Palliation of Visceral Recurrences and Metastases and Treatment of Oligometastatic Disease

Question 1

Malignant Lower Airway Obstruction

What are the recommended doses/fractionation for endobronchial brachytherapy?

Answer 1

7.5 Gy x 3
or
10 Gy x 2

Question 2

Malignant Lower Airway Obstruction

What kind of compression usually benefits from endobronchial therapy?

Answer 2

intrinsic

Question 3

Malignant Lower Airway Obstruction

What are the recommended doses/fractionation for the external beam radiation therapy for extrinsic compression?

Answer 3

30-45/3/10-15
or
50-60/2/25-30

Question 4

Liver Metastases

12% to 36% of patients with few metastatic lesions and no evidence of extrahepatic metastases can be cured with ____?

Answer 4

surgical resection.

Question 5

Liver Metastases

Aside from surgery, what are other options for patients with “one or few” hepatic metastases?

Answer 5

RFA
mircowave coagulation therapy
TACE
SBRT

Question 6

Liver Metastases

What is the initial treatment for patients found to have multiple hepatic metastases?

Answer 6

chemotherapy

Question 7

Liver Metastases

RILD is treatment-limiting sequelae in RT of the liver metastases.

This toxicity becomes apparent ________ after RT.

Answer 7

1 to 3 months

Question 8

Liver Metastases

For treatment of the whole liver, the threshold for RILD is approximately __________ or __________ twice daily fractions.

Answer 8

30 Gy in 2 Gy fractions
or
33 Gy in 1.5 Gy

respectively

Question 9

Liver Metastases

What doses are associated with a 5% risk of RILD risk upon uniform irradiation of

one-third

two-third

and

whole-liver?

Answer 9

90, 47, and 31 Gy

If the effective liver volume irradiated is <25%, doses >100 Gy can be given with little risk of RILD.

Question 10

Liver Metastases

What radioactive agent is used frequently in SIRT?

The patients who received SIRT had a significantly better overall response rate, time-to-tumor progression, and overall survival.

Answer 10

Yttrium-90

Question 11

Adrenal Metastases

What is the recommended “palliative” dose using conventional AP-PA fields?

Answer 11

30 Gy in 10-12 fractions

Question 12

Splenic Metastases

Which is true regarding the treatment of splenic metastases with RT?

I. Treatment with radiation therapy can be very effective at reducing the size of the spleen and palliating the other symptoms associated with splenomegaly.

II. The doses required for palliation of symptoms are much lower than the doses typically used for palliation of other visceral metastases.

III. The response may be quite rapid, which necessitates evaluation of the field sizes on a frequent basis.

IV. The regimens frequently used include doses of 0.25 to 1 Gy given two to three times per week.

Answer 12

All

Question 13

Vaginal Bleeding

What is the initial treatment in the palliation of vaginal bleeding?

Answer 13

packing

Question 14

Vaginal Bleeding

What is the typically used dose per fraction in this setting?

Answer 14

2.5 to 4 Gy

Question 15

Vaginal Bleeding

How long does RT takes to control vaginal bleeding if given in 3 Gy/ fraction?

Answer 15

usually 2-3 treatments.

Question 16

Vaginal Bleeding

How long does RT takes to control vaginal bleeding if given in 10 Gy single fraction?

Answer 16

24 to 48 hours

Question 17

Pelvic Recurrence

There is a dose-response relationship between pelvic tumors’ responses in general and the dose of RT, hence most studies use ≥50 Gy or aa BED >40Gy10.

TRUE or FALSE?

Answer 17

True
***
Relatively high doses of radiation therapy are required for palliation of
symptoms. A review by Wong et al. showed that total dose was important in
achieving a response, with the highest responses seen in patients receiving ≥50
Gy. In their series, the patients with the best prognostic factors received higher
doses, but the dose–response relationship was still predictive of local control and
survival in a multivariate analysis. Bae et al. also found improvement in the
rate and duration of symptom control in patients who received higher doses.
They recommended a biologic effective dose >40 Gy10 when possible.

Question 18

Pelvic Recurrence

Patients who have received prior irradiation and subsequently develop locally
recurrent rectal cancer are frequently treated with surgery, chemotherapy, or a
combination of the two. However, there are circumstances in which additional
radiation therapy may be beneficial.

What is the recommended “hyperfractionated” dose if the goal of treatment is pain relief and cessation of bleeding?

Answer 18

30.6 median dose /1.2 twice daily

Question 19

Oligometastatic Liver Metastases

A multi-institutional phase I and II trial of 47 patients with one to three liver lesions (each <6 cm in size) tested dose-escalated
SBRT of 36 to 60 Gy in 3 fractions, reporting a 2-year local control of
92% for all lesions.

With a median follow-up
of 16 months, an overall survival of 20.5 months was reported, with no
documented radiation-induced liver disease and grade ≥3 toxicity of 2%.

What are their findings in the 60 Gy cohort in terms of local control?

Answer 19

Local control rates of 100% for lesions ≤3 cm and 77% for

lesions >3 cm were also achieved in the 60-Gy cohort.

Question 20

Oligometastatic Liver Metastases

More recently, Goodman et
al. evaluated the long term safety and efficacy of SBRT treatment for
oligometastatic liver disease.

They found that
local control was 94% after 33 months, and a partial or complete response was
observed in 69% of lesions treated. Grade 3 liver toxicity occurred in 5% of the
cases.

What was their dose-fractionation?

Answer 20

median dose of 54 Gy in 3 to 5 fractions.

Question 21

Oligometastatic Metastases

Oligometastatic state is a potentially curable and can be treated with definitive RT rather than a palliative intent.

TRUE or FALSE?

Answer 21

True.