radiation for pituitary tumors & radiation for spinal cord compression

Guiding your journey through cancer care

RADIATION RADIATION ONCOLOGY CASE ONCOLOGY CASE

ROUNDSROUNDSDr. Vimoj J. NairDr. Vimoj J. Nair

Dept. of radiation oncologyDept. of radiation oncology

Prince Edward island cancer treatment Centre, Prince Edward island cancer treatment Centre,

CharlottetownCharlottetown


OBJECTIVEOBJECTIVE

• 2 case scenarios2 case scenarios

• A rare pituitary massA rare pituitary mass

• Spinal cord compressionSpinal cord compression


CASE 1CASE 1


CASE HISTORYCASE HISTORY

• 64 year old lady, previously worked as staffing 64 year old lady, previously worked as staffing

coordinator at Reginacoordinator at Regina

• In 2003- breast cancer stage II Post op, post In 2003- breast cancer stage II Post op, post

chemotherapy, no hormoneschemotherapy, no hormones

• IDCIDC

• In 2011- stage 1 lung cancer, post surgeryIn 2011- stage 1 lung cancer, post surgery

• Adenosquamous caAdenosquamous ca


SYMPTOM HISTORYSYMPTOM HISTORY

• Since dec 2013, headache , vision changesSince dec 2013, headache , vision changes


• IS IT A MET???IS IT A MET???

• CT SCAN Chest abd pelvis +bone scan –veCT SCAN Chest abd pelvis +bone scan –ve

• FINAL DIAGNOSISFINAL DIAGNOSIS

• Pituitary adenomaPituitary adenoma


MAY 2014MAY 2014

• Patient worsenedPatient worsened• Reduced hormone functionReduced hormone function

• Pan hypo pituitarismPan hypo pituitarism

• Reduced vision right eyeReduced vision right eye


NEURO-SURGEON NEURO-SURGEON REFERRALREFERRAL


• Unfortunately patient had injury to opthalmic artery Unfortunately patient had injury to opthalmic artery

during the procedure, lost vision in the right eye during the procedure, lost vision in the right eye

permanentlypermanently


POST OP SCANPOST OP SCAN


FINAL PATHFINAL PATH

• CARCINOMACARCINOMA• MetMet

• ? Lung versus breast? Lung versus breast

• Final report pendingFinal report pending


PITUITARY METASTASISPITUITARY METASTASIS

• 3-5% of the patients with carcinoma3-5% of the patients with carcinoma

• Females – breast; males – lungFemales – breast; males – lung

• Pituitary is intraduralPituitary is intradural


TREATMENT OPTIONSTREATMENT OPTIONS

• Surgery Surgery

• Radiation Radiation

• Chemotherapy Chemotherapy


TREATMENT PLANTREATMENT PLAN


PEICTCPEICTC

• Repeat stagingRepeat staging• CT Chest, abdomen, pelvisCT Chest, abdomen, pelvis

• Bone scanBone scan

• Final path reviewFinal path review

• ALL IMAGING = confirmed no ALL IMAGING = confirmed no other metother met• Solitary metastasis to pituitarySolitary metastasis to pituitary


RT PLANRT PLAN

• Focal VMAT IMRTFocal VMAT IMRT• 54Gy/30 fractions54Gy/30 fractions

• WBRT if future recurrence. WBRT if future recurrence.

• Conventional fractionation preferred. Conventional fractionation preferred.

• OARSOARS• Optic chiasm- need MRI to find itOptic chiasm- need MRI to find it

• Optic nervesOptic nerves

• Brain stemBrain stem

• Brain parenchymaBrain parenchyma


TREATMENT PLANNING TREATMENT PLANNING CONSIDERATIONSCONSIDERATIONS

• MRIMRI

• Small slice thickness preferredSmall slice thickness preferred

• Cuboidal sequences, zero gapCuboidal sequences, zero gap

• No tilt preferredNo tilt preferred


CASE 2CASE 2


RADIATION RADIATION ONCOLOGY ONCOLOGY

EMERGENCIESEMERGENCIESSPINAL CORD COMPRESSIONSPINAL CORD COMPRESSION


DEFINITIONDEFINITION

• ““Compression of the dural sac and its contents (spinal Compression of the dural sac and its contents (spinal

cord and/or cauda equina) by an cord and/or cauda equina) by an extraduralextradural tumour tumour

mass. mass.

