PRACTICE PATTERNS OF PALLIATIVE

RADIATION THERAPY IN PEDIATRIC

ONCOLOGY PATIENTS IN AN
INTERNATIONAL PEDIATRIC
RESEARCH CONSORTIUM

Penyaji :
dr. Ferdinand Maubere

Pembimbing :
dr. Endang Nuryadi, Sp.Onk.Rad, Ph.D
 Article Overview
Title:
Practice patterns of palliative radiation therapy in pediatric oncology patients in an
international pediatric research consortium
Free Access
First published: 11 July 2017 https://doi.org/10.1002/pbc.26589

Journal: Pediatric Blood & Cancer (Vol 64, Issue 11, November 2017)
Type: Research Article
Funding Information: Elekta Industries Scientific Grant
Conflict Of Interest:
The authors declare that there is no
conflict of interest.
Rao AD, Chen Q, Ermoian RP, et al. Practice patterns of palliative
radiation therapy in pediatric oncology patients in an international
pediatric research consortium. Pediatr Blood Cancer.
2017;64(11):10.1002/pbc.26589. doi:10.1002/pbc.26589

1. Avani Dholakia Rao
(Baltimore)
2. Qinyu Chen (Baltimore)
3. Ralph P. Ermoian (Seattle)
4. Sara R. Alcorn (Baltimore)
5. Maria Luisa S. Figueiredo
(São Paulo)
6. Michael J. Chen (São Paulo)
Authors:
7. Karin Dieckmann (Vienna)
8. Shannon M. MacDonald
(Boston)
9. Matthew M. Ladra
(Baltimore)
10. Daria Kobyzeva (Moscow)
11. Alexey V. Nechesnyuk
(Moscow)
12. Kristina Nilsson (Uppsala)
13. Eric C. Ford (Seattle)
14. Brian A. Winey (Boston)
15. Rosangela C. Villar
(São Pauloe Região)
16. Stephanie A. Terezakis
(Baltimore)
In this presentation:
1. Introduction
2. Methods and Materials
3. Results
4. Discussion
5. Key Points
Introductio
n
1/5
 Introduction

Palliative RT in Palliative RT in Children This study

Adult • Sparse data and • evaluates the
• management of consensus practice
symptoms due to • Special considerations patterns of
progressive primary in pediatric patients pediatric
or metastatic disease palliative RT
Current practices are
pain, cord compression, based on extrapolations highlight the various
intracranial symptoms, from the adult palliative indications for therapy
respiratory distress, RT literature and regimens employed
obstructive symptoms,
and superior vena cava
Regimens should be scrutinized for data can be used to identify
syndrome
their appropriateness for the opportunities for future palliative
pediatric population RT clinical trials
Methods and
Materials
2/5
 Methods and Materials

Pediatric radiation oncologists at eight international institutions with dedicated pediatric expertise:

1. Radiation Oncology and Molecular Radiation Sciences,

Johns Hopkins School of Medicine, Baltimore, MD, USA Participating International Institutions
2. Department of, University of Washington, Seattle, WA,
USA
3. Department of Radiation, Grupo de Apoio ao
Adolescente e à Criança com Câncer, São Paulo, Brazil
4. Department of Radiation Oncology, Universität Klinik
Für Strahlentherapie und Strahlenbiologie, Vienna, 7 6
Austria 5 4
5. Department of Radiation Oncology, Massachusetts 2 1
General Hospital, Boston, MA, USA
6. Department of Radiotherapy, Federal Scientific Clinical
Centre of Children's Hematology, Oncology and
Immunology, Moscow, Russia
7. Department of Oncology, Uppsala University Hospital,
Uppsala, Sweden
3, 8
8. Department of Radiation Oncology, Centro Infantil
Boldrini, São Paulo e Região, Brazil
 Methods and Materials

