Brisbane Veterinary Specialist Centre

A Division of Straw Veterinary Support Pty Ltd ABN 81 688 511 416

Radiation Therapy
Surgery Tania Banks BVSc, FACVSc

How Does Radiation Therapy Work?

Radiation therapy is based on the principle that radiation affects the cells ability to grow and divide. The DNA contained in the cell is damaged and it interferes with the cells ability to divide and the cell dies. The slower growth rate and ultimate death of the cancer cells causes the tumour to shrink over time. Radiation affects both normal and cancer cells, but the radiation treatment is designed to produce the maximum effect on the tumour and minimize the effect on normal tissue. Radiation therapy (megavoltage) is supplied by a Linear Accelerator. This device generates high energy photons or electrons (similar to conventional X-Rays but much more powerful) used to treat many kinds of cancer. Radiation therapy is typically applied to one site in an attempt to provide loco-regional therapy (primary tumour and regional lymph nodes) of a cancer but is not efficacious against metastatic cancer

Bruce A. Smith BVSc, Ms, FACVSc, Dip ACVS Richard Mitchell BSc, BVSc, CertSAS, DECVS

Ophthalmology Anna Deykin BVSc, FACVSc

Edith Hampson BVSc, PhD FACVSc

What is the goal?

When choosing radiation therapy for any patient, we have to consider what the goals of therapy are are we trying to cure or eradicate all local tumour cells, or are we trying to shrink a cancer to make it operable or more amenable to chemotherapy, or are we simply trying to make pain control easier?

Oncology Rod Straw BVSc, DACVS Valerie Poirier DVM, DACVIM, DACVR Tania Banks BVSc, FACVSc

Full course treatments (Curative)

Radiation therapy is delivered to a total dose of between 42-57 Gray for most types of cancer. This dose is more than 500 times what a diagnostic xray (radiograph) would be so it cannot be tolerated by any normal tissue as a single dose. We divide up that dose into many fractions which are then delivered on a Monday-Friday basis until the total dose needed for that cancers control has been given. Radiation therapy is a key feature in the treatment of patients with the following cancers: Nasal carcinomas Nasal sarcomas Nasal lymphoma

Internal Medicine Darren Fry MA, VetMB, FACVSc

Dentistry Gary Wilson BVSc, MVSc, MACVSc, CMAVA, Cert Teach Aaron Forsayeth BVSc, MACVSc

Laryngeal lymphoma Brain tumours Pituitary tumours Oral squamous cell carcinomas in dogs Skull tumours Incompletely excised (but not yet recurrent) mast cell tumours
cnr old northern rd and keong rd albany creek, qld 4035 07 3264 9400 fax 07 3319 6398 international +61 7 3264 9400 www.bvsc.com.au

 Incompletely excised (but not yet recurrent) soft tissue sarcomas (oral and other locations) Non-resectable plasma cell tumours Treatment of the patient with nasal tumour, brain tumour or large oral tumour typically involves a CT-based 3D (computer generated) radiation treatment plan, while more superficial tumour (Mast Cell Tumours, Vaccine Associated Sarcomas in Cats, Soft Tissue Sarcomas) are treated with an electron field and hand calculation; 10 20 treatments are administered over a 3-4 week time period. Lymphoma/plasmacytoma therapy takes fewer treatments as these tumour types are very sensitive to radiation therapy and we do not need as high a total dose.

Coarse fractionation treatment (palliative)

Radiation therapy can also be used in palliative fashion to try to slow an aggressive/nonresectable tumours growth, to shrink an oral tumour, decrease the vascularity of a cancer, or to kill pain associated with a cancer such as the following: Oral melanoma Bulky soft tissue sarcoma Bulky carcinomas Oral squamous cell carcinoma in cats Osteosarcoma Typically, palliative radiation therapy is given on as a twice a week fraction for 5 treatments, 5 weekly fractions, once a week fraction for 4 fractions or a single fractions depending on the patient characteristics.

How is it performed?
All radiation therapy requires perfect positioning of patients to avoid side effects to portions of the body that should not be in the treatment field! That means that each patient will have to be anesthetized for each therapy. Radiation therapy anaesthesia protocols are designed for safety in repetitive use often in an elderly patient population. Fentanyl, propofol and/or gas anaesthesia are used to try to have patients back on their feet as quickly as possible. The treatment field may be shaved and marks placed on the skin during the first imaging session to be certain that the treatment field stays the same with each treatment.

Admitting patients:
1. Patients for radiation therapy must first be seen by the radiation oncologist to discuss treatment options, prognosis, and overall state of health. 1. Imaging for treatment planning would be accomplished next so that a detailed treatment plan can be designed. 2. Once imaging and treatment planning are complete, radiation therapy would typically begin on a Monday (for full course treatments) although schedules can be adjusted to meet patient needs. Clients can drop their pets off early in the morning for the day, or

leave the patient for the entire treatment period. Pets must be fasted for at least 12 hours prior to their radiation therapy (due to anaesthesia needs).

Side Effects:
Radiation therapy cannot tell the difference between normal and cancer tissues it simply kills cells as they divide. Since most cancers divide much faster than normal tissues, we get a selective effect on the cancer cells. We expect, however, to see side effects of radiation therapy. Acute (or short term) effects include: loss of hair, moist desquamation of skin/mucus membranes (radiation burn like a blistering sunburn), and corneal irritation if these tissues are in the treatment field.