• The minimum The minimum radiologicalradiological evidence for cord compression evidence for cord compression

is indentation of the theca at the level of clinical is indentation of the theca at the level of clinical

features. Clinical features include any or all of the features. Clinical features include any or all of the

following: following: pain (local or radicular), weakness, sensory pain (local or radicular), weakness, sensory

disturbance, and/or evidence of sphincter dysfunctiondisturbance, and/or evidence of sphincter dysfunction


SPINAL CORD COMPRESSIONSPINAL CORD COMPRESSION

• 5% of cancer patients develop spinal cord compression5% of cancer patients develop spinal cord compression

• ‐‐2nd most common neurologic complication after brain 2nd most common neurologic complication after brain

metsmets

• Prostate Prostate – 20%– 20%

• ‐‐Breast Breast – 20%– 20%

• ‐‐Lung Lung – 20%– 20%

• ‐‐LymphomaLymphoma, , Melanoma Melanoma and and Renal cell ca Renal cell ca – 10% – 10%

eacheach

• ‐‐Ewing and neuroblastoma in childrenEwing and neuroblastoma in children


LOCATION IN THE CORDLOCATION IN THE CORD

• 70% thoracic (12 vertebrae)70% thoracic (12 vertebrae)

• 20% lumbar (5 vertebrae )20% lumbar (5 vertebrae )

• 10% cervical (7 vertebrae)10% cervical (7 vertebrae)

• 85% are anterior85% are anterior

• vertebrae can be involved either ANT , Middle or POST vertebrae can be involved either ANT , Middle or POST

portionportion

• if 2 elements of those involved lead to destabilization if 2 elements of those involved lead to destabilization


SINS SCORE


SINS SCORESINS SCORE

• 0 to 6 denotes stability0 to 6 denotes stability

• 7 to 12 denotes 7 to 12 denotes

indeterminate (possibly indeterminate (possibly

impending) instabilityimpending) instability

• 13 to 18 denotes 13 to 18 denotes

instability. instability.

• A surgical consultation is A surgical consultation is

recommended for patients recommended for patients

with SINS scores greater with SINS scores greater

than 7.than 7.


CLINICAL PICTURECLINICAL PICTURE

• Pain – 90% (most common and earliest symptom)Pain – 90% (most common and earliest symptom)

• Weakness – 75%Weakness – 75%

• Sensory disturbances – 25%Sensory disturbances – 25%

• Gait ataxiaGait ataxia

• Autonomic dysfunction – 50%Autonomic dysfunction – 50%

• Occurs late and is unfavorableOccurs late and is unfavorable• Urinary and stool incontinence in SCCUrinary and stool incontinence in SCC

• Urinary retention but not stool incontinence in cauda Urinary retention but not stool incontinence in cauda equinaequina


WORK UP SUMMARYWORK UP SUMMARY

• Examination:Examination:

• ‐‐Neuro exam and DRENeuro exam and DRE

• Imaging:Imaging:

• Plain filmPlain film• Vertebral collapseVertebral collapse

• Erosion or loss of pedicleErosion or loss of pedicle

• Paraspinal massParaspinal mass

• ‐‐CT spineCT spine

• ‐‐CT myelogram if MRI is CT myelogram if MRI is unavailableunavailable

• MRI spine:MRI spine:

• Sensitivity, specificity and PPV of Sensitivity, specificity and PPV of 95%95%

• Do entire spine to r/o other lesionsDo entire spine to r/o other lesions


• 3 risk factors for spinal 3 risk factors for spinal

cord compressioncord compression

1.1.Back pain,Back pain,

2.2.Abnormal neurologic Abnormal neurologic

exam, exam,

3.3.Vertebral mets on X‐rayVertebral mets on X‐ray

• 1 factor >> 30% risk1 factor >> 30% risk

• 2 factors >> 60% risk2 factors >> 60% risk

• 3 factors >> 90% risk3 factors >> 90% risk


TREATMENTTREATMENT

• ‐‐CorticosteroidsCorticosteroids

• ‐‐Always started at Always started at

diagnosis , decrease diagnosis , decrease

edema and direct edema and direct

oncological effect e,g oncological effect e,g

lymphoma MM lymphoma MM

• ‐‐SurgerySurgery

• ‐‐Indications:Indications:

• Need for tissue diagnosisNeed for tissue diagnosis

• Unstable spineUnstable spine

• Previous RT precluding Previous RT precluding

further RTfurther RT

• Progression during RTProgression during RT


• ‐‐RT alone RT alone or or adjuvant RTadjuvant RT


LONG OR SHORTLONG OR SHORT

• Short and long course RT similar functional outcome and Short and long course RT similar functional outcome and

OS. OS.

• However, long course RT significantly better for PFS and However, long course RT significantly better for PFS and

LCLC

But surgery + RT is the best!!!But surgery + RT is the best!!!


CAUTION AGAINST SINGLE CAUTION AGAINST SINGLE FRACTION FOR MSCC!FRACTION FOR MSCC!

• Single fraction reasonable if poor estimated survival .Single fraction reasonable if poor estimated survival .

• But main mechanism of compression as well as RIM (radiaiton But main mechanism of compression as well as RIM (radiaiton induced myelopathy) is vascular ischemiainduced myelopathy) is vascular ischemia• For AVMs; SRS Dose as low as 8Gy produce obliteration of For AVMs; SRS Dose as low as 8Gy produce obliteration of

vessels approx 6 months or earliervessels approx 6 months or earlier

““Abbreviated schedules should be routinely Abbreviated schedules should be routinely avoided unless the patient is chemo avoided unless the patient is chemo refractory and has convincing evidence of refractory and has convincing evidence of progressive systemic disease with limited progressive systemic disease with limited expected survival.”expected survival.”


• ““AmbulatoryAmbulatory” refers to patients who are able to walk ” refers to patients who are able to walk

with or without assistance and who may be mildly with or without assistance and who may be mildly

paraparetic; paraparetic;

• ““pareticparetic” =patients who are non-ambulatory and ” =patients who are non-ambulatory and

parapareticparaparetic

• ““plegicplegic” refers to those patients who have only a flicker ” refers to those patients who have only a flicker

of or no muscle movementof or no muscle movement


• ‐‐Ambulating >> 85% retain the ability to ambulateAmbulating >> 85% retain the ability to ambulate

• ‐‐Impaired >> 33% regainImpaired >> 33% regain

• ‐‐Paraplegic >> 5% recoverParaplegic >> 5% recover


WILL I IMPROVE?WILL I IMPROVE?


PROGNOSTIC FACTORS FOR PROGNOSTIC FACTORS FOR RECOVERYRECOVERY

• Good neurologic function at the time of treatmentGood neurologic function at the time of treatment

• Slow development of symptoms (>2 wk)Slow development of symptoms (>2 wk)

• Favourable histology (lymphoma, myeloma, breast or Favourable histology (lymphoma, myeloma, breast or

prostate) vs lungprostate) vs lung


• Median OS ~3 monthsMedian OS ~3 months

• If ambulatory after treatment, median OS ~7 monthsIf ambulatory after treatment, median OS ~7 months

• If non-ambulatory after treatment, median OS ~1.5 monthsIf non-ambulatory after treatment, median OS ~1.5 months

• Approximately 30% can survive >1 yearApproximately 30% can survive >1 year


MULTI-NATIONAL; 2011MULTI-NATIONAL; 2011 PMID 20605351 -- "VALIDATION OF A SCORE -- "VALIDATION OF A SCORE PREDICTING POST-TREATMENT AMBULATORY STATUS AFTER RADIOTHERAPY PREDICTING POST-TREATMENT AMBULATORY STATUS AFTER RADIOTHERAPY

FOR METASTATIC SPINAL CORD COMPRESSION." (RADES D, INT J RADIAT FOR METASTATIC SPINAL CORD COMPRESSION." (RADES D, INT J RADIAT ONCOL BIOL PHYS. 2011 APR 1;79(5):1503-6.)ONCOL BIOL PHYS. 2011 APR 1;79(5):1503-6.)

