Repeat radiation to spine after a gap of one year

Portal Forums Radiation Oncology Radiation for Distant Metastases Repeat radiation to spine after a gap of one year

This topic contains 17 replies, has 5 voices, and was last updated by  Apra 5 years, 3 months ago.

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July 30, 2012 at 8:45 am  #1246095    

Apra

Dear doctors or anyone in the know,

My husband was having continuos pain in the rib cage spine and upper stomach areas. Today we met the onco and he examined my husband and advised for total spine MRI. He said there is possibility of new bone mets.

I told him my husband had already received radiation to the spine when he was first diagnosed in May 2011. I wondered whether the spine could be re-radiated if the need arose. He said re radiation could be done if there was a time gap of more than a year after the last radiation. This is a medical oncologist talking. I would like to know whether this is actually true and whether this is a common practice. I mean re radiation of a previously radiated area if the time gap is sufficient.

Thank you


Husband 62 NSCLC Adenocarcinoma stage IV. Dx 5/11. Carbo/Taxol 3 rds. Carbo/alimta 6 rds. Alimta maintenance 8th rnd over in August 2012. Pet Ct 8/12 showed progression, with mild ascites. Start Tarceva Sept. 2012 100mg and then 150 mg. Radiation to spine, femur in 6/11. Radiation to bilateral lower end femur 10/11. June 2012 RT left femur, left iliac and sternum.

July 30, 2012 at 11:32 am  #1246103    
catdander forum moderator
catdander forum moderator

Hi Apra, I’ve wondered that also. While I didn’t find an answer directly relating to spinal mets I did find this. It’s specifically about chest radiation. It seems to have a lot of overlapping reasonings such as “it depends”, and what other structures are in the field, and worries about the spinal cord.

Read that and in the meantime I’ll ask Dr. Loiselle, the author, to respond directly about your question.

Is your husband receiving enough pain medication?

Hopes for the best,
Janine

http://cancergrace.org/radiation/2011/07/14/repeating-chest-rt/

July 30, 2012 at 11:50 am  #1246104    
JimC Forum Moderator
JimC Forum Moderator

Hi Apra,

From the experience I had with my wife’s spine mets, we were told that generally one wouldn’t repeat radiation to the same exact spot, since the treatment does kill cells and it’s possible to weaken the bone structure if there’s too much radiation in the same area. On the other hand, when my wife developed a spine met in a vertebra near one which had been previously radiated, the accuracy of the delivery of the radiation allowed that nearby met to be radiated. We’ll see what Dr. Loiselle has to say, but it seems like the answer is what Janine said “it depends”.

I’ll add my hopes for the best, whether that means no new mets or that if there are that they are treatable.

JimC
Forum moderator


Jul 2008 Wife Liz (51/never smoker) Dx Stage IV NSCLC EGFR exon 19
4 cycles Carbo/alimta, 65% shrinkage
Tarceva maintenance
Mar 2010 progression, added Alimta, stable
Sep 2010 multiple brain mets, WBR
Oct 2010 large pericardial effusion, tamponade
Jan 2011 progression, start abraxane
Jun 2011-New liver, brain mets, add Tarceva
Oct 2011-Dx Leptomeningeal carcinomatosis; pulsed Tarceva
At rest Nov 4 2011
Since then: http://cancergrace.org/blog/jim-and-lisa

July 30, 2012 at 12:20 pm  #1246107    

Dr Loiselle

Hi,

All correct so far. Generally it depends, often yes.

The spine consists of the bony vertebral column, the spinal cord and associated exiting nerves, discs, and supportive muscles and ligaments. All of these components of the spine generally tolerate re-irradation well, except for the spinal cord itself. The spinal cord does have increasing total dose tolerance over time, perhaps 5-10% of total dose can be fogotten after the first year. As well, “tolerance dose” is often a balance of risks and benfits. We typically keep spinal cord radiation dose to below the threshold associated with less than a 0.1% risk of spinal cord dysfunction. At times the benefits of re-irradiation merit a higher accepted risk of spinal cord dysfunction.

Thus, in order to determine if re-irradiation is possible, it depends on the extent of the disease, proximity to the spinal cord, previous radiation dose to the spinal cord and timeframe, acceptable total spinal cord dose, and potential applicability of image guided radiation techniques (such as cyberknife) which can deliver dose to tumors which are very close to, but do not touch the spinal cord.