Pediatric radiation oncologists at eight international institutions with dedicated pediatric expertise:
1. Department of, University of Washington, Seattle, WA,
USA
2. Department of Radiation, Grupo de Apoio ao
Adolescente e à Criança com Câncer, São Paulo, Brazil • Participating institutions independently
3. Department of Radiation Oncology, Universität Klinik
Für Strahlentherapie und Strahlenbiologie, Vienna, evaluated their palliative RT practice
Austria
4. Department of Radiation Oncology, Massachusetts
General Hospital, Boston, MA, USA
patterns for pediatric patients
5. Department of Radiotherapy, Federal Scientific Clinical
Centre of Children's Hematology, Oncology and
• Six institutions completed the survey
Immunology, Moscow, Russia
6. Department of Oncology, Uppsala University Hospital, based on their internal review
Uppsala, Sweden
7. Department of Radiation Oncology, Centro Infantil • Two of the six institutions were equipped
Boldrini, São Paulo e Região, BrazilRadiation Oncology
and Molecular Radiation Sciences, Johns Hopkins with Proton RT capabilities.
School of Medicine, Baltimore, MD, USA
8. Department of Radiation Oncology, Centro Infantil
Boldrini, São Paulo e Região, Brazil
 Methods and Materials

Pediatrics + Palliative RT Palliative intent

treatment with the goal
to improve symptoms
• Age ≤21 years old
• treated from OR
January 2010 to
December 2015 to prevent impending
symptoms such as in the
case of intracranial or
Consortium participants
spine involvement
individually reviewed all
respective pediatric cases at
their institutions and identified
Patients were treated with palliative RT
specific pediatric palliative RT based on the individual practice
cases pattern of each consortium institution.

Survey
122-item survey:
• mixed rank order
• constant sum
• mixed dichotomous
• multiple choice
• open-ended questions
regarding individual
practice of palliative RT
Methods and Materials
10 subjective questions
on physician perceptions • Never • Sometimes
and attitudes regarding • Rare • Frequently
palliative RT for pediatric
patients

Descriptive statistics:
Surveys were collected • means
and coded by a single • medians
physician affiliated with • frequencies
the consortium
Calculated using
Microsoft Excel
Results
3/5
 Results
Patient Characteristics

3,225 365 patients

6 consortium
institutions pediatric specifically treated with
patients palliative intent
 Results
Palliative RT
Treatment Intent

11%
Palliative RT

Nonpalliative RT
89%

3,225 365 patients

6 consortium
institutions pediatric specifically treated with
patients palliative intent
Lesion Type Results

Lesion Type

Metastatic
54% 46%
Primary

Palliation was required due to:

metastatic disease in 196 patients (54%) primary disease in 169 patients (46%)
(range 33–81% across institutions) (range 19–67% across institutions)
 Results
Anesthesia Usage
Anesthesia

10%
No anesthesia

Anesthesia
90% required

Anesthesia was required in 38 of 365 patients (10%)

 Results
Anesthesia Usage (cont.)
Anesthesia Usage by Age

16%
≥5 years old

<5 years old

84%

Anesthesia was required in 38 of 365 patients

(10%), of which 32 (84%) were <5 years old and 6 (16%) were >5 years of age
 Results
Anatomic Sites of Palliative RT
 Anatomic Sites of Palliative RT Results

6 Anatomic site necessitating pediatric palliative RT

5

4
Institution

0 10 20 30 40 50 60 70
Other Liver Lung Brain (primary) H&N
A&P Brain (meta) Spine Nonspine bone
Anatomic site (frequencies)
 Results
Anatomic Sites of Palliative RT
9. Other - 1%
Anatomic site
2. Brain (primary) - 16%

6. Brain (meta) - 6%

35% 5. H&N - 9%
Nonspine
bone
8. Liver - 1% 7. Lung - 5%

4. Spine -12%
3. A&P - 15%

Nonspine bone Spine Brain (meta) 1. Nonspine bone - 35%

A&P H&N Brain (primary)
Lung Liver Other
 Results

Dose and fractionation

regimens based on
anatomic sites
 Results

Malignant histology of Palliative RT

Malignant histology of Palliative RT Results

6
Malignant histology
necessitating palliative radiation
5
Institution

3
Other nonbrain sarcoma Ewing sarcoma
Medulloblastoma/ependymoma Rhabdomyosarcoma
2
Leukimia/lymphoma Osteosarcoma
Neuroblastoma bone
1

0 10 20 30 40 50 60 70 80 90

Malignant histology (frequencies)

 Results
Malignant histology of
Palliative RT Malignant histology

1. Neuroblastoma – 30% Neuroblastoma

2. Ostesarcoma – 18% Osteosarcoma
3. Rhabdomyosarcoma – 12% 30% Leukimia/lymphoma
4. Leukimia/lymphoma – 12% Neuroblastoma
Rhabdomyosarcoma
5. Medulloblastoma/ependymoma Medulloblastoma/
ependymoma
– 12%
Ewing sarcoma
6. Ewing sarcoma – 8%
Other nonbrain cancer
7. Other nonbrain cancer – 8%
 Results

