Radiation Therapy/Immunutherapy Flashcards
Clinical situation where hypo-fractionated RT is preferred over Single-fraction XRT?
Radiation to lesion at base of tongue
Hypo-fractionated (more frequent, lower dose) sessions (usually 5-14 sessions) can be helpful, need to carefully monitor for mucositis, thrush, dry mouth, dental disease)
Which is more likely to require re-treatment for pain control- single fraction. or hypo-fractionated radiation, for pain control related to metastasis for pain?
SINGLE fraction- more likely to need re treatment (20% vs 8% for hypo-fractionated)
Typical course of palliative XRT in terms of Gy and Fractions?
Gy of 8-30 in 1-10 fractions
8 Gy in 1 fraction provides EQUIVALENT PAIN RELIEF for bone mets as does 30 Gy in 10 fractions
Single dose MORE likely to need re-treatment
When to use palliative isotopes (Sr, Ra)?
1) Only impact pain related to bone mets (not nerve root pain)
2) Useful for WIDESPREAD mets in patients with prognosis of many months/decent PS
3) SE include myelosuppression, need to monitor renal function
About the same cost as single fraction of XRT (i.e. not more or less expensive)
What is an appropriate use for palliative radio-surgery (SBRT)?
Brain metastasis with “good” prognosis
Single lesion: best TX with resection and/or radio surgery
Multiple lesions: Radio surgery or whole brain RT, size MUST be < 4 CM
For “poor prognosis”–> best to do WBRT or “supportive care” alone
Examples of CTLA-4 inhibitors?
Ipilumumab
Tremelimumab
Examples of PD-1/PD-L1 inhibitors?
Nivolumab
Cemiplimab
Pembrolizumab
Atezolizumab
Avelumab
Durvalumab
Side effects more commonly seen with CTLA-4 inhibitors?
Diarrhea and colitis
Rash
Itching
LESS likely to have pneumonitis (compared to PD1/PDL1)
Side effects more commonly seen with PD-1/PD-L1 inhibitors?
Rash
Itching
Pneumonitis/cough/dyspnea
More likely to have thyroid effects (5-10%)
LESS likely to have diarrhea/colitis (compared to CTLA4)
Death risk from immunotherapy?
Overall risk is low 2-4%
Highest RISK is for myocarditis- 40-50% mortality rate but RISK of getting myocarditis is very low
Opioids that with chronic use can be immunosuppressive?
Morphine/fentanyl are worst»_space; oxycodone/tramadol> buprenorphine (weakest effect)
Chronic use for patients on immunotherapy associated with WORSE progression free survival, LOWER response rates, LOWER overall survival
Issues with steroids and immunotherapy?
Studies show that patients on equivalent of prednisone 10 mg daily or higher associated with
1) LOWER response rates to immunotherapy
2) LOWER progression free survival
3) LOWER overall survival rates
Just be CAREFUL
What % of patients on long term immunotherapy will have side effects?
40-50% will have a chronic side effect
96% of these SE’s are mild and 4% are severe
