semin Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 18
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Konski Semin Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 19
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Overall
response
rate
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 20
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Complete
response
rate
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 21
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Retreat
ment
rate
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 22
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull EBRT significant palliation of painful bone metastasis in
50-80 of patients complete pain relief in up to 13 of
patients (Chow JCO 2007)
bull Optimal fractionation RT technique combination with other
treatment options
bull Systematic review combined with expert opinions
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 23
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Uncomplicated bone
metastasis
Single vs multiple
fractions
bull Pain relief
equivalent
bull Long term toxicity
equivalent
bull Single fraction
optimal patient and
caregiver
convenience
bull Retreatment rate
20 vs 8
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 24
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Repeat treatment of painful spinal metastasis
bull Pain relief in 46-80
bull Cave dose to spinal cord
bull Dosefractionation unclear
bull Recommendation prospective trial
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 25
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Comparable fracture risk Chow Clin Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 26
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Comparable risk of
spinal cord
compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 27
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SBRT of spinal metastasis
bull Mostly retrospective single-institution series
bull Recommendation prospective trial
bull Not primary treatment for spinal met causing spinal cord
compression
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 28
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 29
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 30
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 31
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 75
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 76
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Thanks
Questions
Discussion
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References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
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Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 15
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lievens RO 2000
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 16
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lievens RO 2000
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 17
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Konski Semin Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 18
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Konski Semin Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 19
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Overall
response
rate
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 20
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Complete
response
rate
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 21
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Retreat
ment
rate
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 22
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull EBRT significant palliation of painful bone metastasis in
50-80 of patients complete pain relief in up to 13 of
patients (Chow JCO 2007)
bull Optimal fractionation RT technique combination with other
treatment options
bull Systematic review combined with expert opinions
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 23
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Uncomplicated bone
metastasis
Single vs multiple
fractions
bull Pain relief
equivalent
bull Long term toxicity
equivalent
bull Single fraction
optimal patient and
caregiver
convenience
bull Retreatment rate
20 vs 8
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 24
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Repeat treatment of painful spinal metastasis
bull Pain relief in 46-80
bull Cave dose to spinal cord
bull Dosefractionation unclear
bull Recommendation prospective trial
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 25
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Comparable fracture risk Chow Clin Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 26
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Comparable risk of
spinal cord
compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 27
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SBRT of spinal metastasis
bull Mostly retrospective single-institution series
bull Recommendation prospective trial
bull Not primary treatment for spinal met causing spinal cord
compression
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 28
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 29
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 30
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 31
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
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Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
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Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
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Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Randomisierte Studien
Homs Lancet 2004
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bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
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bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
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Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Thanks
Questions
Discussion
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References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
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Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Lievens RO 2000
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Konski Semin Oncol 2005
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Konski Semin Oncol 2005
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Chow Clin Oncol 2012
Overall
response
rate
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 20
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Chow Clin Oncol 2012
Complete
response
rate
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Chow Clin Oncol 2012
Retreat
ment
rate
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull EBRT significant palliation of painful bone metastasis in
50-80 of patients complete pain relief in up to 13 of
patients (Chow JCO 2007)
bull Optimal fractionation RT technique combination with other
treatment options
bull Systematic review combined with expert opinions
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Uncomplicated bone
metastasis
Single vs multiple
fractions
bull Pain relief
equivalent
bull Long term toxicity
equivalent
bull Single fraction
optimal patient and
caregiver
convenience
bull Retreatment rate
20 vs 8
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Repeat treatment of painful spinal metastasis
bull Pain relief in 46-80
bull Cave dose to spinal cord
bull Dosefractionation unclear
bull Recommendation prospective trial
Lutz IJROBP 2011
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Comparable fracture risk Chow Clin Oncol 2012
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Chow Clin Oncol 2012
Comparable risk of
spinal cord
compression
