Brachial plexus dose constraints for re-irradiation

[Kroll2013]

Dear colleagues,
What is the estimated dose recuperation of he brachial plexus one year after irradiation ?
I have a pt who have recurrent lesion of the apex of the RT lung. The dose received by he brachial plexus during the first course of RT is Dmax 55Gy . He was referred back to me for progression of the apical lesion that is giving him a great amount of pain. I plan to give him 30 Gy in 10 fr . What additional dose could the brachial plexus receive ?
Tx


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[seper]

No good data for BP repair that I'm aware of. Spinal cord data was from animal model, anyway. So just like in spinal-cord re-irradiation, I consent patients for a possibility of complete loss of function.
30Gy/10 is a good palliative dose, IMHO.

 

[medgator]

The goal is to have the tumor take out the plexus before you do 😉 I would consent the pt for brachial plexopathy, loss of function with whatever you end up doing.

http://www.ncbi.nlm.nih.gov/pubmed/22658442

 

[seper]

nice paper, thanks

 

[Cancerdancer]

The goal is to have the tumor take out the plexus before you do 😉]

Um, was this a joke? If so humor was lost on me...
Some of the most miserable pts I've ever seen have been those with tumor-induced brachial plexopathy. Very difficult to manage pain and total arm dysfunction...these are the patients that you sadly hope have competing distant mets.
If the patient has pain now, being aggressive, controlling tumor pain, and having the patient lose some function at the timeframe needed for RT-induced plexopathy (i.e. late) is a huge win.
I would try to get control of the tumor with whatever dose you think you need based on the competing risks. If there are no distant mets I would be aggressive...perhaps BID with chemo.
Undertreating these tumors upfront to avoid some arbitrary Dmax is the biggest mistake in these cases. At current suggested NSCLC doses of 60-66 Gy you would rarely (ever?) see RT-induced plexopathy. We treat the plexus to 70 Gy with chemo all the time in H&N.
I'm guessing that's what happened given it received 55 Gy, implying it was a curable case upfront?

 

[medgator]

Um, was this a joke? If so humor was lost on me...
Some of the most miserable pts I've ever seen have been those with tumor-induced brachial plexopathy. Very difficult to manage pain and total arm dysfunction...these are the patients that you sadly hope have competing distant mets.
If the patient has pain now, being aggressive, controlling tumor pain, and having the patient lose some function at the timeframe needed for RT-induced plexopathy (i.e. late) is a huge win.
I would try to get control of the tumor with whatever dose you think you need based on the competing risks. If there are no distant mets I would be aggressive...perhaps BID with chemo.
Undertreating these tumors upfront to avoid some arbitrary Dmax is the biggest mistake in these cases. At current suggested NSCLC doses of 60-66 Gy you would rarely (ever?) see RT-induced plexopathy. We treat the plexus to 70 Gy with chemo all the time in H&N.
I'm guessing that's what happened given it received 55 Gy, implying it was a curable case upfront?

It wasn't a joke. In the community, worrying about toxicity is just as important as worrying about the tumor.

As per the paper I posted previously, the BP can take quite a bit and usually tumor is the bigger problem. I think the OPs case will be difficult because it's been partially treated. With such a low dmax to the bp, I'm wondering if it was a preop case. It's going to be very difficult to control the tumor at this point without going to a dose that ends up causing a big risk of plexopathy when the previous dose is accounted for.

As you and the paper mentioned, being aggressive upfront is the way to go to reduce risk of the OPs situation happening

 

[Reaganite]

Dear colleagues,
What is the estimated dose recuperation of he brachial plexus one year after irradiation ?
I have a pt who have recurrent lesion of the apex of the RT lung. The dose received by he brachial plexus during the first course of RT is Dmax 55Gy . He was referred back to me for progression of the apical lesion that is giving him a great amount of pain. I plan to give him 30 Gy in 10 fr . What additional dose could the brachial plexus receive ?
Tx


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How big is recurrence? Does he have mets elsewhere?

 

[Kroll2013]

How big is recurrence? Does he have mets elsewhere?

No mets for the moment. The recurrence is big. You may say progression rather than recurrence as if he never responded.


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[Kroll2013]

Um, was this a joke? If so humor was lost on me...
Some of the most miserable pts I've ever seen have been those with tumor-induced brachial plexopathy. Very difficult to manage pain and total arm dysfunction...these are the patients that you sadly hope have competing distant mets.
If the patient has pain now, being aggressive, controlling tumor pain, and having the patient lose some function at the timeframe needed for RT-induced plexopathy (i.e. late) is a huge win.
I would try to get control of the tumor with whatever dose you think you need based on the competing risks. If there are no distant mets I would be aggressive...perhaps BID with chemo.
Undertreating these tumors upfront to avoid some arbitrary Dmax is the biggest mistake in these cases. At current suggested NSCLC doses of 60-66 Gy you would rarely (ever?) see RT-induced plexopathy. We treat the plexus to 70 Gy with chemo all the time in H&N.
I'm guessing that's what happened given it received 55 Gy, implying it was a curable case upfront?

He received 60 Gy because initially the lesion was not apical. That s why he didn t receive full dose


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[Kroll2013]

The goal is to have the tumor take out the plexus before you do 😉 I would consent the pt for brachial plexopathy, loss of function with whatever you end up doing.

http://www.ncbi.nlm.nih.gov/pubmed/22658442

Thx alot. Very helpfull.


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[nkmiami]

I have used pulsed dose rate in this situation to retreat to near 50 Gy, depending on the clinical scenario. I opened a protocol in Philadelphia and was surprised by how well it works. You can call Steven Howard at Wisconsin. He has a retreat service and is good about answering questions.


Breast Cancer Res Treat. 2009 Mar;114(2):307-13. doi: 10.1007/s10549-008-9995-3. Epub 2008 Apr 4.
Pulsed reduced dose-rate radiotherapy: a novel locoregional retreatment strategy forbreast cancer recurrence in the previously irradiated chest wall, axilla, or supraclavicular region.
Richards GM1, Tomé WA, Robins HI, Stewart JA, Welsh JS, Mahler PA, Howard SP.
Author information

Abstract

 

[Lamount]

How long since prior treatment was completed?

 

[Palex80]

My gut feeling is that this patient is doomed. If the initial 55 Gy didn't lead to any response then there's a good chance your 30/3 will be of little to no use at all.