Variable Class Points

Tumor TypeMyeloma/lymphoma

9

Breast 8

Prostate 7

Colorectal 6

SCLC 6

Renal Cell 6

Other tumors 6

NSCLC 5

Unknown Primary

5

Interval Since Tumor Dx

>15 months 8

≤15 months 6

Visceral Mets No 8

Yes 5

Motor FunctionAmbulatory, No Aid

10

Ambulatory, Aid

9

Not Ambulatory 3

Paraplegic 1

Time to Motor Deficit

>14 days 9

7-14 days 7

≤7 days 4

Prospective series

(RT alone)(n = 653)

Laminectomy plus

stabilizationfollowed by RT

(n = 63)

Group I (≤28) 10.6% 14.3%

Group II (29-37)

70.9% 83.9%

Group III (≥38) 98.5% 100%

Total 66.2% 82.5%


SBRT/IMRT??SBRT/IMRT??


• For patients with 0-4 points, For patients with 0-4 points,

• 48 Gy/16 Fr was prescribed to PTV1, 48 Gy/16 Fr was prescribed to PTV1,

• 44 Gy/16 Fr to PTV2, 44 Gy/16 Fr to PTV2,

• 40 Gy/16 Fr to PTV3. 40 Gy/16 Fr to PTV3.

• For patients with 5-8 points, For patients with 5-8 points,

• 40 Gy/8 Fr was prescribed to PTV1, 40 Gy/8 Fr was prescribed to PTV1,

• 36 Gy/8 Fr to PTV2, 36 Gy/8 Fr to PTV2,

• 32 Gy/8 Fr to PTV3.32 Gy/8 Fr to PTV3.


• : SIB-IMRT could be successfully applied to VM with : SIB-IMRT could be successfully applied to VM with

spinal cord compression in up to 4 consecutive spinal cord compression in up to 4 consecutive

vertebrae.vertebrae.

• Good ADL preservation and pain control were achieved Good ADL preservation and pain control were achieved

with acceptable toxicity.with acceptable toxicity.

• The 1-year local control rate was 84% (95% confidenceThe 1-year local control rate was 84% (95% confidence

• interval, 70%-100%). No grade≥2 neurologic toxicity interval, 70%-100%). No grade≥2 neurologic toxicity

resulting from SIB-IMRT was observedresulting from SIB-IMRT was observed


INTRA-MEDULLARY SPINAL INTRA-MEDULLARY SPINAL CORD METASTASIS (ISCM)CORD METASTASIS (ISCM)

• Rare only 1% of intra-medullary tumorsRare only 1% of intra-medullary tumors

• in ISCM in ISCM only 38% had pain (VS.only 38% had pain (VS. Back pain common in SCC Back pain common in SCC

(90%)(90%)

• High sensory deficits 79%, sphincter dysfn (60%), weakness High sensory deficits 79%, sphincter dysfn (60%), weakness

(91%)(91%)

• Synchronous brain mets in 41%- Synchronous brain mets in 41%- so do MRI brain!so do MRI brain!

• Tx Similar to SCC- surgery rareTx Similar to SCC- surgery rare

• Only 32 case of surgery reportedOnly 32 case of surgery reported

• Prompt RT + steroidsPrompt RT + steroids


FRIDAYFRIDAY SCC! SCC!


Significantly more referrals took place on Friday, 30%, 12% on Monday17% on Tuesday15% on Wednesday20% on Thursday5% on Saturday 1% on Sunday


THANK YOUTHANK YOU

21 DAYS TILL CHRISTMAS!!!

radiation for pituitary tumors & radiation for spinal cord compression

Health & Medicine

Transcript of radiation for pituitary tumors & radiation for spinal cord compression