Common symptoms necessitating palliative RT

 Results
Symptoms necessitating palliative RT

Common symptoms necessitating palliative RT

5
Institution

3 Other Bowel obstruction

Bleeding Postop spine
2 Abdominal distention Respiratory compromise
Cord compression Intercranial symptoms
Pain
1

0 10 20 30 40 50 60 70

Symptoms (frequencies)
 Results
Common symptoms
necessitating palliative RT Symptoms

1. Pain – 43%
Pain
2. Intracranial symptoms – 23%
Intracranial symptoms
3. Respiratory compromise – 14% Cord compression
4. Cord compression – 8% 43% Respiratory compromise

5. Abdominal distention – 6% Pain Abdominal distention

Postop spine
6. Bowel obstruction – 3%
Bleeding
7. Postop spine – 2%
Bowel obstruction
8. Other – 1%
Other
9. Bleeding – 0,5%
 Results

Dose and fractionation regimens

based on
presenting symptoms
 Results

RT technique used for palliation

 Results
RT technique for Palliative
6

RT technique used for palliation

5
Institution

2 Other Proton Electron SBRT IMRT AP/PA 3D-CRT

0 20 40 60 80 100

RT technique (frequencies)
 Results

RT technique for Palliative RT technique

1. 3D-CRT – 41%
2. AP/PA – 26% 3D-CRT AP/PA

3. IMRT – 23% 41% IMRT SBRT

4. SBRT – 6% 3D-CRT Electron Proton

5. Other – 2% Other

6. Electron – 1%
7. Proton – 1%
 Results

Radiation oncologists’ conception of barriers to pediatric palliative

 Results

Radiation oncologists’ conception of barriers to pediatric palliative

1. Referring provider’s concern about toxicity of treatment - (5/6)

2. Other logistics (travel, time away from home, etc.) - (4/6)
3. Referring provider’s willingness to consider - (2/6)
4. Other provider’s awareness of RT for palliation - (2/6)
5. Anesthesia availability- (1/6)
6. Parental/patient concerns - (1/6)
7. Availability of limited RT treatment resources - (1/6)
8. Insurance authorization/health agency authorization - (1/6)
Discussions
4/5
 Discussions

Significant • Palliative RT usage (1-28%)

variability in the use
of RT as a palliative • Variety of anatomical site and histologies for palliative RT
resource • Different palliative RT regimen in consortium institutions

• Various considerations in planning the optimal dose and fractionation

Clinical
• Multifactors: histologies, patient’s life expectancy, need for durable
practice
control, site of symptomatic disease, indication for treatment,
anesthesia, patient logistics

only few retrospective studies exist to

Pediatric RT describe the clinical experience of
Consensus? palliative RT in the pediatric population
 Discussions
Palliative RT studies

Bertsch et al. 91 courses of palliative RT for pediatric cancers (12% of

(1998) the referrals)
• 93% with pain
• 72% with respiratory compromise
• 66% with intraabdominal tumors causing symptoms
• 63% with intracranial symptoms
• 55% in cord compression

Rahn et al. 45 pediatric patients treated with 83 courses of palliative RT

(2015)
• overall partial or complete response rates of 72%
 Discussions
Palliative RT studies

Bhasker et al.
(2008) 40 pediatric patients treated with palliative RT

• Regimens: 5 or 8 Gy delivered in a single fraction, or 20 Gy in 5 fractions, or 30 Gy in 10 fractions

• 60% had complete or good response

• 38% had little response
• only 1 patient had no response

Deutsch and Tersak 37 children treated with 150 courses of palliative RT

(2004)

• Neuroblastoma as the most common malignant histology

• 93% of the patients were considered to have a good clinical response, of which
40% were treated with a single fraction of RT
 Discussions
Palliative RT studies

Koontz et al. 21 patients with metastatic Ewing sarcoma

(2006)

• Palliative RT for pain to 63 metastatic sites

• Median dose of RT was 30 Gy (range 4.5 – 68.5 Gy)
• Complete response in 55%
• Partial response in 29% of the patients
• Median duration of response of 4 months Palliative RT as a technique to
improve quality of life
 Discussions
Palliative RT studies (dose–response analysis)

