Radiation therapy for intracardiac metastasis

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Kroll2013

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Dear colleagues ,
my patient 56 yo known to have a history of oligometastatic STS, recently presented with a secondary lesion in the heart. He was strictly asymptomatic.
we decided to go forward with systemic treatment not considering radiation in this setting.
Unfortunately, he passed away secondary to arrhythmia (most probably related to his lesion).

1- i would like to know about your experience in the indication of radiation therapy (SBRT or other ) to treat similar lesions? selection criterias, results? do you have any institutional protocols?
2- do you think that a prophylactic ICD would have saved this patient 'life ?

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Dear colleagues ,
my patient 56 yo known to have a history of oligometastatic STS, recently presented with a secondary lesion in the heart. He was strictly asymptomatic.
we decided to go forward with systemic treatment not considering radiation in this setting.
Unfortunately, he passed away secondary to arrhythmia (most probably related to his lesion).

1- i would like to know about your experience in the indication of radiation therapy (SBRT or other ) to treat similar lesions? selection criterias, results? do you have any institutional protocols?
2- do you think that a prophylactic ICD would have saved this patient 'life ?
Quick pubmed search comes up with this experience. MR guidance seems like a good use case for the situation, but perhaps @Neuronix knows more.
 
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Dear colleagues ,
my patient 56 yo known to have a history of oligometastatic STS, recently presented with a secondary lesion in the heart. He was strictly asymptomatic.
we decided to go forward with systemic treatment not considering radiation in this setting.
Unfortunately, he passed away secondary to arrhythmia (most probably related to his lesion).

1- i would like to know about your experience in the indication of radiation therapy (SBRT or other ) to treat similar lesions? selection criterias, results? do you have any institutional protocols?
2- do you think that a prophylactic ICD would have saved this patient 'life ?

I have done this a few times for primary and metastatic sarcoma. I like fractionated SBRT for this indication 25-35 Gy in 5 fractions, but have also done single fraction 15-18 Gy. I've never had a set institutional protocol and have done it a few ways including MRgRT. You are only really gating for respiratory motion so its not clear that is better than non-MRgRT SBRT.

Not really aware of selection criteria, but would approach similar to other metastases.

I would likely not treat an asymptomatic cardiac met as these patients have a very poor prognosis. But all the ones I've seen have been symptomatic and I've treated.

Quick pubmed search comes up with this experience. MR guidance seems like a good use case for the situation, but perhaps @Neuronix knows more.

Once had a project that was going to look at target volume differences for MRgRT versus fusing a cardiac MR to a CT sim and treating on a regular linac. We presented single institution results at a VR user meeting but it never got off the ground to look wider. I agree this is a good use of MRgRT.
 
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I have done this a few times for primary and metastatic sarcoma. I like fractionated SBRT for this indication 25-35 Gy in 5 fractions, but have also done single fraction 15-18 Gy. I've never had a set institutional protocol and have done it a few ways including MRgRT. You are only really gating for respiratory motion so its not clear that is better than non-MRgRT SBRT.

Not really aware of selection criteria, but would approach similar to other metastases.

I would likely not treat an asymptomatic cardiac met as these patients have a very poor prognosis. But all the ones I've seen have been symptomatic and I've treated.



Once had a project that was going to look at target volume differences for MRgRT versus fusing a cardiac MR to a CT sim and treating on a regular linac. We presented single institution results at a VR user meeting but it never got off the ground to look wider. I agree this is a good use of MRgRT.
how do you counsel your patient about the risks related to radiation?
necrosis / arrythmias secondary to fibrosis / blow out ??? or not relevant ?
are these risks related to the primary tumor' pathology ? sarcoma vs melanoma vs other ?
 
Quick pubmed search comes up with this experience. MR guidance seems like a good use case for the situation, but perhaps @Neuronix knows more.

Sorry I've never actually treated one of these. I'm not sure if anyone in our institution has either.

I like the experience you posted though. That's probably what I would do. You can likely see that met you posted on a ViewRay sim/daily setup MRI to verify position. The typical sequence used diagnostically for cardiac imaging is the same one they use on a ViewRay, albiet with lower resolution (temporal and spatial).
 
how do you counsel your patient about the risks related to radiation?
necrosis / arrythmias secondary to fibrosis / blow out ??? or not relevant ?
I cannot imagine that blowout is an issue here. Not with the typical doses that have been suggested.
Arrhythmia may indeed happen if one causes a lot of fibrosis, perhaps the risk is higher with more hypofractionated schedules with high dose / fraction?
are these risks related to the primary tumor' pathology ? sarcoma vs melanoma vs other ?
I can imagine that melanoma may be more prone to bleeding or something like that?

Personally, I would keep it simply 5-15 fractions with a palliative dose, for instance:
5 x 5 Gy, 10 x 3.5 Gy, 15 x 3 Gy?

Of course a lot depends on the overall prognosis of the patient: is this oligo-, polymetastatic, performance status, etc...
 
