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STUDY OF EPIDEMIOLOGY AND
TREATMENT OUTCOME USING
BARTHEL’S INDEX IN METASTATIC
BRAIN TUMORS
PATRO K.C,SOY.L.M, KAKKAR.S, ...
WHY THIS STUDY
In recent years there have been important
advances in the diagnosis and management of
brain metastasis. As ...
AIMS & OBJECTIVES OF STUDY
To study various epidemiological aspects i.e. age,
sex, single vs. multiple, primary site distr...
STUDY DETAILS
PLACE OF STUDY
---REGIONAL CANCER CENTRE
CUTTACK
PERIOD OF STUDY
---October 2003-Octeber 2005
TOTAL NO OF PA...
MATERIAL & METHODS
INCLUSION CRITERIAS FOR TREATMENT
1. Brain secondaries diagnosed on the basis of
CT/MRI scan with multi...
EXCLUSION CRITERIAS FOR
TREATMENT
1. Brain secondaries diagnosed on the basis
of CT/MRI scan with single metastasis.
2. Pa...
TREATMENT DETAILS
Machine  Cobalt—60
Portal  As for whole brain RT
Technique  Bilateral opposing
Dose ARM—A300cGy/# x...
END POINTS & STATISTICAL ANALYSIS;
Distribution of age
Distribution of Sex
Site of lesion in brain:
Type of lesion: (singl...
EPIDEMIOLOGICAL
ANALYSIS
AGE DISTRIBUTION
C
A
S
E
S
0
1 1
8
18
22
1
0
5
10
15
20
25
0-10
yrs
11-20
yrs
21-30
yrs
31-40
yrs
41-50
yrs
51-60
yrs
61-7...
SEX DISTRIBUTION
49%
51%
MALE FEMALE
Patients Male Female
51 26 25
100% 51% 49%
DISTRIBUTION OF PRIMARY
37%
35%
4%
4%
2%
2%
2%
2% 10%
2%
Lungs
Breast
Esophagus
Renal cell carcinoma
Lymphoma
Ewings sarco...
SOLITARY VS MULTIPLE
C
A
S
E
S
35%
65%
0%
10%
20%
30%
40%
50%
60%
70%
SINGLE
METASTASIS
MULTIPLE
METASTASIS
Total cases Si...
LESION SITES IN BRAIN
54%
23%
3%
17%
2% 1%
PARIETAL
FRONTAL
TEMPORAL
OCCIPITAL
CEREBELLAR
OTHER
Total
Lesion
Frontal Parie...
SYMPTOMATIC PRESENTATION
28
18
12
2
9
32
HEADACHE VOMITING
NEUROLOGCAL DEFICIT SEIZURE
CEREBELLAR SIGNS VISUAL SUMPOM
Sl.
...
CONTROLLED PRIMARY VS
UNCONTROLLED PRIMARY
12
39
0
5
10
15
20
25
30
35
40
controlled primary
uncontrolled primary
C
A
S
E
...
DISTRIBUTION OF PATIENTS IN
DIFFRERENT TREATMENT ARMS
18 15
0
3
6
9
12
15
18
ARM-A ARM-B
LESION ARM Patient Dose/# TTD NO....
ANALYSIS OF
SYMPTOMATIC
IMPROVEMENT USING
BARTHEL’S INDEX
BARTHEL INDEX)
No. Activity 0 1 2
1 Bowel Incontinent Occasional Accident Continent
2 Bladder Incontinent Occasional Accid...
ASSESSMENT OF SYMPTOMATIC IMPROVEMENT
AFTER RADIOTHERAPY USING BARTHEL’S
ADJUSTMENT DAILY LIFE (ADL) SCORE IN ARM-A
0
2
4
...
ASSESSMENT OF SYMPTOMATIC IMPROVEMENT
AFTER RADIOTHERAPY USING BARTHEL’S
ADJUSTMENT DAILY LIFE (ADL) SCORE IN ARM-B
0
2
4
...
TREATMENT MORBIDITY ARM-A
0
15
3
0 0
4
11
3
0 0
8
4
4
2
0
0
2
4
6
8
10
12
14
16
Skin GI CNS
Grade-0 Grade-1 Grade-2
Grade-...