I hope that helps.

Dr Loiselle


Chris Loiselle, MD
Radiation Oncologist
Swedish Cancer Institute

Views expressed here represent my opinion, not those of GRACE or Swedish Cancer Institute. This information does not constitute medical advice and is intended to supplement and not replace medical information provided by your doctor.

July 30, 2012 at 9:24 pm  #1246148    

Apra

Janine,

Thanks for the link. I went through it. It was very helpful.

JimC,

Your input was invaluable. Thank you. I am grateful that you continue to lend your expertise to this forum.

Dr. Loiselle,

Thank you for your prompt reply. Today we will get the results of the MRI. The last time, I.e. in June last year, he received 35 Gy in 14 fractions over two and a half weeks to D-spine, 15 Gy in 3 fractions by 3D CRT technique.

I have read on this forum about people receiving 18 fractions or 15 fractions in a single sitting. I have wondered why this is done. Why is it not done over a period of time as in our case. Could it be because time was not available as they had to start other treatment options? Or is this a standard procedure for palliative care?

I will ask the doctor about feasibility of cyber knife at this point. I truly hope this is not a recurrence but just residual disease that has not been responding to Alimta. I find that the bone lesions do not respond to pemetrexed in our case.

Thank you for your concern.


Husband 62 NSCLC Adenocarcinoma stage IV. Dx 5/11. Carbo/Taxol 3 rds. Carbo/alimta 6 rds. Alimta maintenance 8th rnd over in August 2012. Pet Ct 8/12 showed progression, with mild ascites. Start Tarceva Sept. 2012 100mg and then 150 mg. Radiation to spine, femur in 6/11. Radiation to bilateral lower end femur 10/11. June 2012 RT left femur, left iliac and sternum.

July 31, 2012 at 6:35 am  #1246163    
catdander forum moderator
catdander forum moderator

From a blog/post by Dr. West, “ Overall, multiple trials have shown that a short course of 1-5 “fractions” of radiation can achieve comparable pain control and overall results as longer courses of radiaion. There can sometimes be more side effects to surrounding tissues if a single treatment or just a few are done, so this is a particularly appealing for metastases to extremities, where internal organs are not included in the radiation field.” http://cancergrace.org/lung/2007/02/18/treating-bone-mets-focus-on-radiation/

Unless I’m mistaken Dr. West has suggested a smaller number of fractions may be decided on solely for the convenience of the patient who may live far away or otherwise couldn’t make it into the cancer center as often as a longer 3 week course.

I hope this helps,
Janine

July 31, 2012 at 10:51 am  #1246170    

Apra

Janine,

Thank you for your helpful link. The MRI showed that the spinal area did not have any new mets, only residual disease. The doctors have not decided o do irradiation at he moment.

Today he onc decided that he would drain the remaining loculated pleural effusion (which is only about 100 ml) to try and ease the pain in the rib cage as it is seen that the effusion is lying on a neve and also mutation tests would be done from this effusion.

We are going with this plan for now as we really wan to know his EGFR or Alk status as the case maybe.

I hope this plan sounds ok.


Husband 62 NSCLC Adenocarcinoma stage IV. Dx 5/11. Carbo/Taxol 3 rds. Carbo/alimta 6 rds. Alimta maintenance 8th rnd over in August 2012. Pet Ct 8/12 showed progression, with mild ascites. Start Tarceva Sept. 2012 100mg and then 150 mg. Radiation to spine, femur in 6/11. Radiation to bilateral lower end femur 10/11. June 2012 RT left femur, left iliac and sternum.

July 31, 2012 at 12:38 pm  #1246173    
catdander forum moderator
catdander forum moderator

That’s great that the MRI shows no new disease. It’s difficult to know what “residual disease” really means in bone after it’s been treated. Since the effusion is irritating a nerve it makes perfect since to alleviate the pressure on the nerve. Add to that the possibility of enough cancer cells to gain knowledge of mutations sounds very reasonable.
D has pretty bad nerve damage. From what I understand the longer the irritation/pressure on the nerve lasts the more likely it will become permanent. I hope it is relieved by this procedure.