Caussa et al. 34 children with neuroblastoma with 69 metastatic sites

(2011) treated with palliative RT

• 84% response rate among the 19 cases of soft tissue metastases

• response rates increasing to 100% for doses >15 Gy compared to 57% with doses ≤15 Gy
• 63% response rates for 38 cases of bone metastases (median doses of 16.5 Gy)
• 44% response rates for 9 cases of central nervous system metastases (median doses of 16.9 Gy)

Paulino (2003) 29 children with 53 sites of metastatic neuroblastoma

• 77% of cases resulted in complete or partial symptom response

• sites receiving ≥20 Gy having a greater probability of achieving a complete or partial response
 Discussions

Palliative RT studies

Doses ≥20 Gy appear to be favorable for

increased response rates in palliative RT
for neuroblastoma
 Recent Palliative RT studies Discussions
Stachelek GC, Terezakis SA, Ermoian R. Palliative radiation oncology in pediatric patients. Ann Palliat Med. 2019;8(3):285-292. doi:10.21037/apm.2019.05.01
 Discussions
Recent Palliative RT studies

It remains important to counsel

patients and parents that while repeat irradiation may be
beneficial, it is not intended or expected to be curative.

Stachelek GC, Terezakis SA, Ermoian R. Palliative radiation oncology in pediatric patients.
Ann Palliat Med. 2019;8(3):285-292. doi:10.21037/apm.2019.05.01
 Discussions
Recent Palliative RT studies

Recent studies showed avorable outcomes in the pediatric population, similar to the
palliative RT in the adult oncology population.

The side effects of palliative RT in children are generally mild and manageable in both
the inpatient and outpatient setting.

Effective palliation can occasionally be achieved with as little as a single radiation

treatment

o the judicious use of palliative RT may minimize the need for narcotic medications, additional
time spent in the hospital, more invasive interventions, and disruptions to a child’s normal
routine.

Stachelek GC, Terezakis SA, Ermoian R. Palliative radiation oncology in pediatric patients.
Ann Palliat Med. 2019;8(3):285-292. doi:10.21037/apm.2019.05.01
 Discussions
Radiation oncologists’ conception of barriers to pediatric palliative

Medical multidisciplinary team Patient’s perspective

Referring provider’s concern about toxicity of Other logistics (travel, time away from home, etc.)
treatment - (5/6) (4/6)

Insurance authorization/health agency authorization

Referring provider’s willingness to consider - (2/6)
(1/6)

Other provider’s awareness of RT for palliation - (2/6)

Anesthesia availability- (1/6)

Parental/patient concerns - (1/6)

Availability of limited RT treatment resources - (1/6)

 Discussions
Pros and Cons of the study

PRO CONS
• Data variety  treatment sites, tumor types,
• Survey format  limits the ability to report
indications, dose regimens, and delivery
specific details of particular individual treatment
techniques
regimens
• Combined with subjective data of potential
• data do not attempt to assess response to
factors limiting the ability to offer palliative RT
therapy or toxicity to therapy
• As a preliminary survey of practice  starting
point for the design of future clinical trials and
consensus statements regarding the use of
pediatric palliative RT
Key Points
5/5
 Key Points
Optimal Pediatric Palliative RT

Better Palliative Outcome

Multidisciplinary
Vertical-
Horizontal Radiation Oncologist
cooperation
Referring Specialists
GP
Government, Stakeholders
Medical
Future research
Provider’s
and consensus
Knowledge of Medical
needed
Palliative RT Practitioners

Patients, Cancer Organizations

 Key Points
Optimal Pediatric Palliative RT

Multidisciplinary
Vertical-
Horizontal
cooperation

Medical
Future research
Provider’s
and consensus
Knowledge of
needed
Palliative RT
Training Multidisciplinary Research
meetings
 Key Points
Optimal Pediatric Palliative RT

Multidisciplinary, Participating International Institutions

multilevel
Vertical-Horizontal
cooperation
7 6
1 4
2 5
Future research Medical Provider’s
and consensus Knowledge of
needed Palliative RT
3, 8
 Key Points
Optimal Pediatric Palliative RT

Multidisciplinary
Vertical-
Horizontal
cooperation

Medical
Future research
Provider’s
and consensus
Knowledge of
needed
Palliative RT
 Key Points

Palliative RT in Pediatric

Palliative RT is an indispensable addition

to a comprehensive palliative care effort
for the pediatric cancer patient
 When you have
exhausted all possibilities,
remember this:
You haven’t!
- Thomas Alva Edison -

THANK