Common late side effects of radiation therapy include: permanent hair loss, permanent hair colour change, cataracts, retinal degeneration, keratoconjunctivitis sicca again only if these tissues are in the treatment field. Some organs have more difficulties with radiation than others eyes are clearly sensitive, but tubular organs (oesophagus, colon, rectum, urethra) can also be they could heal from acute radiation effects by scarring (stricture). The heart and lungs can only tolerate a limited amount of radiation therapy so we try to avoid these structures. Bone marrow is very sensitive to radiation if used in a whole or half body therapy. Bone density within a treatment field decreases. One in 10,000 patients could develop a bone tumour in a treated bone 5-10 years following therapy. The spinal cord and brains vasculature can also be sensitive to some types of radiation therapy (late effects). Because we want to minimize side effects, imaging and treatment planning are essential for most patients.

Symptom care for side effects:

Dogs and cats getting full course radiation therapy WILL develop acute side effects. Palliative or short course radiation therapy rarely causes acute side effects other than the hair loss needed in order to shave/mark the treatment field. Dogs with moist desquamation (cats more commonly get dry desquamation with dry flaky skin and itchiness) need to have their treatment sites kept clean and dry (with water not other products). We try NOT to bandage as we dont want dirt and moisture to build up that means that E-collars are often necessary as a dogs licking will only make the side effects worse. If a pet is scratching, sometimes T-shirts, socks or hobbles must be used to prevent self-trauma. Antiinflammatories and rarely narcotics can be used to help through this time period. Typically, these radiation burns form in the second to third week of full course therapy, and then form crusts, and then the skin heals under the crusts. The whole process takes about 2-3 weeks.

Mucositis is seen when the gums, tongue, cheeks, throat or other mucus membrane-lined tissue is in the treatment field (often with nasal or oral tumours). The mucosa will get very red, and may ulcerate or blister during the second week of full course radiation therapy. Bad smell to the breath (halitosis), drooling, and difficulty eating can occur. Oral rinses (black tea) are often helpful. Some cats and small dogs could require a temporary feeding tube if a large portion of their mouths are in the treatment field. Mucosa heals quickly following the conclusion of radiation therapy. Ocular side effects are of concern if the eyes are in the treatment field. Acute side effects include dry eye and corneal irritation so artificial tears and optimmune are often needed. Eyes are checked for corneal ulcer formation at least weekly if they are in the treatment field. Late side effects of radiation (permanent keratoconjunctivitis sicca or dry eye, cataracts, and retinal degeneration can be irreversible side effects of radiation therapy if the eye gets full dose or even scatter radiation. It takes between 6-12 months for cataracts to form following radiation therapy cataract surgery could be considered if the tumour is under control. Certain types of delayed side effects are very dangerous or deadly (spinal cord malacia, kidney fibrosis or scarring, lung fibrosis, death of bone) so every effort to avoid late side effects is made in full course radiation therapy the risks of developing these problems is small (5 %). The multiple fractions of radiation therapy as well as careful treatment planning are the ways that we attempt to avoid late side effects.

What if patient also needs other types of treatment?

If a patient has a type of cancer that would benefit from multimodality therapy (surgery, chemotherapy, etc), then there are additional timing concerns healing from surgery may be altered based upon when radiation therapy is started. Some chemo drugs make anti-cancer activity of radiation therapy stronger while some cause worsened radiation burns. The oncology team will help to design the best treatment plan to take into consideration all of these variables for the patient.

How much does radiation will cost?

The cost of radiation will depends on the protocol used and the complexity of the treatment planning. In general, a curative protocol will cost (including anesthesia, day care and RT fractions) from $2000-4000. A palliative protocol would be from $500-1250. Radiation planning should be added to the estimate. If a 3D planning is necessary (ex: brain tumor or nasal tumor), the cost would be $1200 (inclusive: CT scan, moulage and planning). For manual planning, the cost would be $100-200. If you have any questions or want a more precise estimate, do not hesitate to call 07 3264 9400.

What is the outcome with RT Tumour location and type Brain tumor-dogs and cats - All - Meningioma - Pituitary macroadenoma Osteosarcoma-dog Mast cell tumor Soft tissues sarcoma-dog Squamous cell carcinoma-cat Thyroid carcinoma-dog Localised lymphoma-cat Nasal tumor-dog Nasal tumor-cat - Lymphoma - Other Perianal tumors-dogs - Perianal adenoma - Anal sac carcinoma Oral tumors-dogs - Acanthomatous Epulis - Squamous cell carcinoma - Fibrosarcoma Treatment RT RT +/- Sx RT Pall RT RT Sx + RT RT Sx + RT RT RT Pall RT RT +/chemo RT RT RT RT Sx + RT + Chemo Pall RT Control or survival MS: 12-38 months MS: 16.5 months Mean S: 47 months MS: 4-8 mois TTP: 12 months 90% local cure 67% 1 year control 85% 3 years control 60% 1 year control 3 years PFS: 72% MS: 24 months MS: 28 months MS: 12-19.7 months MS: 20.8 months MS: 11.5 months 69% 1 year control MS: 32 months MS: 6-12 monts Commentary Role of surgery is unknown RT does not control the Cushings signs Pain relieved (74-92%) For grade 2 Marginal resection pre-RT Usually solar-induced Inoperable tumor Not nodal

Chemo: mitoxantrone

RT 85% cure RT 65% 1 year survival Excluding caudally located RT TTP: 11 months tumor Pall RT TTP: 6 months Sx+RT MS: 18 months - Melanome Pall RT MS: 7 months Metastasis frequent MS: Median survival, RT: Radiation therapy, Sx: surgery, Pall: palliative, TTP: Time to progression PFS: progression free survival