Best of luck,
Janine

July 31, 2012 at 5:58 pm  #1246195    
Dr West
Dr West

Janine’s very right that it’s somewhere between hard and impossible to evaluate residual disease with regard to bone lesions.

Good luck with obtaining results on molecular marker studies from the pleural fluid. It’s easier with larger volumes, so it may be challenging to obtain enough cells to do this testing from just a small, loculated effusion — and 100 ml is definitely a rather small effusion.

-Dr. West

August 1, 2012 at 6:42 am  #1246213    

Apra

Thank you Janine and thank you Dr. West,

One of the radiologists thought that the pain in the rib cage could be due to pressure being placed on a nerve by the loculated effusion. However when we went for the pleural fluid tapping, the Dr. Who was to do the ct guided fluid tapping also expressed reservation on whether my husband would experience any pain relief with the removal of such a small amount of fluid. However, if it is pressing down on a nerve could it be the cause of the pain?

Yes, I was also wondering about the residual disease. He already had palliative radiation to the spine and the pain had resolved totally, except now the pain is back and we are wondering whether radiation is an option.

Chemo is being held at bay waiting for the pleural tapping to be done. The radiologist says we have to wait for another couple of days because he was on acitrom, the blood thinner, so he cannot introduce a needle at this time.

You have raised a very pertinent point about the amount of pleural effusion available for conducting molecular testing. I will discuss this further with the onc. I also had some reservations on this point.

Can you tell me more about evaluating bone lesions? The exact words on the report were “residual heterogenously enhancing marrow lesions with interspersed necrotic changes are seen. Focal lesions are seen at D3 L5 & S2 not appreciated in previous study. (inadequate comparison for lesion at S2)” etc.

It is possible that lesion at S2 is a new met. If this is a new met does it mean that Alimta is not working?

Sorry for the long post. Thank you for your patient hearing.


Husband 62 NSCLC Adenocarcinoma stage IV. Dx 5/11. Carbo/Taxol 3 rds. Carbo/alimta 6 rds. Alimta maintenance 8th rnd over in August 2012. Pet Ct 8/12 showed progression, with mild ascites. Start Tarceva Sept. 2012 100mg and then 150 mg. Radiation to spine, femur in 6/11. Radiation to bilateral lower end femur 10/11. June 2012 RT left femur, left iliac and sternum.

August 1, 2012 at 8:01 am  #1246219    
catdander forum moderator
catdander forum moderator

Apra, I really think Dr. West did tell you what he could about evaluating treated bone lesions, ” it’s somewhere between hard and impossible to evaluate residual disease with regard to bone lesions.
Even if this is a new lesion, I’m sorry but the doctors can’t interpret imaging reports, the info they don’t have also needs to be taken into account. That is something your husband’s team will need to determine. It may be time for a second opinion if you are having second thoughts about his care.

If there is growth in the spine that does suggest that alimta isn’t doing what you want in that area. So yes. However, if that is true but there is no other progression and especially if the met is painful or could possibly cause fracture radiation would be highly considered. In other words, radiation is considered standard for painful mets and for mets that could cause a fracture in the bone. There is much research being done to prove or disprove that giving radiation to just one or so areas of progression can prolong life. It seems to be our first instinct to get rid of mets, I know it’s true for me. Now that it is being researched when there is just one or so areas of progression, I’d be completely inclined to speak to D’s radiation onc about this option, in or out of the trial setting.

I hope this is helpful. And remember all this I got from reading on Grace so don’t be a stranger to our archives.

Best of luck to your husband,
Janine

August 1, 2012 at 10:36 am  #1246236    

Apra

Thanks Janine,

I think the evaluation that was done to come to a conclusion of ‘residual disease’, was just to see the MRI images taken at the time of diagnosis and the images taken now, after a course of radiation, and full course of chemo plus maintenance. Maybe they just saw that the images, which was in the same place as initial image remained the same or was either bigger or smaller or regressed somewhat. If that was how the conclusion of ‘residual disease’ was reached it would certainly be questionable.

Thanks for your thought about causing fracture, I can take that up with the onc and ask for radiation if necessary.

We have already changed oncologists, so the option of changing again so soon does not exist, so I need to arm myself with more information.