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SBRT of spinal metastasis
bull Mostly retrospective single-institution series
bull Recommendation prospective trial
bull Not primary treatment for spinal met causing spinal cord
compression
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
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Lutz IJROBP 2011
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Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
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Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
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Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
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Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
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Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Konski Semin Oncol 2005
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Konski Semin Oncol 2005
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Chow Clin Oncol 2012
Overall
response
rate
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 20
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Complete
response
rate
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Retreat
ment
rate
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull EBRT significant palliation of painful bone metastasis in
50-80 of patients complete pain relief in up to 13 of
patients (Chow JCO 2007)
bull Optimal fractionation RT technique combination with other
treatment options
bull Systematic review combined with expert opinions
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Uncomplicated bone
metastasis
Single vs multiple
fractions
bull Pain relief
equivalent
bull Long term toxicity
equivalent
bull Single fraction
optimal patient and
caregiver
convenience
bull Retreatment rate
20 vs 8
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Repeat treatment of painful spinal metastasis
bull Pain relief in 46-80
bull Cave dose to spinal cord
bull Dosefractionation unclear
bull Recommendation prospective trial
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Comparable fracture risk Chow Clin Oncol 2012
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Chow Clin Oncol 2012
Comparable risk of
spinal cord
compression
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SBRT of spinal metastasis
bull Mostly retrospective single-institution series
bull Recommendation prospective trial
bull Not primary treatment for spinal met causing spinal cord
compression
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 30
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 31
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Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Thanks
Questions
Discussion
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References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Konski Semin Oncol 2005
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Chow Clin Oncol 2012
Overall
response
rate
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Chow Clin Oncol 2012
Complete
response
rate
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Chow Clin Oncol 2012
Retreat
ment
rate
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull EBRT significant palliation of painful bone metastasis in
50-80 of patients complete pain relief in up to 13 of
patients (Chow JCO 2007)
bull Optimal fractionation RT technique combination with other
treatment options
bull Systematic review combined with expert opinions
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Uncomplicated bone
metastasis
Single vs multiple
fractions
bull Pain relief
equivalent
bull Long term toxicity
equivalent
bull Single fraction
optimal patient and
caregiver
convenience
bull Retreatment rate
20 vs 8
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Repeat treatment of painful spinal metastasis
bull Pain relief in 46-80
bull Cave dose to spinal cord
bull Dosefractionation unclear
bull Recommendation prospective trial
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Comparable fracture risk Chow Clin Oncol 2012
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Chow Clin Oncol 2012
Comparable risk of
spinal cord
compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 27
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SBRT of spinal metastasis
bull Mostly retrospective single-institution series
bull Recommendation prospective trial
bull Not primary treatment for spinal met causing spinal cord
compression
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 30
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 31
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Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
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Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Chow Clin Oncol 2012
Overall
response
rate
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Complete
response
rate
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Retreat
ment
rate
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull EBRT significant palliation of painful bone metastasis in
50-80 of patients complete pain relief in up to 13 of
patients (Chow JCO 2007)
bull Optimal fractionation RT technique combination with other
treatment options
bull Systematic review combined with expert opinions
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 23
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Uncomplicated bone
metastasis
Single vs multiple
fractions
bull Pain relief
equivalent
bull Long term toxicity
equivalent
bull Single fraction
optimal patient and
caregiver
convenience
bull Retreatment rate
20 vs 8
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Repeat treatment of painful spinal metastasis
bull Pain relief in 46-80
bull Cave dose to spinal cord
bull Dosefractionation unclear
bull Recommendation prospective trial
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Comparable fracture risk Chow Clin Oncol 2012
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Comparable risk of
spinal cord
compression
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SBRT of spinal metastasis
bull Mostly retrospective single-institution series
bull Recommendation prospective trial
bull Not primary treatment for spinal met causing spinal cord
compression
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 30
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 31
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
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Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Chow Clin Oncol 2012
Complete
response
rate
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Chow Clin Oncol 2012
Retreat
ment
rate
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull EBRT significant palliation of painful bone metastasis in
50-80 of patients complete pain relief in up to 13 of
patients (Chow JCO 2007)
bull Optimal fractionation RT technique combination with other
treatment options
bull Systematic review combined with expert opinions
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Uncomplicated bone
metastasis
Single vs multiple
fractions
bull Pain relief
equivalent
bull Long term toxicity
equivalent
bull Single fraction
optimal patient and
caregiver
convenience
bull Retreatment rate
20 vs 8
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Repeat treatment of painful spinal metastasis
bull Pain relief in 46-80
bull Cave dose to spinal cord
bull Dosefractionation unclear
bull Recommendation prospective trial
Lutz IJROBP 2011
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Comparable fracture risk Chow Clin Oncol 2012
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Chow Clin Oncol 2012
Comparable risk of
spinal cord
compression
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SBRT of spinal metastasis
