Radiation therapy for cancer pain management · 2015-08-11 · Far Eastern Memorial Hospital, Taiwan Department of Radiation Oncology • 47y/o, female • IDC of left breast •

Department of Radiation Oncology Far Eastern Memorial Hospital New Taipei City, Taiwan

熊佩韋亞東醫院放射腫瘤科

Radiation therapy for cancer pain management

Champ(Comprehensive and holistic management of pain) for cancer patients

Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan

Outline • Undertreatment of cancer pain • A Tailored Approach of RT for Cancer pain

• Locally advanced disease • Bone metastases • Spinal cord compression • Brain tumor

• Radiation induced pain flare • Do no harm – avoiding side effect



• Locally advanced disease • bone metastases • Spinal cord compression • Brain tumor



Palliative Care An Extra Layer of Support

• Reduces symptom burden • Reduces depression • Improves quality of life • May improve length of survival • Increases patient and family satisfaction • May decrease burnout among other providers


Prevalence of cancer pain systematic review of the past 40 years

• A major issue of healthcare systems worldwide

• Cancer pain prevalence • after curative Tx: 33% • on anticancer Tx: 59% • Metastatic/advanced/terminal : 64%

Beuken-van Everdingen et al. Ann Oncol 2007


Pain management index

Cleeland CS, et al. NEJM, 1994


Undertreatment in cancer pain prospective study

• Pain Management Index ( PMI) • 110 centers, 1801 in- and outpatients,

dvanced/metastatic solid tumors • centers specifically devoted to cancer

and/or pain management • 61% of cases, WHO-level III opioid • potentially undertreated: 25.3% (9.8%–55.3% )

Apolone G, et al. Br J Cancer 2009


Prevalence of undertreatment cancer pain

• 2014 Updated systematic review:

Greco,T. JCO. 2014



• Locally advanced disease • Bone metastases • Spinal cord compression • Brain tumor



Palliative radiotherapy 緩和性(治標性)放射線治療

腦及脊髓、骨骼、呼吸道、泌尿道等部位的轉移性癌症或局部侵犯嚴重的原發性腫瘤，常引起嚴重的疼痛、出血、阻塞等症狀，放療能迅速有效的減輕這些症狀，提高患者生活品質。


Questions to palliative RT

• The most important question: • To treat or not to treat?

(based on previous discussions about goals, priorities, prognosis...)

• If treatment is appropriate: • What dose/fractionation scheme ? • What technique ?


RT of locally advanced status


RT +/- Chemo for unresectable oral cancer

13


Tomo isodose curves NPC, cT4N3

100%

90%

80%

50%

晚期鼻咽癌的同步放化療緩解出血、頭痛等症狀 Concurrent chemoradiation(CCRT) of locally advanced NPC

14


有效改善肺上溝癌引起之肩臂疼痛 Relief of Pancoast syndrome

• Unresectable, good performance status CCRT • Poor performance status or distant mets RT+/-C/T

J Clin Oncol 2007 & 2008

Pancoast Tumor seen on MRI

http://www.nature.com/eye/

Pancoast syndrome：手臂肩膀疼痛（最常見的初發症狀），Horner's syndrome，及手部小肌肉的萎縮

Right Horner’s syndrome: ptosis, miosis , anhidrosis


Ｄ232 Ｄ103 Ｄ1

16

BioMed Research International 2013

亞東全球首例頑固性皮膚T-cell淋巴瘤的全身皮膚螺旋斷層放療

Helical Irradiation of the Total Skin (HITS)


螺旋刀放療巧妙治療頑固頭皮鱗狀細胞癌 Tomotherapy of recurrent scalp SCC

• 84 y/o, male • Recurrent squamous cell Ca • Multiple surgical excision on the scalp • Poor response to chemotherapy • Palliate tomotherapy: good response and

sparing critical organs

Courtesy of An Liu, Ph.D.