I will try to get more familiar with the archives, but I do not have that much time, moreover the Internet connection in our place is not good, I can only surf and post while I am in Delhi. I am so thankful for people like you who have become fountains of information and who share their discoveries and knowledge so selflessly.

God bless you.


Husband 62 NSCLC Adenocarcinoma stage IV. Dx 5/11. Carbo/Taxol 3 rds. Carbo/alimta 6 rds. Alimta maintenance 8th rnd over in August 2012. Pet Ct 8/12 showed progression, with mild ascites. Start Tarceva Sept. 2012 100mg and then 150 mg. Radiation to spine, femur in 6/11. Radiation to bilateral lower end femur 10/11. June 2012 RT left femur, left iliac and sternum.

August 1, 2012 at 11:55 am  #1246249    
Dr West
Dr West

I’m sorry that I really don’t have any more information to offer. It’s very hard to interpret bone lesions in someone with pre-existing disease in the skeleton, and it’s all but impossible to say anything meaningful about someone in whom we don’t have the images and all of the details.

-Dr. West

August 2, 2012 at 3:50 am  #1246267    

Apra

Dr. West,

There’s nothing to be sorry about. I learned what I needed to know from this discussion. Thank you for taking the time and the interest.

Sincerely

Apra


Husband 62 NSCLC Adenocarcinoma stage IV. Dx 5/11. Carbo/Taxol 3 rds. Carbo/alimta 6 rds. Alimta maintenance 8th rnd over in August 2012. Pet Ct 8/12 showed progression, with mild ascites. Start Tarceva Sept. 2012 100mg and then 150 mg. Radiation to spine, femur in 6/11. Radiation to bilateral lower end femur 10/11. June 2012 RT left femur, left iliac and sternum.

August 2, 2012 at 5:27 am  #1246269    
catdander forum moderator
catdander forum moderator

Apra, I understand about not having a lot of time to search the site. Do what you can and we will do what we can and we’ll get you there.

August 2, 2012 at 12:54 pm  #1246289    

Apra

Thank you Janine,

Your efforts on this site have been very helpful to me and I am sure a lot of people have been blessed by the information you so meticulously search and give out. People like you have made this site special. Keep it up.


Husband 62 NSCLC Adenocarcinoma stage IV. Dx 5/11. Carbo/Taxol 3 rds. Carbo/alimta 6 rds. Alimta maintenance 8th rnd over in August 2012. Pet Ct 8/12 showed progression, with mild ascites. Start Tarceva Sept. 2012 100mg and then 150 mg. Radiation to spine, femur in 6/11. Radiation to bilateral lower end femur 10/11. June 2012 RT left femur, left iliac and sternum.

August 3, 2012 at 7:39 am  #1246307    
catdander forum moderator
catdander forum moderator

Thank you Apra, It’s good to know my efforts have an impact. For full disclosure you should know that I have recently been given a paid position as moderator. It doesn’t cover all my time here but it sure makes a difference for me. I think too the changes that have been so difficult are now paying dividends.

August 3, 2012 at 10:54 am  #1246309    

Apra

Janine, congratulations, you deserve it.

An update on my husband’s treatment plan. They gave up the idea of tapping the pleural fluid. The onc says as his pain does not seem to be emanating from the lung area there is no point in making him go through the stress! All this after we had paid the money, done all the tests, and was off the blood thinner.

Anyway so it’s back to routine, and he will be receiving 900mg Alimta and 400mg Zometa 2morow. Yayyy!!

The pain has been managed on Mobizox one tab once a day.

No need for radiation also as the onc does not think the lesions shown on MRI are active as the pet scan taken in May 2012 did not mention activity in the spine. So we are happy though a lot of unnecessary activities took place. Only after this infusion a pet ct scan will be taken in August.

Thanks for your inputs and concern, everyone on Grace.


Husband 62 NSCLC Adenocarcinoma stage IV. Dx 5/11. Carbo/Taxol 3 rds. Carbo/alimta 6 rds. Alimta maintenance 8th rnd over in August 2012. Pet Ct 8/12 showed progression, with mild ascites. Start Tarceva Sept. 2012 100mg and then 150 mg. Radiation to spine, femur in 6/11. Radiation to bilateral lower end femur 10/11. June 2012 RT left femur, left iliac and sternum.

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