bull Mostly retrospective single-institution series
bull Recommendation prospective trial
bull Not primary treatment for spinal met causing spinal cord
compression
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
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Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 31
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
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Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
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Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
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Lutz Chow Hartsell Konski Cancer 2007
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Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Thanks
Questions
Discussion
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References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Chow Clin Oncol 2012
Retreat
ment
rate
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull EBRT significant palliation of painful bone metastasis in
50-80 of patients complete pain relief in up to 13 of
patients (Chow JCO 2007)
bull Optimal fractionation RT technique combination with other
treatment options
bull Systematic review combined with expert opinions
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Uncomplicated bone
metastasis
Single vs multiple
fractions
bull Pain relief
equivalent
bull Long term toxicity
equivalent
bull Single fraction
optimal patient and
caregiver
convenience
bull Retreatment rate
20 vs 8
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Repeat treatment of painful spinal metastasis
bull Pain relief in 46-80
bull Cave dose to spinal cord
bull Dosefractionation unclear
bull Recommendation prospective trial
Lutz IJROBP 2011
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Comparable fracture risk Chow Clin Oncol 2012
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Chow Clin Oncol 2012
Comparable risk of
spinal cord
compression
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SBRT of spinal metastasis
bull Mostly retrospective single-institution series
bull Recommendation prospective trial
bull Not primary treatment for spinal met causing spinal cord
compression
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
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Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 31
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Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
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Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
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Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
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Lutz
Cancer
2007
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Lutz Chow Hartsell Konski Cancer 2007
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Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
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Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
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Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Thanks
Questions
Discussion
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References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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bull EBRT significant palliation of painful bone metastasis in
50-80 of patients complete pain relief in up to 13 of
patients (Chow JCO 2007)
bull Optimal fractionation RT technique combination with other
treatment options
bull Systematic review combined with expert opinions
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Uncomplicated bone
metastasis
Single vs multiple
fractions
bull Pain relief
equivalent
bull Long term toxicity
equivalent
bull Single fraction
optimal patient and
caregiver
convenience
bull Retreatment rate
20 vs 8
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Repeat treatment of painful spinal metastasis
bull Pain relief in 46-80
bull Cave dose to spinal cord
bull Dosefractionation unclear
bull Recommendation prospective trial
Lutz IJROBP 2011
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Comparable fracture risk Chow Clin Oncol 2012
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Chow Clin Oncol 2012
Comparable risk of
spinal cord
compression
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SBRT of spinal metastasis
bull Mostly retrospective single-institution series
bull Recommendation prospective trial
bull Not primary treatment for spinal met causing spinal cord
compression
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
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Lutz IJROBP 2011
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Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
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Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Uncomplicated bone
metastasis
Single vs multiple
fractions
bull Pain relief
equivalent
bull Long term toxicity
equivalent
bull Single fraction
optimal patient and
caregiver
convenience
bull Retreatment rate
20 vs 8
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Repeat treatment of painful spinal metastasis
bull Pain relief in 46-80
bull Cave dose to spinal cord
bull Dosefractionation unclear
bull Recommendation prospective trial
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Comparable fracture risk Chow Clin Oncol 2012
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Chow Clin Oncol 2012
Comparable risk of
spinal cord
compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 27
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SBRT of spinal metastasis
bull Mostly retrospective single-institution series
bull Recommendation prospective trial
bull Not primary treatment for spinal met causing spinal cord
compression
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 28
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 29
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 30
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 31
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
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Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
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Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
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Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
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Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
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Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
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Lutz
Cancer
2007
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Lutz Chow Hartsell Konski Cancer 2007
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Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
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Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
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Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Repeat treatment of painful spinal metastasis
bull Pain relief in 46-80
bull Cave dose to spinal cord
bull Dosefractionation unclear
bull Recommendation prospective trial
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 25
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Comparable fracture risk Chow Clin Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 26
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Comparable risk of
spinal cord
compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 27
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SBRT of spinal metastasis
bull Mostly retrospective single-institution series
bull Recommendation prospective trial