RT of Bone metastasis


C. I. Ripamonti et al. Ann Oncol 2012


Indications for surery Bone metastasis

Radiol Oncol 2009


Recommendation: All patients with painful bone metastases should be evaluated for

external beam RT ; Dose: 8-Gy in single dose [I, A]. Higher doses, protracted fractionations: for selected cases [II, B]. Stereotactic body radiosurgery: for clinical trials [V, D].

RT for painful bone metastases An ASTRO evidence-based guideline

• Pain relief : 60%–80% • Different RT regimens

• 3Gy x 10 , 4Gy x 6, 4Gy x 5, 8Gy x 1 • No significant differences: pain control and acute toxicity • Repeat treatment rate:

• 8%, fractionated RT vs 20%, 8-Gy single dose

Int J Radiat Oncol Biol Phys 2011


Uncomplicated bone metastases: painful bone metastases unassociated with impending or existing pathologic fracture or existing spinal cord or cauda equina compression.


RT of complicated bone mets • Generally use longer

dose/fractionation schemes • More bone remineralization

after longer dose/fractionation • Reirradiation: feasible with

avoiding critical organ injury


Metastatic Spinal cord compression (MSCC)


Metastatic Spinal Cord Compression

• Oncology emergency • Pain in ∼90% of patients, usually

precedes the Dx by days to months. • local (back/ neck), radicular or both.

• Positive neurologic deficits : poor prognosis

• Early diagnosis and prompt therapy are powerful predictors of outcome


Immediate steroids after Dx

• Dexamethasone, the most frequently used • Dose:

• moderate (16 mg/day) vs.high (36–96 mg/day) eventually preceded by a bolus of 10–100 mg iv

• usually tapered over 2 wks • high-dose vs moderate dose ?

• 16 mg/day more often prescription J Clin Oncol 2005


Treatment of MSCC surgery + RT or RT alone

• RT: usually the first line treatment • back pain relief: 50%–58% of cases with an

interesting rate of pain disappearing (30%–35% )

• Optimal RT schedule: remains unknown • Hypofractionated RT regimen can be considered • More protracted RT regimens (e.g. 5 × 4Gy,

10 × 3 Gy) can be used in selected patients with a long life expectancy.


Recommendations of Tx for MSCC

• Early Dx/ prompt therapy: powerful predictors of outcome [I, A]. • RT alone for the majority & surgery for selected cases [II, B]. • Hypofractionated RT regimen can be the choice [I, A], while more

protracted RT regimens can be used in selected pts with a long life expectancy [III, B].

• Prescribe dexamethasone [II, A] at a medium dose [III, B]. • Radioisotope treatment can be evaluated in selected pts with

multiple osteoblastic bone metastases (esp.breast, lung)[II, C].

Ann Oncol (2012) 23 (suppl 7)


A Score Predicting Posttreatment Ambulatory

Status in 2096 Patients Irradiated for MSCC

Rades D, Int J Radiat Oncol Biol Phys. 2008


Conclusion: • score ≤28: short course RT for palliation of pain • score 29-37: consider adding laminectomy plus stabilization to RT • score ≥38: RT alone provides excellent results

Rades D, Int J Radiat Oncol Biol Phys. 2011

Validation of a score predicting post-treatment ambulatory status after RT for MSCC: prospective trial

Post-RT ambulatory rate

6-month OS of Group I, II and III: 11.3%, 46.4%, and 92.0%


Pain flare during palliative bone RT

Cancer Progression ?

RT ?


Radiation induced pain flare A real phenomenon

• Definition: • Increase worest pain scale>=2 • increase analgesic dose>=25%

• Incidence:2%-44% (20-40%) , but small numbers

• Occurs from 1-5 days post-RT • No difference between

different RT schemes • Higher rates with SBRT

– up to 2/3 of patients ?