TREATMENT MORBIDITY ARM-B
0
13
2
0 0
8
6
1
0 0
4
9
2
0
0
0
2
4
6
8
10
12
14
Skin GI CNS
Grade-0 Grade-1 Grade-2
Grade-3 Gr...
RESPONSE RATE(%)
62
53
28
20
5
20
5 7
0
10
20
30
40
50
60
70
CR PR SD PD
ARM-A ARM-B
Response
Criteria
Arm A Arm B
Complet...
CT scan picture of multiple brain secondaries before treatment and CT scan picture
of same patient 3 months after treatmen...
CT scan picture of multiple brain secondaries before treatment and CT scan picture
of same patient 3 months after treatmen...
CT scan picture of multiple brain secondaries before treatment and CT scan picture
of same patient 3 months after treatmen...
MEDIAN SURVIVAL
S
U
R
V
I
V
A
L
(WKs)
24
27.43
0
4
8
12
16
20
24
28
ARM A ARM B
ARM Median Survival (wks)
ARM-A-WBRT 30Gy ...
Survival Function
SURVIVAL
400
300
200
100
0
1.0
.8
.6
.4
.2
0.0
GROUP
Survival Function
SURVIVAL
400
300
200
100
0
Cum
Su...
Survival Functions
SURVIVAL
400
300
200
100
0
1.0
.8
.6
.4
.2
0.0
GROUP
20 Gy
30 Gy
Survival Analysis for 30 Gy
Survival T...
REVIEW OF LITERATURE
Distribution of primary
Author Lung Breast GIT Renal Mela-
noma
unknown Oth.
Zimm
et.al
1981
64% 15% ...
Symptomatic presentation
Author HEAD
ACHE
VOMITING NEUROL
OGICAL
DEFICIT
SEIZURE CEREBELL
AR SIGNS
VISUAL
SYMPTOMS
Posnere...
Median survival
Author Patients TOTAL DOSE NUMBER OF # MEDIAN
SURVIVAL
(MO)
Broglet et.al
1973
910 30Gy 10 5.2
Broglet et....
SUMMARY :
The present work conducted in a span of two years
It is an uncontrolled prospective study of patients with brain...
CONCLUSION
The present study highlights that the incidence of brain metastasis is
common in elderly population and mostly ...
THESIS-STUDY OF EPIDEMIOLOGY AND TREATMENT OUTCOME USING BARTHEL’S INDEX IN METASTATIC BRAIN TUMORS
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THESIS-STUDY OF EPIDEMIOLOGY AND TREATMENT OUTCOME USING BARTHEL’S INDEX IN METASTATIC BRAIN TUMORS

THESIS-STUDY OF EPIDEMIOLOGY AND TREATMENT OUTCOME USING BARTHEL’S INDEX IN METASTATIC BRAIN TUMORS

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THESIS-STUDY OF EPIDEMIOLOGY AND TREATMENT OUTCOME USING BARTHEL’S INDEX IN METASTATIC BRAIN TUMORS

  1. 1. STUDY OF EPIDEMIOLOGY AND TREATMENT OUTCOME USING BARTHEL’S INDEX IN METASTATIC BRAIN TUMORS PATRO K.C,SOY.L.M, KAKKAR.S, PADHI.S, SENAPATI S.N, SINGH D.N
  2. 2. WHY THIS STUDY In recent years there have been important advances in the diagnosis and management of brain metastasis. As a result most patients receive effective palliation and the majorities do not die due to complication of brain metastases. Controversy still exists regarding the demographic profile, radiotherapeutic dose fractionation in brain secondaries, which requires further evaluation. In view of the challenging role of radiotherapy in management of intracranial neoplasms, the aim of present study is to analyze the epidemiology and treatment outcome in metastatic brain tumors.