bull Not primary treatment for spinal met causing spinal cord
compression
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 28
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 29
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 30
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 31
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
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Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
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Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
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Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
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Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
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Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
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Lutz
Cancer
2007
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Lutz Chow Hartsell Konski Cancer 2007
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Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
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Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
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Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 25
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Comparable fracture risk Chow Clin Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 26
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Chow Clin Oncol 2012
Comparable risk of
spinal cord
compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 27
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SBRT of spinal metastasis
bull Mostly retrospective single-institution series
bull Recommendation prospective trial
bull Not primary treatment for spinal met causing spinal cord
compression
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 28
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 29
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 30
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 31
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Chow Clin Oncol 2012
Comparable risk of
spinal cord
compression
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SBRT of spinal metastasis
bull Mostly retrospective single-institution series
bull Recommendation prospective trial
bull Not primary treatment for spinal met causing spinal cord
compression
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 28
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 29
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
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Maranzano Radiother Oncol 2009
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Maranzano Radiother Oncol 2009
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
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Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
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Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
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Van Lonkhuijzen
Radiother Oncol 2011
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Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
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Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
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bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
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Lutz
Cancer
2007
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Lutz Chow Hartsell Konski Cancer 2007
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Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
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Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
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Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Thanks
Questions
Discussion
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References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 27
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SBRT of spinal metastasis
bull Mostly retrospective single-institution series
bull Recommendation prospective trial
bull Not primary treatment for spinal met causing spinal cord
compression
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 28
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 29
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 30
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 31
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
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Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
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Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
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Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
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Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 28
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Radionuclides
bull Important often underused option for multifocal bone
metastasis
bull For osteoblastic metastasis
bull Based on available data do not obviate need for EBRT
bull Recommendation prospective studies on prophylactic use
of radiopharmaceuticals in patients with limited bone
metastases combination with other systemic agents
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 29
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 30
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 31
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
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Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
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Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
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Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
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Lutz
Cancer
2007
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Lutz Chow Hartsell Konski Cancer 2007
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Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 29
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 30
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 31
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
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Lutz
Cancer
2007
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Lutz Chow Hartsell Konski Cancer 2007
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 30
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Biphosphonates
bull Several prospective studies on concurrent EBRT and
biphosphonates successful pain relief promotion of re-
ossification of damaged bone acceptable risk of toxicity
bull Not shown that combination better than EBRT alone for
pain relief
bull Recommendation prospective trial on optimum RT
fractionation EBRT versus radionuclides dose and
duration of biphosphonates and scheduling
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 31
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
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Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
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Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
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Van Lonkhuijzen
Radiother Oncol 2011
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Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
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Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
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Lutz
Cancer
2007
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Lutz Chow Hartsell Konski Cancer 2007
