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Palliative Radiotherapy for Locally Advanced and Metastatic NSCLC

Updated November 2013

Recommendation: 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.

Symptomatic patients

Radiation therapy can help with symptoms from local disease and metastases. In the case of spinal cord compression and brain metastases an urgent referral to radiation oncology should occour.

Examples where radiation may be useful for the treatment of symptoms due to direct extension of local disease or involvement of lymph nodes may include:

a) Atelectasis
b) Obstruction of a main stem bronchus
c) Superior vena cava obstruction
d) Hemoptysis
e) Severe Dysphagia
f) Pain

Examples where radiation may be useful for the treatment of symptoms due to metastases include:

a) Bone metastases
b) Spinal Cord Compression
c) Brain Metastases
d) Fungating Cutaneous Mass

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) A lesion occludes a significant proportion of a large bronchial lumen
b) A lesion on CT scan shows compression of the superior vena cava without clinical superior venal caval obstruction
c) A lesion near the spinal column with potential risk of spinal cord compression
d) Paraspinal mass
e) Large lytic lesion in a weight-bearing bone. Surgical consultation regarding prophylactic stabilization may be necessary as well
f) Asymptomatic multiple brain 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. Randomized 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.

Re-treatment

While palliative radiation may be repeated to an area several factors are taken into account including:

a) The location of the radiation (anatomical region and field size)
b) The dose and fractionation of radiation received
c) The time since the last radiation was given
d) The response to the prior radiation
e) The patients symptoms

Usually this is best discussed on a case by case basis.

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.

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

9. Fairchild A, Harris K, Barnes E, et. al. Palliative thoracic radiotherapy for lung cancer: a systematic review. J Clin Oncol. 2008;26(24):4001.

SOURCE: Palliative Radiotherapy for Locally Advanced and Metastatic NSCLC ( )
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