  3. 3. AIMS & OBJECTIVES OF STUDY To study various epidemiological aspects i.e. age, sex, single vs. multiple, primary site distribution, controlled vs. uncontrolled primary, sign and symptoms, Analysis of symptomatic improvement after treatment using Barthel’s index. To assess any survival advantage by using two radiation protocols (ARM-A 300cGy/# X10# ,ARM- B 400cGy/# x5#)
  4. 4. STUDY DETAILS PLACE OF STUDY ---REGIONAL CANCER CENTRE CUTTACK PERIOD OF STUDY ---October 2003-Octeber 2005 TOTAL NO OF PATIENTS ---51
  5. 5. MATERIAL & METHODS INCLUSION CRITERIAS FOR TREATMENT 1. Brain secondaries diagnosed on the basis of CT/MRI scan with multiple metastasis. 2. Patients having ECOG performance status 0, 1, 2 3. Life expectancy >3 month 4. No prior RT to brain
  6. 6. EXCLUSION CRITERIAS FOR TREATMENT 1. Brain secondaries diagnosed on the basis of CT/MRI scan with single metastasis. 2. Patients having ECOG performance status >2 3. Life expectancy <3 months 4. Prior RT to brain
  7. 7. TREATMENT DETAILS Machine  Cobalt—60 Portal  As for whole brain RT Technique  Bilateral opposing Dose ARM—A300cGy/# x10# over 2week ARM—B400cGy/# x5# over 1week Medications Low dose steroids, antiematics, anticonvulsants as needed and supportive care.
  8. 8. END POINTS & STATISTICAL ANALYSIS; Distribution of age Distribution of Sex Site of lesion in brain: Type of lesion: (single vs. Multiple) Site of primary giving rise to metastasis: Clinical features Controlled primary vs. uncontrolled primary Symptomatic improvement analysis just after treatment using Barthel’s index. Response rate on CT scan after 3 month: Treatment morbidity Median survival following RT Stastical analysis was done on SPSS version 11.0
  9. 9. EPIDEMIOLOGICAL ANALYSIS
  10. 10. AGE DISTRIBUTION C A S E S 0 1 1 8 18 22 1 0 5 10 15 20 25 0-10 yrs 11-20 yrs 21-30 yrs 31-40 yrs 41-50 yrs 51-60 yrs 61-70 yrs AGE GROUP 0-10 YRS 11-20 YRS 21-30 YRS 31-40 YRS 41-50 YRS 50-60 YRS 60-70 YRS NO. OF CASES 0 1 1 8 18 22 1 TOTAL-51=100% 0% 2% 2% 15% 35% 43% 2%
  11. 11. SEX DISTRIBUTION 49% 51% MALE FEMALE Patients Male Female 51 26 25 100% 51% 49%
  12. 12. DISTRIBUTION OF PRIMARY 37% 35% 4% 4% 2% 2% 2% 2% 10% 2% Lungs Breast Esophagus Renal cell carcinoma Lymphoma Ewings sarcoma Ovary Choriocarcinoma Urinary bladder Unknown primary
  13. 13. SOLITARY VS MULTIPLE C A S E S 35% 65% 0% 10% 20% 30% 40% 50% 60% 70% SINGLE METASTASIS MULTIPLE METASTASIS Total cases Single metastasis Multiple metastasis 51 18 33 100% 35% 65%
  14. 14. LESION SITES IN BRAIN 54% 23% 3% 17% 2% 1% PARIETAL FRONTAL TEMPORAL OCCIPITAL CEREBELLAR OTHER Total Lesion Frontal Parietal Temporal Occipital Cerebellar Other 94 22 50 3 16 2 1 100% 23% 54% 3% 17% 2% 1%
  15. 15. SYMPTOMATIC PRESENTATION 28 18 12 2 9 32 HEADACHE VOMITING NEUROLOGCAL DEFICIT SEIZURE CEREBELLAR SIGNS VISUAL SUMPOM Sl. No Symptoms No. of Cases Percent age 1 Headache 32 62% 2 Vomiting 28 55% 3 Neurological deficit 18 35% 4 Seizures 12 24% 5 Cerebellar signs 2 4% 6 Visual symptoms 9 18%
  16. 16. CONTROLLED PRIMARY VS UNCONTROLLED PRIMARY 12 39 0 5 10 15 20 25 30 35 40 controlled primary uncontrolled primary C A S E S Cases Controlled Primary Uncontrolled Primary 51 12 39 100% 24% 76%