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Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
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bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
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Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
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Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 31
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 32
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 75
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Denosumab
Lipton Curr Opp Supp Pall Care 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 33
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Lipton Curr Opp Supp
Pall Care 2011
Denosumab versus
Zoledronate
Prevention of SREs (path fracture RT or OP to bone
spinal cord compression)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 34
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 36
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Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Breast
superior
Prostate
superior
Other solid
tumors or
multiple
myeloma
non inferior
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 35
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
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Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
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Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
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Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Vertebroplastykyphoplasty
bull No prospective data to suggest
that vertkyph obviates the
need for EBRT in painful bone
met
bull Small series of patients treated
by vertkyph plus EBRT
bull Recommendation prospective
trials on patient selection
efficacy toxicity and timing of
vertkyph and RT
Lutz IJROBP 2011
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Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 37
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
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Maranzano Radiother Oncol 2009
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
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Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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bull Non inferiority study
bull 272 patients randomized
Neuropathic pain
Roos Radiother Oncol 2005
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Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
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Lutz IJROBP 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
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Maranzano Radiother Oncol 2009
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Maranzano Radiother Oncol 2009
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
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Rades IJROBP 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
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Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 38
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 39
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Roos Radiother Oncol 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
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Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
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Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
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Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 40
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Spinal cord compression
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
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Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
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Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
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Lutz
Cancer
2007
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Lutz Chow Hartsell Konski Cancer 2007
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Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
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Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 41
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
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Lutz
Cancer
2007
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Lutz Chow Hartsell Konski Cancer 2007
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Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
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Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 42
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 43
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Patchell Lancet 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 44
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 46
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Patchell Lancet 2005
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Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
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Maranzano Radiother Oncol 2009
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Maranzano Radiother Oncol 2009
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Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
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Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
RT short versus
long course
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 45
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Maranzano Radiother Oncol 2009
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Maranzano Radiother Oncol 2009
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 47
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz IJROBP 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 48
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 49
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rades IJROBP 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 50
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
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Lutz Chow Hartsell Konski Cancer 2007
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Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
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Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
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Scoccianti Radiother Oncol 2012
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
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Rades IJROBP 2008
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Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
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Scoccianti Radiother Oncol 2012
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull SRO tutorial CNS PD Dr A Pica
bull ScocciantiRicardi Radiother Oncol 2012 Review
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 51
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 75
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 76
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
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Scoccianti Radiother Oncol 2012
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemorrhage
bull Bleeding in 6-10 of patients with advanced
cancer (Pereira et al Topics in Palliative Care Vol 4 New York
Oxford University Press 2000)
bull haemoptysis
bull haematemesis
bull haematocheziamelaena
bull vaginal bleeding
bull haematuria
bull bleeding in ulcerated skin lesions
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 75
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 76
