radiation therapy for cancer pain management · 2015-08-11 · far eastern memorial hospital,...
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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
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
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
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
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
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
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
Pain management index
Cleeland CS, et al. NEJM, 1994
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
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
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
Prevalence of undertreatment cancer pain
• 2014 Updated systematic review:
Greco,T. JCO. 2014
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
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
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。
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
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 ?
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
RT of locally advanced status
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
RT +/- Chemo for unresectable oral cancer
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Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
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
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Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
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
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
D232 D103 D1
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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)
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
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.
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
RT of Bone metastasis
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
C. I. Ripamonti et al. Ann Oncol 2012
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
Indications for surery Bone metastasis
Radiol Oncol 2009
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
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
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
Uncomplicated bone metastases: painful bone metastases unassociated with impending or existing pathologic fracture or existing spinal cord or cauda equina compression.
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
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
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
Metastatic Spinal cord compression (MSCC)
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
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
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
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
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
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.
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
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)
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
A Score Predicting Posttreatment Ambulatory
Status in 2096 Patients Irradiated for MSCC
Rades D, Int J Radiat Oncol Biol Phys. 2008
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
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%
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
Pain flare during palliative bone RT
Cancer Progression ?
RT ?
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
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 ?
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
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
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
Do no harm – avoiding side effect
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Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
Goals of palliative RT
• Rapid & durable symptom relief • Minimize side effects • Minimize treatment time
Courtesy of Joshua Jones, MD, MA
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
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
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
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
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直線加速器 近接放療機
電腦刀 加馬刀 螺旋刀
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
缓和性 36.4% 960
2006~2014 螺旋刀治療人次
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亞東醫院雙導航螺旋刀中心
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
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
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
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
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
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
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
• 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
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
• 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
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
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
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
螺旋刀放療改善骨痛但不傷害鄰近器官
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
螺旋刀放療改善症狀但不傷害鄰近器官
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
螺旋刀同次多目標放射治療
Total Metastases Irradiation (TMI) / Extended Oligometastases
Department of Radiation Oncology Far Eastern Memorial Hospital, Taiwan
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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