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Have >2yr LC so far in a 30s F with oligo myxoid liposarc. No significant toxicity. Disappeared on subsequent MRs following 35 Gy / 5 EOD. She’s doing well last I heard.

Also have done whole heart 30 Gy / 10 with chemo for pericardial angiosarc. Went to the autopsy after sudden death - was a spontaneous bleed into the peritoneum from an abdominal met. Pericardium a bit fibrosed but heart tissue otherwise good. Still a lot of mets, some of them necrotic around the heart.

A few other mets adjacent to pericardium or primary in pulmonary artery I’ve treated to high dose w/o significant issue.

Have also done a fair amount SABR for VTach. 25 Gy/1. Heart tolerates quite well, but usually irradiating ‘dead’ myocardium.

Given the above patient’s sudden death, might have benefit from prophylactic ICD. Will have to remember that in the future for my own patients.

Re protocols - used our VTach protocol for sim and IGRT. Patient selection - tumor board.

Dont need MR for this though I’m sure it helps. All above done on regular linac with SRS capability.
 
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I have treated a few... so far so good. I tend to fractionate a bit more, especially if they are intraluminal and I am worried about a piece breaking off with a quick response. I typically do 45-50/10 or 54-60/15...ish.

MRI Linac would be nice. For planning, MRI is fine but you have to specifically ask for volumetric T1+C studies... a lot of time, they are doing cine stuff to look for blood flow/EF. Another alternative is an EKG-gated CT, which can show the cardiac anatomy beautifully (during diastole).
 
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Have >2yr LC so far in a 30s F with oligo myxoid liposarc. No significant toxicity. Disappeared on subsequent MRs following 35 Gy / 5 EOD. She’s doing well last I heard.

Also have done whole heart 30 Gy / 10 with chemo for pericardial angiosarc. Went to the autopsy after sudden death - was a spontaneous bleed into the peritoneum from an abdominal met. Pericardium a bit fibrosed but heart tissue otherwise good. Still a lot of mets, some of them necrotic around the heart.

A few other mets adjacent to pericardium or primary in pulmonary artery I’ve treated to high dose w/o significant issue.

Have also done a fair amount SABR for VTach. 25 Gy/1. Heart tolerates quite well, but usually irradiating ‘dead’ myocardium.

Given the above patient’s sudden death, might have benefit from prophylactic ICD. Will have to remember that in the future for my own patients.

Re protocols - used our VTach protocol for sim and IGRT. Patient selection - tumor board.

Dont need MR for this though I’m sure it helps. All above done on regular linac with SRS capability.

How come whole heart for angiosarcoma? I've done a couple cases of that in the curative setting and just did a mediastinal CTV based approach, long course chemorads with taxol. Both cases had a pCR at surgery.

I used the VTach sim protocol for the last case cardiac case I did at my old job and it was awesome.

how do you counsel your patient about the risks related to radiation?
necrosis / arrythmias secondary to fibrosis / blow out ??? or not relevant ?
are these risks related to the primary tumor' pathology ? sarcoma vs melanoma vs other ?

Like above posters, I think you can take the VTach data/experience and other data to confident that blow out wont be an issue. It's a huge muscle and the doses are not in the aggressive re-irradiation range where you see blow outs in the neck.

I counsel them for pericarditis and arrhythmia (theoretical) in the short term and heart failure in the long term. I do not think there is a high percentage of patients with metastatic sarcoma involving the heart that make it to the chronic toxicity period.

I would use sarcoma histotype to modulate dose. Myxoid liposarcoma and angiosarcoma are wimpy and in MLS you can get excellent responses with 36 Gy in 18 fractions. Also think its very reasonable to use standard hypofractionated palliative doses in any of these cases instead of SBRT.
 
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Patient presented metastatic with pericardial and pleural effusions, etc. Ineligible for transplant, started on first line chemo with excellent response. Continued to progress only within the heart and fairly significantly and so we discussed and pulled the trigger on consolidation. Obviously incurable though so with palliative doses given histology and otherwise expected prognosis. Of course progressed systemically a few months later. Patient outlived the mean expectancy w/o transplant by quite a bit and was only on second line chemo so bit too bad about the bleed, could have gone on for quite a bit longer otherwise. At the end of the day I think it was a reasonable approach for the patient.

Yup - myxoids are wimpy for sure. Have moved to 36 Gy preop and not looking back.

The heart SABR case was technically ’operable’ but this was something like their 6th or 7th met we SABR’d over a handful of years and so patient declined OR in favor of SABR when discussed each option.

One thing that’s not been mentioned so far is that the WASH U team I think had a patient develop post RT arrhythmia and stroke so they now make sure each patient is routinely anticoagulanted around their treatment iirc. I take the same approach with these heart SABR cases and discuss and prescribe them empiric DOACs for 2-3 months just in case, though fortunate to not have any arrhythmias with malignant cardiac RT.

Side note we just reviewed our local VTach outcomes and like everywhere so far, small numbers, but in the encouraging category. Will be interesting to see how this plays out in the longer term.
 
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