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 52
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Mechanisms of haemostatic radiotherapy
bull Sparse literature
bull Coagulation activationsup1
ndash Oxydative endothelial damage
ndash Activation of thrombocytes
ndash Activation of inflammation
bull Long term anti-angiogenetic
sup1 Hallahan et al Oncology (Huntingt) 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 75
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 76
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 53
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Prostate cancer
bull Reduction of pain and bleeding in hormone refractory
prostate cancer (Kynaston Br J Urol 1990 Kawakami Nippon
Hinyokika Gakkai Zasshi 1993 Kalapurakal Int J Radiat Oncol Biol Phys
2003)
bull 100 improvement in patients with important hematuria (Carlton J Urol 1972)
Bladder cancer (Srinivasan et al Clin Oncol (R Coll Radiol) 1994)
bull 17 Gy in 2 fractions3 days 59 clearance of hematuria
bull 45 Gy in 12 fractions26 days 16 clearance of
hematuria
bull Selection by performance status Palliation (pain and
hematuria) better with hypofractionated RT worse
survival
bull No important side effects
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
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SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 54
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung cancer
bull Control of hemoptysis in up to 80 of patients (Brundage
Can J Oncol 1996 Medical Research Council Lung Cancer Working Party
Br J Cancer 1992 Hoskin in Doyle et al Second Edition New York
Oxford University Press 1998 Langendijk Int J Radiat Oncol Biol Phys
2000)
bull Optimal dosefractionation
ndash Hypofractionated RT seems to be equally effective to multiple
fractions (Rees Clin Oncol (R Coll Radiol) 1997 Sundstrom JCO
2004 Phase III Stevens Australas Radiol 1995 Phase III studies of
the MRC (s above)
ndash 10 Gy Single fraction equally effective to multiple fractions less
toxic (Hoskin in Doyle et al Second Edition New York Oxford
University Press 1998 Medical Research Council Lung Cancer
Working Party Br J Cancer 1992)
ndash Mostly total dose of around 20 Gy (multiple fractions) or 8 Gy
single fraction recommended
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 55
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
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Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
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Ozkok Lung Cancer 2008
Endobronchial brachytherapy
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Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
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Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
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Homs Eur J CancerLancet 2004
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ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
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Randomisierte Studien
Homs Lancet 2004
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
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References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
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Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
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Scoccianti Radiother Oncol 2012
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
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Van Lonkhuijzen
Radiother Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
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Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 75
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 76
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 56
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gynaecologic tumours
bull Cf review van Lonkhuijzen Radiother Oncol 2011
bull Consider intracavitary HDR brachytherapy
Rectal cancer
bull Up to 85 control of rectal bleeding (Hoskin in Doyle et al Second Edition New York Oxford University Press 1998)
Kaposi sarcoma
bull Good palliation for pain bleeding or edema TD 15-40 Gy SD 2 Gy gt90 response 70 complete remission (Review Becker et al Onkologie 2006)
Skin tumours (Miller in Doyle Oxford Textbook of Palliative Medicine New York Oxford University Press 1993)
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 75
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 76
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 57
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duration of treatment effect
Lung cancer
bull Median duration of palliation 50 of remaining life span (30 Gy10d
27 Gy6d 17 Gy2 fract1w apart) (Medical Research Council Br J
Cancer 1991)
bull 1 fract 10 Gy vs 2 fract 85 Gy more patients need repeat RT (Medical Research Council Lung Cancer Working Party Br J Cancer 1992)
bull 417 pat need repeat RT within 3 m after 1x10 Gy (Scolaro Radiol
Med 1995)
Rec ovarian cancer
bull Median duration of palliation 4 m in 90 of patients until death (Corn Cancer 1994)
Cervical endometrial cancer
bull In 50 of patients pall Effect until death with 1-2x10 Gy
ndash Halle IJROBP 1986
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 75
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 76
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 58
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull RT effective for improvement of
ndashThoracic symptoms (haemoptysis cough thoracic pain
dyspnoea airway obstruction) (Sirzeacuten Acta Oncol 2003 and others)
ndashQOL in about 13 of patients (Langendijk IJROBP 2000)
RT schedules
bull Systematic review (Fairchild JCO 264001-4011 2008)
ndash13 randomized trials 3473 patients
ndashdifferent RT schedules
ndashAim find optimal RT schedule for maximal palliation with
minimal toxicityneed for reirradiation
Thoracic symptoms
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 75
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 76
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 59
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz
Cancer
2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 75
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 76
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 60
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lutz Chow Hartsell Konski Cancer 2007
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 75
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 76
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 61
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Haemoptysis
bull Fig2 toux
733 689
812 802
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 75
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 76
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 62
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig3 doul thor 321 279
535 482
Cough
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 75
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 76
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 63
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 4 overall symptom burden
575 519
648 638
Thoracic pain
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 75
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 76
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 64
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 5 survie 1a
Cutoff (sensitivity analysis) BED[10] 35Gy vs LD
100 162
555 609
Overall symptom burden
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 75
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 76
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 65
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Cutoff BED[10] 35Gy vs LD
265 217
Overall survival at 1y
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 75
