Performance Status required for CSI

[xrt123]

I have a 35 yo male who is not doing well after posterior fossa surgery/infections/hydrocephalus for adult medulloblastoma. He is trached, nonverbal, has a decubitus ulcer, fevers, and a KPS probably of 20-30. He needs CSI 36 Gy and boost. He is barely following commands 30+ days from surgery and very slowly improving. I am torn ethically about what to do. Any guidance or thoughts on when to initiate radiation if ever?

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[Radonc90]

Personally, I'd leave the patient alone until his KPS is > 50%.
At the present time, KPS = 20-30% is way too low.

Also, look at surg alone data from the old days, if no negative path/MRI features, the risk of recurrence is lower than those with negative prognostic features.

So, if your pt has complete resection with neg margins and normal postop MRI, you can wait a bit more.

I am not saying the does not need XRT, I am saying that by having no negative path/MRI features, you/your pt have a little room to wiggle...

 

[seper]

One option is to wait a few more weeks and then administer local-only RT. I'm sure his family can be brought onboard with your plans.

 

[Palex80]

This is obviously a case where guidelines won't help you a lot.

I woulnd't treat him with CSI in this condition.

One way would be to withhold CSI for now and treat locally only. If he recovers during the next weeks, you can then proceed with CSI.

If this doesn't work out and he needs longer time to recover you will have treated him only locally and have a treatment gap to CSI (or may never be able to give CSI, in which case there is no point in pursuing it, since his prognosis would be misearble anyway).

We know from the German trial that giving chemo prior to CSI is not as good as giving chemo after CSI (in kids). Withholding CSI for now, giving chemotherapy (perhaps in a deescalated matter), then moving on with CSI may have been an option. However his general condition (decubitus ulcer especially) makes him a bad candidate for chemo as well.


At the end of the day, one probably has to calculate the chances of any therapy being successful in this patient or if the chance of curing him with the available treatments (given his condition) is viable. If chances of cure are slim, then it may be more likely that you will hurt the patient with any treatment right now, rather than actually help him.

Is this a high-risk medulloblastoma case and if yes, what makes him high-risk?
You mentioned 36 Gy CSI not 23.4 Gy. I am aware that some protocols still call for adults to receive full-dose CSI and do not allow deescalation of CSI dose even in standard-risk.

 

[evilbooyaa]

Would not treat somebody who is potentially on the precipice of dying from post-op complications. Especially not with CSI.

Risk of failure after surgery alone is not 100%.

 

[Manatee3]

Radiation therapy right now is not going to help this patient.

 

[xrt123]

Is this a high-risk medulloblastoma case and if yes, what makes him high-risk? Technically he did not have a GTR and the re-eval imaging has been poor quality due to movement. I technically haven't determined standard or high risk yet, but either way I wanted to decide if treatment was even reasonable before putting him through imaging and sedation. Its been a hot mess with things going wrong when trying to assess, but surgeon was thinking he left a "good bit behind".

Thanks for the responses but clearly difficult to guide the family in this horrendous situation.

 

[Neuronix]

My rule of thumb is: if the patient's half dead, radiation will probably make them fully dead.

This is a really sucky position for all involved. Yes RT within 30 days is important when possible, but I doubt that applies to KPS 20-30.

Another one of my rules of thumb is I don't treat if the patient is on a vent. I make only rare exceptions to that one. A post-op case like this is not one of them. Let the patient's PS improve a bit before knocking them back down with RT.

 

[elementaryschooleconomics]

My rule of thumb is: if the patient's half dead, radiation will probably make them fully dead.

This is a really sucky position for all involved. Yes RT within 30 days is important when possible, but I doubt that applies to KPS 20-30.

Another one of my rules of thumb is I don't treat if the patient is on a vent. I make only rare exceptions to that one. A post-op case like this is not one of them. Let the patient's PS improve a bit before knocking them back down with RT.

Well I'll be adding that to my "thumb rule" book...

 

[Palex80]

Is this a high-risk medulloblastoma case and if yes, what makes him high-risk? Technically he did not have a GTR and the re-eval imaging has been poor quality due to movement. I technically haven't determined standard or high risk yet, but either way I wanted to decide if treatment was even reasonable before putting him through imaging and sedation. Its been a hot mess with things going wrong when trying to assess, but surgeon was thinking he left a "good bit behind".