  17. 17. DISTRIBUTION OF PATIENTS IN DIFFRERENT TREATMENT ARMS 18 15 0 3 6 9 12 15 18 ARM-A ARM-B LESION ARM Patient Dose/# TTD NO. OF # Multiple A 18 300cGy 30 10 Multiple B 15 400cGy 20 5
  18. 18. ANALYSIS OF SYMPTOMATIC IMPROVEMENT USING BARTHEL’S INDEX
  19. 19. BARTHEL INDEX) No. Activity 0 1 2 1 Bowel Incontinent Occasional Accident Continent 2 Bladder Incontinent Occasional Accident Continent 3 Feeding Unable Can manage with some help Independent 4 Grooming Unable Can manage with some help Independent 5. Dressing Unable Can manage with some help Independent 6 Transfer Unable Can manage with some help Independent 7 Toilet use Unable Can manage with some help Independent 8 Walking Unable Can manage with some help Independent 9 Stairs Unable Can manage with some help Independent 10 Bathing Unable Can manage with some help Independent Adjustment Daily Life (ADL) SCORE Maximum Score - 20 Dependant - <10 Semi dependant - 10-14
  20. 20. ASSESSMENT OF SYMPTOMATIC IMPROVEMENT AFTER RADIOTHERAPY USING BARTHEL’S ADJUSTMENT DAILY LIFE (ADL) SCORE IN ARM-A 0 2 4 6 8 10 12 14 16 PRE TT JUST AFT.TT AT 6WK 0--10 11--14 15--20 ADL SCORE PRE TREATMENT ARM- A POST TREATMENT ARM-A JUST AFTER TT POST TREATMENT ARM-A AT 6WK 0 – 10 0 0 0 11 – 14 8 2 3 15 – 20 10 16 13
  21. 21. ASSESSMENT OF SYMPTOMATIC IMPROVEMENT AFTER RADIOTHERAPY USING BARTHEL’S ADJUSTMENT DAILY LIFE (ADL) SCORE IN ARM-B 0 2 4 6 8 10 12 PRE TT JUST AFT.TT AT 6WK 0--10 11--14 15--20 ADL SCORE PRE TREATMENT ARM-B POST TREATMENT ARM-B JUST AFTER TT POST TREATMENT ARM-B AT 6WK 0 – 10 0 0 0 11 – 14 9 3 4 15 – 20 6 12 11
  22. 22. TREATMENT MORBIDITY ARM-A 0 15 3 0 0 4 11 3 0 0 8 4 4 2 0 0 2 4 6 8 10 12 14 16 Skin GI CNS Grade-0 Grade-1 Grade-2 Grade-3 Grade-4 Acute Morbidity RTOG Grade-0 (n) RTOG Grade-1 (n) RTOG Grade-2 (n) RTOG Grade-3 (n) RTOG Grade-4 (n) Skin Changes 0 15 3 0 0 Up.Gi Changes 4 11 3 0 0 Cns Changes 8 4 4 2 0
  23. 23. TREATMENT MORBIDITY ARM-B 0 13 2 0 0 8 6 1 0 0 4 9 2 0 0 0 2 4 6 8 10 12 14 Skin GI CNS Grade-0 Grade-1 Grade-2 Grade-3 Grade-4 Acute Morbidity RTOG Grade-0 (n) RTOG Grade-1 (n) RTOG Grade-2 (n) RTOG Grade-3 (n) RTOG Grade-4 (n) Skin Changes 0 13 2 0 0 UP.GI changes 4 9 2 0 0 CNS Changes 8 6 1 0 0
  24. 24. RESPONSE RATE(%) 62 53 28 20 5 20 5 7 0 10 20 30 40 50 60 70 CR PR SD PD ARM-A ARM-B Response Criteria Arm A Arm B Complete response (CR) 62% 53% Partial response (PR) 28% 20% Stable disease (SD) 5% 20% Progressive disease (PD) 5% 7%
  25. 25. CT scan picture of multiple brain secondaries before treatment and CT scan picture of same patient 3 months after treatment showing complete response COMPLETE RESPONSE PRE RT POST RT(AT 3M)
  26. 26. CT scan picture of multiple brain secondaries before treatment and CT scan picture of same patient 3 months after treatment showing progressive disease PROGRESSIVE DISEASE PRE RT POST RT(AT 3M)
  27. 27. CT scan picture of multiple brain secondaries before treatment and CT scan picture of same patient 3 months after treatment showing stable disease STABLE DISEASE PRE RT POST RT(AT 3M)
  28. 28. MEDIAN SURVIVAL S U R V I V A L (WKs) 24 27.43 0 4 8 12 16 20 24 28 ARM A ARM B ARM Median Survival (wks) ARM-A-WBRT 30Gy IN 10# 24 ARM-B-WBRT 20Gy IN 5# 27.43
  29. 29. Survival Function SURVIVAL 400 300 200 100 0 1.0 .8 .6 .4 .2 0.0 GROUP Survival Function SURVIVAL 400 300 200 100 0 Cum Survival 1.0 .8 .6 .4 .2 0.0 GROUP 20 GY 30 GY KAPLAN-MEIERSURVIVAL ANALYSIS