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 76
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 66
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Fig 7 Tox dysphagie
Cutoff BED[10] 30Gy vs LD
205 149
about x 2
Toxicity (dysphagia)
Fairchild JCO 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 75
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 76
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 67
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomized trial 250 patients (Falk BMJ 2002)
bull Locally advanced non resectable NSCLC with minimal thoracic symptoms
bull Immediate vs delayed RT (at symptom onset)
bull In delayed arm 56 of patients died without RT
bull No difference in QOL odr OS
bull More acute toxicity in immediate RT arm
Randomized trial (Sundstrom Radiother Oncol 2005)
bull Advanced NSCLC
bull 2 RT schedules (5x4Gy vs 2x85 Gy) immediate RT
bull Stratification according to presenceabsence of thoracic symptoms
bull In asymptomatic patients no long term symptom control but important dysphagia
Timing
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 75
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 76
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 68
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull in 97 malignant
bull in 5-10 of lung cancer patients
bull Histology (exclude benign disease RT-chemosensible tumours
bull Generally spontanous improvement of symptoms by formation of collaterals
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 75
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 76
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 69
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Treatment
1 symptomatic
bull steroids
bull diuretics
bull Elevation of headthorax
2 causal bull chemotherapy (SCLC
lymphomas germinal tumours)
bull Endovascular stent placement
bull radiotherapy Palliative care in lung cancer ACCP
evidence- based clinical practice guidelines
(2nd edition)
Kvale Chest 2007
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 75
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 76
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 70
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
Radiotherapy
bull Mostly clinical response within 72 h
bull Complete clinical response at 2 w in 78 of patients with SCLC
and 63 of patients with NSCLC
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 75
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 76
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 71
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 75
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 76
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 72
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Rowell Clin Oncol (R Coll Radiol) 2002
Superior vena cava syndrome
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 75
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 76
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 73
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Duhamel Atlas clinique des maladies
des voies aeacuteriennes Elsevier
wwwupmccancercenterscom
Endobronchial brachytherapy
Cochrane analysis (Cardona The Cochrane
Library 2008)
bull No improved
symptom relief by
addition of
endobronchial
brachytherapy to
EBRT
bull Indicated in selected
patients pretreated
by EBRT with
central
endobronchial
obstruction
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 75
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 76
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 74
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Ozkok Lung Cancer 2008
Endobronchial brachytherapy
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 75
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 76
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 75
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Take home lung cancer
Dosefractionation
bull Minimum 10x3 Gy 5xw or equivalent
ndash better symptom control and better overall survival
ndash But more toxicity
bull Short schedule for symptom control and limited toxicity
ndashPoor performance status limited life expectancy
Timing
bull RT at the moment of symptom onset
bull No place for bdquoprophylactic palliative RTldquo according to evidence based guidelines
ndashExceptions
bull Young patient good PS aim of local control
bull Imminent symptoms (superior vena cava syndrome central airway obstruction
Rodrigues Pract Rad Oncol 2011
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 76
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 76
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 77
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 78
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Superior vena cava syndrome
bull RT effective
bull Consider stent
Endobronchial brachytherapy
bull Indicated in selected patients pretreated by EBRT with
central endobronchial obstruction
Take home lung cancer
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 79
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Diseases of the Esophagus 2005
65 patients Stent vs 3 x 7 Gy brachytherapy in 2-4 we Dysphagia ge grade 2 T4 or M1 Estimated OS gt 1 month Stent bdquoself-expandableldquo Ultraflex metal with cover Stent 10 -15 cm Brachytherapy 10 mm applicator if possible (17mm) Brachytherapy 10 mm margin craniocaudally Brachytherapy prescription depth 10 mm HRQL QLQ Nr C30
Dysphagia
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 80
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results
bull OS comparable (around 120 days)
bull 2 fistulas in stent1 in brachytherapy group
bull 1 bleeding in stent group
bull 2 perforations in brachytherapy group
bull QOL after 1 month stent = brachytherapy
bull QOL after 3 months stent = brachytherapy
bull QOL after 6 months stent worse than brachytherapy
bull More instant relief of dysphagia by stent but QOL more stable in brachytherapy
group
bull Patients with better prognosis should be treated by brachytherapy
Bergquist Diseases of the Esophagus 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 81
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 82
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash209 patients
ndashStent vs brachytherapy (SD)
ndashStent bdquoself-expandableldquo Ultraflex metal with cover
ndashBrachytherapy 1 x 12 Gy
ndashBrachytherapy prescription depth
ndashEndpoint QOL
ndashEORTC QLQ C30
Homs Eur J CancerLancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 83
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
ndash Results bull More complications in stent arm
ndash Fistula 6 vs 3
ndash Perforation 2 vs 2
ndash bleeding 14 vs 5
ndash pain3 vs 1
bull More rapid improvement of dysphagia in stent arm
bull Dysphagia score at 1 month Stent = Brachytherapy
bull Long-term relief of dysphagia better after brachytherapy
bull QOL in brachytherapy arm better
bull Costs comparable
bull Better for QOL long-term relief of dysphagia less complications brachytherapy
bull bad prognosis Stent
bull Single Dose feasible
Homs Eur J Cancer 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 84
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 85
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Randomisierte Studien
Homs Lancet 2004
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 86
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull 3x6 Gy and 2x8 Gy equally effective and toxic
IJROBP 2002
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 87
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neg prognostic factors in 607 pat
ndash Tumor length gt 10 cm
ndash Performance status
ndash Distant metastases
ndash Grade of dysphagia and tumour histology are no independant prognostic
factors
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 88
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Entscheidungshilfe
