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(BQ) Part 2 book Radiation oncology in palliative cancer care has contents: Palliative radiotherapy for gastrointestinal and colorectal cancer, genitourinary malignancies, hematologic malignancies and associated conditions, pediatric palliative radiation oncology,... and other contents.
CHAPTER 15 Palliative radiotherapy for gastrointestinal and colorectal cancer Robert Glynne-Jones, Mark Harrison Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, London, UK Introduction The aims of palliative radiation therapy (RT) are to alleviate symptoms, restore function, diminish suffering, and improve quality of life Palliative RT has been shown to be an effective and simple method of providing relatively rapid relief in both locally advanced and metastatic cancer [1,2] for symptoms of pain, bleeding, ulceration, compression, or obstruction It is accepted that the majority of patients will have a limited life span, and the duration of symptom relief may be short Box 15.1 lists the indications for use of palliative radiotherapy More than 50 years of experience means that safe doses of radiation can be delivered quickly in one or a few daily fractions Although larger fraction sizes may lead to increased late effects, this toxicity will take months or years to develop and is unlikely to prove problematic in a population with a short life span Current palliative radiotherapy regimens for colorectal and gastrointestinal cancer commonly deliver doses ranging from 8 Gy as a single fraction, 20–25 Gy in fractions, 30 Gy in 10 fractions, to 27–30 Gy in fractions over weeks (Figure 15.1) We often have insufficient information to choose the optimal regimen Very few studies have used validated endpoints for symptom relief or have included formal measures of quality of life Hence, it is probably best to tailor radiation fraction regimens and duration of treatment to the individual and their estimated survival time, although, due to their close patient contact, oncologists tend to be overly optimistic and unrealistic This chapter reviews the role of palliative radiation therapy in gastrointestinal and colorectal cancer as well as the selection of patients who are appropriate for radiotherapy Patients with advanced gastrointestinal and colorectal Radiation Oncology in Palliative Cancer Care, First Edition Edited by Stephen Lutz, Edward Chow, and Peter Hoskin © 2013 John Wiley & Sons, Ltd Published 2013 by John Wiley & Sons, Ltd 177 178 Radiation oncology in palliative cancer care Box 15.1 Symptoms commonly associated with gastrointestinal cancers • Pain • Bleeding • Dysphagia • Nausea/vomiting • Malnutrition • Deydration • Small or large bowel obstruction • Fungating or ulcerative mass cancers suffer from a range of symptoms which include bleeding, pain, and obstruction, but there are a number of challenges somewhat distinct from other malignancies Though the management of bone, cerebral, and painful metastases parallels other cancers, a significant amount of palliative treatment is aimed at preserving luminal patency Dysphagia is a uniquely distressing symptom since immediate consequences are obvious and, for those with some luminal patency, there is an obvious discomfort evident to the patient and their carers We describe the various clinical scenarios amenable to palliation by radiotherapy, as well as the commonly used doses, fractionation schemes, and techniques More conformal techniques such as stereotactic ablative radiotherapy (SART), CyberKnife, and brachytherapy are also described Finally we recommend specific studies to accumulate evidence for decisionmaking and define the optimal way to utilize radiotherapy for palliation of colorectal cancer Treatment of dysphagia Esophageal cancer generally presents at a late stage, with severe dysphagia An inability to swallow solid foods progresses to difficulty in swallowing even liquids In general, radical treatments for cure are only possible in the minority of patients, with the remainder requiring optimal palliation Early intervention to prevent obstruction is important, and palliative radiotherapy has an important role to play in this scenario Other options for management of dysphagia include stenting, laser ablation, and possibly chemotherapy, though radiotherapy has been shown to offer the best dysphagia-free survival [3] Endoscopic dilatation can be useful in the short term, but requires serial endoscopy, with a consequent risk of perforation Laser ablation using the Nd:YAG laser can be used if the tumor is exophytic and projects into the esophagus, but it is less effective for circumferential tumors, where perforation is a risk, especially in stenosing lesions where the direction of the lumen is not obvious [4] Argon plasma coagulation is an alternative and addresses tumor that is more superficial, with a lower risk of perforation • • • • • • 50 Gy/20 fractions 50 Gy/25 fractions Stent for mechanical obstruction caused by tumor Chemotherapy given in sequential or concurrent fashion Percutaneous gastric or jejunal feeding tube in patients with swallowing difficulties Laser ablation of exophytic, intraesophageal lesions Medication or nerve root injection for intractable pain Palliative care or hospice consultation Potential adjuvant treatments: Figure 15.1 Algorithm for use of palliative radiotherapy for patients with esophageal cancer 24 Gy/3 fractions 12 Gy/2 fractions 8−10 Gy/1 fraction 27 Gy/6 fractions 30 Gy/10 fractions HDR brachytherapy • Consider higher dose radiotherapy • Consider hypofractionated regimens • Consider short course radiotherapy with low side effects for symptoms • Radiotherapy to palliate symptoms and potentially prolong survival • Palliative radiotherapy for current or potential future symptoms • Supportive care alone Treatment options Prognosis >9 months Treatment options Prognosis 2–9 months Treatment options Prognosis