Thanks for the responses but clearly difficult to guide the family in this horrendous situation.

This is a fair argument. On the other hand, I feel that precisely in this scenario I would do more diagnostic procedures now.

Do you happen to have the molecular subtype? Prognosis and risk of disease spreading is also linked to molecular subtype which may help to guide your decision on how to treat. If this is WNT-subtype for instance (highly unlikely) and M0 but with residual tumor, you may go for a local-only approach (hypofractionate too). There is a fair chance to eliminate the disease locally with RT only and WNT-subtype rarely goes M1.

If this is not WNT-subtype and the imaging shows residual tumor or even disease spreading, then it's clearly palliative and you can forget about any intensive treatment. Then you can discuss with the family BSC vs. some kind of local treatment (if symptomatic).

My rule of thumb: The more you know, the easier it is to talk with the family and discuss options.

 

[Phantom1]

I have a 35 yo male who is not doing well after posterior fossa surgery/infections/hydrocephalus for adult medulloblastoma. He is trached, nonverbal, has a decubitus ulcer, fevers, and a KPS probably of 20-30. He needs CSI 36 Gy and boost. He is barely following commands 30+ days from surgery and very slowly improving. I am torn ethically about what to do. Any guidance or thoughts on when to initiate radiation if ever?

Hmm, this is a tough one. Definitely agree on waiting until he recovers from acute issues such as infection with fevers. However, is it possible he has posterior fossa syndrome and mutism?

If he has recovers from acute issues and is medically stable and improving, I wouldn’t hold radiation just because of a trach and mutism alone. We treat stable patients with trach all the time (Head and Neck), and non-verbal could be due to posterior fossa syndrome. That being said, I would probably only consider a posterior fossa/tumor bed field only and omit CSI...

 

[HardenedBeam]

Don’t withhold curative treatment for posterior fossa syndrome.

 

[thecarbonionangle]

Don’t withhold curative treatment for posterior fossa syndrome.

i agree. This person needs curative treatment at some point.

 

[Neuronix]

Does this person have KPS 20-30 on a vent with active infections, or just posterior fossa syndrome?

I assumed the former from the case description.

Somehow this whole discussion has morphed into not withholding treatment for cerebellar mutism, which is not my understanding of the case presented.

 

[xrt123]

This is not posterior fossa mutism and for brevity's sake I didn't include many of the details before. I appreciate the interest. His course has been complicated by TV/Sigmoid sinus thrombus & leg DVT treated with IVC filter & ultimately heparin gtt also complicated by elevated ICPs & requiring re-intubation, CT-hydrocephalus & posterior fossa edema requiring conversion of craniotomy to craniectomy. MRI 3 weeks after original operation showed ventriculitis & resection cavity abscess taken for washout, he also developed new onset Afib and bleeding ulcers eventually controlled by GI. He failed multiple EVD's and ultimately had VP shunt placed. Currently with large decubitus ulcer requiring regular debridement and ongoing intermittent fevers. Currently not alert and trached (off vent). KPS is probably in the 10-20 range and I kept delaying the question on path (WNT, SHH) to when I thought there was some chance he would improve, but those results are currently pending.

 

[HardenedBeam]

This is not posterior fossa mutism and for brevity's sake I didn't include many of the details before. I appreciate the interest. His course has been complicated by TV/Sigmoid sinus thrombus & leg DVT treated with IVC filter & ultimately heparin gtt also complicated by elevated ICPs & requiring re-intubation, CT-hydrocephalus & posterior fossa edema requiring conversion of craniotomy to craniectomy. MRI 3 weeks after original operation showed ventriculitis & resection cavity abscess taken for washout, he also developed new onset Afib and bleeding ulcers eventually controlled by GI. He failed multiple EVD's and ultimately had VP shunt placed. Currently with large decubitus ulcer requiring regular debridement and ongoing intermittent fevers. Currently not alert and trached (off vent). KPS is probably in the 10-20 range and I kept delaying the question on path (WNT, SHH) to when I thought there was some chance he would improve, but those results are currently pending.

Sounds reasonable to wait until the patient improves from all that.