Palliative Radiotherapy

Definition
Palliative Care Improve quality of life of patient and their families physically,
psychosocially and spiritually.
Prinicple of Palliative Care (4C)
- Centered at patient and family
- Comprehensive $
- Coordinated
- Continuous /
When do we start palliative care?
- Advanced stage of disease
- End stage of disease
- Poor performance status
Supportive Care
o Adverse effect of cancer treatment: N/V, cytopenia, mucositis
o Oncologic emergency: Brain metastasis, oozing tumor, acute spinal cord
compression, SVC obstruction
o Paraneoplastic syndrome: effusion
o Nutritional support
Palliative radiotherapy
Principle
- Not aim for curative treatment***
- Relief symptom
- Maintain quality of life
- Short term treatment
- Choose minimal side effect

Palliative Radiotherapy
Typical Problems
Brain metastasis
/ (20-40%) O Single brain metastasis ( Primary
tumor /) Solitary brain metastasis (/ Primary tumor )
Source: Lung (40-50) > Breast (15-20) > Melanoma (5-20)
Location: Cerebrum (80) > Cerebellum (15) > Brain stem (5)
Effect:
o Local effect: Peritumor edema, Brain tissue destruction, vascular compromise
o Hydrocephalus: Increase ICP
Presentation: Headache, neurological deficit, Cognitive impairment, Hemorrhage
Definite Treatment:
Whole Brain RT
Surgery
(Standard for brain
Stereotactic Radiosurgery (SRS)
metastasis)
Surgery*
Localized RT
SRS
* Surgery when:
Single, Easily accessible lesion***
Symptomatic lesion with mass effect Size > 3 cm***
Tissue diagnosis
Used to address brain metastasis
* RT when:
Brain metastasis***
/
O_ / Brain stem, basal ganglia, speech area, language area,
motor area, visual area

Palliative Radiotherapy
WHRT Dose
Indication
4 Gy x 5
Poor performance status /
3 x 10
Most common
2.5 x 15
2 x 20
Supportive Treatment
- Corticosteroids: dexamethasone 10 mg IV stat then 4-6 mg q 4-6 hr
- Anticonvulsant: Underlying epilepsy / role of propylaxis
Prognostic factor:
- poor performance status***
RPA Class
Recursive Partitioning Analysis (RPA)
Prognosis
1
KPS 70, < 65
Best
Controlled Primary tumor
No extra-cranial metastasis
2
/_ 1 3
Fair
3
KPS < 70
Worst
- old age
- multiple
- lymphoma/germ cell/ breast
- uncontrolled systematic tumor activity
- short period to develop metastasis
Bone metastasis
Characters: mostly lytic lesion by promote osteoclast
Source:
2/3 3/4 CA breast, CA prostate
Location:
Red marrow of Axial bone (70%) spine, pelvis, ribs, skull
High risk area: femoral neck, subtrochanteric region, intertrochanteric region
(10% need surgical intervention)
Assessment: Mirels score

Palliative Radiotherapy
Presentation:
o Bone pain: progressive dull aching pain at rest
o Fractures: 1% Pathological fracture
Mirels score
Score Pain
Site
Cortical destruct
1
Mild (1-3)
Upper Limb
<1/3
2
Moderate (4-6) Lower Limb
1/3-2/3
3
Severe (7-10)
Peritrochanteric >2/3
7 = need surgical intervention, 10 risk of fracture > 50%
o Cord compression: prognosis //
o Hypercalcemia: Lung > Breast > Kidney > Myeloma > Lymphoma

Appearance
Blastic
Mixed
Lytic

PTHrP -> renal absorption of Ca -> cardiac arrhythmia, renal failure (dead)
o Leuko-erythroblastic anemia: $/
_ Transfusion w
Treatment:
o Systemic treatment:
Pharmacological therapy
Chemotherapy
Hormonal therapy
Radionuclides treatment (Sr-89, Sumarium-153)***
Bisphosphonate
o Radiotherapy
Treat Cord compression 2 + 2 /
Treat Bone Pain: 1 + 1 /
__ 2 /_ 2 //
1 _ _ field size
2 _ _ field size

Palliative Radiotherapy
o Surgery: Prevent pathological fracture
Algorithm
Step 1: Spinal fracture + Poor KPS: Vertebroplasty /
- _// Step 1 Step 2:
o Poor KPS, multi-level spine lesion or below conus medullaris, chronic
paraplegia: Teletherapy /
o Impending non-vertebral pathological fracture + Good KPS: Surgical pinning +
RT
o Impending cord compression/ spinal instability (acute) + Good KPS: Sx
decompress + RT
Step 3: RT
o Multiple painful sclerotic lesion?: Redionuclide* or hemibody radiation