Prophylaxis of RT-induced pain flare May discuss dexamethasone

Double-blind randomized study,

Methylprednisolone 5 mg/kg/d infusion day before RT vs Placebo (normal saline infusion) :

• 120 patients with vertebral body metastases • All received 30 Gy in 10 fractions • Pain flare: 6.6%, methylprednisolone vs 20%, placebo

Phase II, dexamethasone 8 mg before RT (8Gy/1fx) and subsequent 3 days • Dexamethasone appears to be effective in lessening pain flare

Hird et al. Clin Oncol. 2009

Yousef et al. JPSM. 2014


Do no harm – avoiding side effect

34


Goals of palliative RT

• Rapid & durable symptom relief • Minimize side effects • Minimize treatment time

Courtesy of Joshua Jones, MD, MA


體外放射治療技術之演進

1960’ 二維定位放射治療

1980’ 三維適形放射治療

1990’ 強度調控放射治療

2000’ 影像導引放射治療

2D radiotherapy

3D conformal radiotherapy (3DCRT)

Intensity Modulated Radiotherapy (IMRT)

Image guided Radiotherapy ( IGRT)

•

高精確

•

高劑量

•

高效率

•

低損傷

螺旋刀

第一代第二代

第三代

第四代


Radiotherapy of brain mets

Stereotactic radiosurgery/radiotherapy

立體定位放射手術/立體定位放射治療 2D Whole Brain Treatment Field

Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan Tomotherapy, 18/ 16 Cyberknife, 5 / 5 Gamma Knife, 9 / 8

HDR Ir192 , 41 / 41 Linac, 132 / 74

23,000,000人 RT Devices in 74 Hospitals

250 Board Certificated Radiation Oncologists

2014年

38

直線加速器近接放療機

電腦刀加馬刀螺旋刀


缓和性 36.4% 960

2006~2014 螺旋刀治療人次

39

亞東醫院雙導航螺旋刀中心


兒童第四腦室瘤螺旋刀放射治療

T1+C 2009/3

T2 2009/3

2009/3 before Tomo

7歲, 2014/7, 64mo 2 歲, 2009/3,during RT


2009/6 1 mo post RT

第四腦室瘤治療後MRI系列變化

TIM +C

2009/8 3 mo post RT

2009/12 7 mo post RT

2013/11 54 mo post RT

2014/12/31 67 mo post RT


63歲女性停經後陰道出血及異常分泌物近3個月

膀胱

直腸

膀胱

直腸

治療前治療後

子宮

子宮

巨大子宮頸癌導航螺旋刀放療後完全消失 Tomotherapy of Bulky cervical cancer

6x4.8x5.8公分


• 48y/o, Male, NPC, cT4aN2，MO post CCRT + adjuvant PF • Distant mets ( liver and Bil pleura) 6 mo later • Tomo 36 Gy

• Decreasing tumor volume: 75% (629 ml 158 ml) • Effective pain relief • No radiation peunomiotis

導航螺旋刀有效降低鼻咽癌肋膜轉移之疼痛

Before RT: Fentanyl patch 75µg/hr Morphine 10 mg qid Diclofenac 100 mg bid Dextromethorphan 60 mg bid Neurontin® 300 mg qid

At the end of RT: Fentanyl patch 25µg/hr Meloxicam 15mg/d


• 47y/o, female • IDC of left breast • herbal medicines with PD in

2013 • cT4cN3bM1 (Rt breast,

pleura, bone), T:18cm • Denosumab, Trastuzumab

and paclitaxel since 2014/1 • PD, extensive chest wall &

skin mets

Tomotherapy 70.2Gy/39fx 4 mo post tomo Before tomo

2014/1 2014/7

導航螺旋刀安全有效地治療乳癌大範圍胸腹壁病灶及疼痛


多發性顱骨轉移之腦部迴避全顱骨螺旋刀放療 Total skull irradiation for skull mets with sparing of brain


螺旋刀放療改善骨痛但不傷害鄰近器官


螺旋刀放療改善症狀但不傷害鄰近器官


螺旋刀同次多目標放射治療

Total Metastases Irradiation (TMI) / Extended Oligometastases


Conclusion

• Be aware of issue of undertreatment • Palliative RT is safe/effective for pain • Palliative RT can tailor dose-

fractionation to individual patients • Using optimal RT technique to

minimize side effects

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Documents

Radiation therapy for cancer pain management · 2015-08-11 · Far Eastern Memorial Hospital, Taiwan Department of Radiation Oncology • 47y/o, female • IDC of left breast •