Updated February 2008 

Guideline: Palliative radiotherapy should be considered for all patients where symptomatic disease can be encompassed within a reasonable radiotherapy volume.

For patients with locally advanced lung cancer who are not eligible for radical treatment or for patients with metastatic disease with respiratory symptoms, palliative radiotherapy to the lung can improve symptoms and improve the quality of life.

Palliative radiotherapy may be given for metastatic osseous, cerebral, subcutaneous, nodal, or pulmonary metastases to improve quality of life and minimize symptoms.

Level of Evidence: I-III

Grade of Recommendation: A-B

1.	Symptomatic patients
	Urgent treatment should be considered in cases of:
	Multiple brain metastases, especially metastasis to brain stem (for small solitary brain metastasis as the only site of relapse, surgical excision followed by radiotherapy may be considered).
	Spinal cord compression
	Brachial-plexopathy
	Radiculopathy
	Metastasis to orbital region
	Skull base metastasis with cranial nerve involvement
	Obstruction of a main stem bronchus
	Acute atelectasis
	Superior vena cava obstruction
	Severe hemoptysis
	Severe dysphagia
	Severe pain
	Fungating cutaneous mass
2.	Palliative radiotherapy may be helpful in symptomatic management of locally advanced disease causing:
	Chest pain
	Cough
	Hemoptysis
	Dyspnea
3.	Asymptomatic patients
	Some patients with advanced lung cancer are asymptomatic or have only mild symptoms. However, palliative radiotherapy should be considered in cases if:
	A lesion occludes a significant proportion of a large bronchial lumen
	A lesion on CT scan shows compression of the superior vena cava without clinical superior venal caval obstruction
	A lesion near the spinal column with potential risk of spinal cord compression
	Paraspinal mass
	Large lytic lesion in a weight-bearing bone. Surgical consultation regarding prophylactic stabilization may be necessary as well
	Asymptomatic multiple brain metastasis
4.	Palliative chest radiation usually has no role in managing:
	Pleural effusion
	Pericardial effusion
	Lymphangitic carcinomatosis
	Extensive pleural deposits.
	Paraneoplastic syndrome
	Widespread intrapulmonary metastasis
	Carcinomatous leptomeningeal metastasis
	Liver metastasis

Duration of Palliative Radiotherapy

In general, a short course of treatment will be given, in most situations one to ten sessions of radiation given over a period of one-two weeks. Randomised trials have shown that prolonged palliative fractionation schedules for thoracic radiotherapy can improve disease-free survival for patients with locally advanced lung cancer, when compared to shorter fractionation schemes. For intraluminal brachytherapy, the whole treatment, including bronchoscopy and insertion of catheter, takes approximately one hour and usually one treatment is given at any one point of time.

In general, palliative radiation is not repeated to the same site of the lung within 4 months of a previous course of radiotherapy in view of the potentially high toxicity of re-treatment. Re-treatment after 4 months depends on the individual circumstances. Palliative radiation may be repeated for certain other sites, depending on the initial dose of radiotherapy given and the anatomic site involved.

Discussion with a radiation oncologist is recommended.

References:

1. Macbeth FR, Bolger JJ, Hopwood P, et al. Randomized trial of palliative two-fraction versus more intensive 13-fraction radiotherapy for patients with inoperable non-small cell lung cancer and good performance status. Medical Research Council Lung Cancer Working Party. Clin Oncol (R Coll Radiol). 1996;8(3):167-75.
2. MRC. Inoperable non-small-cell lung cancer (NSCLC): a Medical Research Council randomised trial of palliative radiotherapy with two fractions or ten fractions. Report to the Medical Research Council by its Lung Cancer Working Party. Br J Cancer. 1991 Feb;63(2):265-70
3. MRC. A Medical Research Council (MRC) randomised trial of palliative radiotherapy with two fractions or a single fraction in patients with inoperable non-small-cell lung cancer (NSCLC) and poor performance status. Medical Research Council Lung Cancer Working Party. Br J Cancer 1992;65:934-41
4. Rees GJ, Devrell CE, Barley VL, et al. Palliative radiotherapy for lung cancer: two versus five fractions. Clin Oncol (R Coll Radiol). 1997;9(2):90-5.
5. Macbeth, The Cochrane Library 2001; CD002143
6. Sundstrøm S, Bremnes R, Aasebø U, et al. Hypofractionated palliative radiotherapy (17 Gy per two fractions) in advanced non-small-cell lung carcinoma is comparable to standard fractionation for symptom control and survival: a national phase III trial. J Clin Oncol. 2004 Mar 1;22(5):801-10.
7. Senkus-Konefka E, Dziadziuszko R, Bednaruk-Młyński E, et al. A prospective, randomised study to compare two palliative radiotherapy schedules for non-small-cell lung cancer (NSCLC) Br J Cancer. 2005 Mar 28;92(6):1038-45
8. Bezjak A, Dixon P, Brundage M, et al. Randomized phase III trial of single versus fractionated thoracic radiation in the palliation of patients with lung cancer (NCIC CTG SC.15). Int J Radiat Oncol Biol Phys. 2002 Nov 1;54(3):719-28