Poor prognosis consider stent
otherwise brachytherapy
Steyerberg Gastrointest Endosc 2005
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 89
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Thanks
Questions
Discussion
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 90
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
References
Palliative care
bull Nccn guidelines palliative care wwwnccnorg
bull Nccn guidelines adult cancer pain wwwnccnorg
Pall RT in general
bull Palliative radiation therapy Konski Semin Oncol 2005 32(2) 156-64
bull Too much too little or just the right amount finding the balance in palliative
radiotherapy Jones Curr Probl Cancer 2011 35 325-36
bull Palliative radiotherapy ndash new approaches Van Oorschot Sem Rad Oncol 2011 38 443-
9
bull Palliative radiotherapy tailored to life expectancy in end-stage cancer patients reality or
myth Gripp Cancer 2010 July 1 3251-6
bull Myth we can tailor palliative care to match life expectancy Reality no we canlsquot Hartsell
Cancer 2010 July 1 3078-9
bull Palliative radiotherapy ndash when is it worth it and when is it not Lutz Cancer J 2010
16(5) 473-82
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 91
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Bone metastasis
bull Palliative radiotherapy for bone metastases an ASTRO evidence-based guideline Lutz
IJROBP 2011 79 965-76
bull Update on the systematic review of palliative radiotherapy trials for bone metastases
Chow Clin Oncol (R Coll Radiol) 2012 24(2) 112-24
bull Palliative radiotherapy practice within Western European countries impact of the
radiotherapy financing system Lievens Radiother Oncol 2000 56 289-295
bull Differences in palliative radiotherapy for bone metastases within Western European
countries Lievens Radiother Oncol 2000 56(3)297-303
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 92
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Neuropathic pain
bull Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic
pain due to bone metastases (Trans-Tasman Radiation Oncology Group TROG 9605)
Roos Radiother Oncol 2005 75(1)54-63
Metastatic spinal cord compression
bull Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer a randomised trial Patchell Lancet 2005 366 643-8
bull 8 Gy single-dose radiotherapy is effective in metastatic spinal cord compression Results
of a phase III randomized multicentre Italian trial Maranzano Radiother Oncol 2009 92
174-9
bull Final results of a prospective study comparing the local control of short-course and long-
course radiotherapy for metastatic spinal cord compression Rades IJROBP 2011
79(2) 524-30
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 93
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Brain metastases
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic
brain tumors A randomized study of doses of 4 8 and 16 mg per day
bull Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy
Oncology Group (RTOG) brain metastases trials Gaspar IJROBP 1997 37(4) 745-51
bull Diagnosis-specific prognostic factors indexes and treatment outcomes for patients with
newly diagnosed brain metastases a multi-institutional analysis of 4259 patients
Sperduto IJROBP 2010 77 655-61
bull Treatment of brain metastases review of phase III randomized controlled trials
ScocciantiRicardi Radiother Oncol 2012 102 168-79
bull Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es)
an ASTRO evidence-based guideline Practical Radiation Oncology 2012 in press
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 94
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Hemorrhage
bull Palliative radiotherapy for cervical carcinoma a systematic review Van Lonkhuijzen
Radiother Oncol 98(3)287-91
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull A comparison of two radiotherapy regimens for the treatment of symptoms from
advanced bladder cancer Srinivasan Clin Oncol (R Coll Radiol) 1994 6(1)11-3
Dysphagia
bull Palliative radiation therapy for advanced gastrointestinal cancer Murakami Digestion
2008 77 Suppl 129-35
bull Stent insertion or endoluminal brachytherapy as palliation of patients with advanced
cancer of the esophagus and gastroesophageal junction Results of a randomized
prospective trial Bergquist et al Goumlteborg in Diseases of the Esophagus 2005 18
131-139
bull Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia
from oesophageal cancer multicentre randomised trial Homs Lancet 2004 264 1497-
504
bull Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer a
prognostic model to guide treatment selection Steyerberg Gastrointest Endosc 2005
62 333-40
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 95
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Lung
bull Palliative thoracic radiotherapy for lung cancer a systematic review Fairchild J Clin
Oncol 2008 26 4001-11
bull Palliative thoracic radiotherapy in lung cancer an ASTRO evidence-based clinical
practice guideline Rodrigues Practical Radiation Oncology 2011 1 60-71
bull Palliative endobronchial brachytherapy for non-small cell lung cancer (Review) Cardona
The Cochrane Collaboration 2008
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 96
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 97
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
bull Neurology 1994 Apr44(4)675-80
bull Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain
tumors a randomized study of doses of 4 8 and 16 mg per day
bull Vecht CJ Hovestadt A Verbiest HB van Vliet JJ van Putten WL
bull Source
bull Department of Neuro-Oncology Dr Daniel den Hoed Cancer Center Rotterdam The Netherlands
bull Abstract
bull The purpose of this study was to determine whether lower doses of dexamethasone for treatment of
brain tumor edema are as effective as the conventional dose of 16 mgd We consecutively executed
two double-blind randomized trials in patients with CT-proven brain metastasis and Karnofsky scores
of 80 or less In the first series we compared 8 mg dexamethasone per day versus 16 mgd in the
second series 4 mgd versus 16 mgd Standardized evaluation of quality of life and side effects took
place at days 0 7 28 and 56 We randomized a total of 96 patients and evaluated eighty-nine The
Karnofsky score improved in the 8-mg group which had improvement of 80 +- 101 (mean +- SD)
points at day 7 versus 73 +- 142 points in the 16-mg group In the second series the 4-mg group
had improvement of 67 +- 113 points at day 7 and 71 +- 182 points at day 28 versus 91 +- 124
and 56 +- 185 points in the 16-mg group Toxic effects occurred more frequently in the 16-mg group
(p lt 003) We conclude that administration of 4 mg dexamethasone per day for treatment of
brain tumor edema results in the same degree of improvement as does administration of 16
mgd after 1 week of treatment in patients who have no signs of impending herniation Toxic
effects are dose-dependent and during a 4-week period occurred more frequently in patients using
16 mgd(ABSTRACT TRUNCATED AT 250 WORDS)
Role of steroids
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 98
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Gaspar IJROBP 1997
GPA (general prognostic
assessment)
age KPS n BM
extracran dis
Sperduto IJROBP 2008
Sperduto IJROBP 2010
Prognostic indices
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 99
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
Scoccianti Radiother Oncol 2012
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 100
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 101
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 102
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 103
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 104
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 105
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie
SRO Tutorial Palliative Care ndash Palliative Radiotherapy 106
Jacqueline Vock Universitaumltsklinik fuumlr Radio-Onkologie