  30. 30. Survival Functions SURVIVAL 400 300 200 100 0 1.0 .8 .6 .4 .2 0.0 GROUP 20 Gy 30 Gy Survival Analysis for 30 Gy Survival Time Standard Error 95% Confidence Interval Mean: 165.78 23.04 ( 120.63, 210.93 ) Median: 168.00 20.03 ( 128.75, 207.25 ) Survival Analysis for 20 Gy Survival Time Standard Error 95% Confidence Interval Mean: 180.47 20.63 ( 140.03, 220.91 ) Median: 192.00 50.24 ( 93.54, 290.46 ) Survival Analysis for 30 Gy vs 20Gy Total Number Events Censored GROUP 30 Gy 18 18 GROUP 20 Gy 15 15 Overall 33 33 Test Statistics for Equality of Survival Distributions for GROUP Statistics df significance Log Rank .25 1 .6190(P value) not significant
  31. 31. REVIEW OF LITERATURE Distribution of primary Author Lung Breast GIT Renal Mela- noma unknown Oth. Zimm et.al 1981 64% 15% 4% 2% 4% 8% 3% Nussabau m et.al. 1996 39% 17% 6% 6% 11% 5% 16% Present study 37% 35% 4% 2% 0% 10% 12%
  32. 32. Symptomatic presentation Author HEAD ACHE VOMITING NEUROL OGICAL DEFICIT SEIZURE CEREBELL AR SIGNS VISUAL SYMPTOMS Posnere t.al. 1980 53% -- 66% 15% 20% --- Posnere t.al. 1995 49% -- 59% 18% 21% 6% Present study 62% 55% 35% 24% 4% 18%
  33. 33. Median survival Author Patients TOTAL DOSE NUMBER OF # MEDIAN SURVIVAL (MO) Broglet et.al 1973 910 30Gy 10 5.2 Broglet et.al 1976 902 20Gy 5 4.0 kurtz et.al 1979 255 30Gy 50Gy 10 20 4.5 4.2 Philips et.al 1993 72 37.5Gy 15 6.1 Present study 18 15 30Gy 20Gy 10 5 6 6.6
  34. 34. SUMMARY : The present work conducted in a span of two years It is an uncontrolled prospective study of patients with brain secondaries, their incidence and response to radiotherapy. 51 eligible patients enrolled during the study. It is more common in male and occurred in 6th decade of life mostly Headache was the commonest presenting symptom. Carcinoma lung was the commonest primary giving rise to brain metastasis followed by breast. Multiple metastases were more common than the single group. Supratentorial lesions were commoner than infratentorial lesions. Among them parietal lobe was the commonest site of involvement. Whole brain irradiation remains the most effective means for treating the patients with brain metastases with symptoms relief occurring in 70-90% of patients. In multiple secondaries in brain the median survival for external radiotherapy 30 Gy in 10 fractions is equally effective as 20 Gy in 5 fractions.
  35. 35. CONCLUSION The present study highlights that the incidence of brain metastasis is common in elderly population and mostly due to primary lung majority of lesions that has been observed at parietal lobe. Radiotherapy is the mainstay of treatment to relieve the symptoms which was observed through the ADL score. There is definite improvement in the relief of symptoms and quality of life in addition of radiotherapy 20Gy in 5# is equally effective with that of the 30Gy in 10#. So we can opt for 20Gy in 5# to palliate the symptoms as there is no change in overall survival in two arms. In a palliative setting short duration of treatment with minimum discomfort to the patient is desirable. So with accrual of more number of patients we can also further confirm of that can we opt for 20Gy in 5# than 30Gy in 10# ?

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