The side effects of radiotherapy and the precautions to take

(Meeting in the presence of Dr. Dhermain, radiotherapist - Gustave Roussy - October 15, 2024)

 

During this meeting we started from 2 concrete cases that we will call here "patient Delphine" and patient "Adeline". Finally you will find questions and answers at this meeting.

Preamble to better understand:

Elements already appear in the article on radiotherapy that we advise you to consult before reading it.
https://amavea.org/la-radiotherapie-questions-de-piets-et-pourpons-du-dr-frederic-dhermain-radiotherapeute/

 

Radiotherapy dosage information:

During radiotherapy of 15 sessions, it is issued to the patient 2 grays/ sessions. So about 30 grays in total.

Classically it takes 2 ½ weeks to deliver 2 grays/sessions. We thus arrive at 26 Grays in total.

During radiotherapy of 5 sessions, it will be issued to the patient 6 grays /sessions. So always 30 grays in total.

During radiotherapy with 1 single session, it can be delivered 20 grays in 1 session.

Depending on the mode of radiotherapy, it is the dose per session which is different and which can be 4-5-6 or even 10 times greater: i.e. 6-8-10 or even 20 grays instead of 2.

Patient Delphine

Inventory: We are on a meningiom of the right cavernous sinus (approximately 5 cm), discovery on symptomatology such as paresthesias of the right hemiface (tingling and tingling on half of the face). Meningioma continuing to progress despite the stop of the progestogen, it was decided to do radiotherapy in December 2021. Namely 5 sessions of Cyberknife.

Reflection

-It is quite exceptional to do hypofraction radiotherapy for tumors measuring more than 3-4 cm

- why this choice: often because the patient lives far, that she is elderly and has difficulty moving

- Often, there is a possibility of making 5 sessions instead of 25 or 30. Or even 1 radiotherapy in 1 single session.

To remember: Information that is useful to give the patient:

- To explain to him that the fact that there are fewer sessions involves sessions with more radiation . So with stronger toxicity and important, or even regular significant side effects. It is therefore important to know the deadlines (weeks? 1 month? 3 months? 6 months? 1 year…) as well as list the side effects that we must expect in relation to so -called classic radiotherapy.

How are immediate consequences:

- The increase in the dose per session can lead to a certain toxicity which can happen the 1st, the 2nd or even the 3rd day.

- But these side effects can also occur for a few weeks or months (between 1 and 3 months) after radiation therapy in about 15 to 20 percent cases.

These main signs are nausea, vomiting, dizziness, asthenia, violent headache.

This may require suspend the treatment, the time the patient is restored.

How to exchange with your radiotherapist:

- ask him to describe the treatment and side effects in the short, medium, long term

- Ask for a second opinion

- Ask if there are several radiotherapy options. What are the criteria that make it possible to choose one rather than another as well as the expected side effects (short, medium and long term)

 

'Radionecrose' type complication:

- Radionecrosis is a late complication of radiotherapy

- The fabric necrosis: late reaction of the brain fabric

-This can occur up to 9-12 months after radiation therapy and even later in an exceptional way

- Symptoms: Varied forms: symptoms neating, or from light headache to signs identical to a stroke but delayed.

- In half of cases, radionecrosis is only radiological and there is no symptomatology. And during the following checks, it decreases.

- radionecrosis, if severe, can be larger than the size of meningioma

- Treatment: corticosteroids

In rare cases, long -term toxicity can settle. This leads to a worsening of the starting symptomatology (that is to say when discovering meningioma). It is found in the case "Delphine" where the paresthesias of the face have been transformed into post radical neuralgia

Patient Adeline

Question asked here:

Is radiotherapy indicated to avoid a regrowth of a meningiomal residue?

Reflection carried out:

There are different grades and different locations of meningiomas. These meningiomas happen to a vein, a venous sinus or nerves and that the surgeon is forced not to go further. It therefore leaves, what is called a residue which can be very small (invisible or qque mm/cm). Sometimes the residue being minimal it is interesting to make an MRI 2-3 months after surgery to see more clearly. If there is a doubt, another MRI can be scheduled 2 months later.

In the case of a grade 1 meningioma, the residue is unlikely to grow (less than 20%) in the following months or years. Radiation therapy will be discussed if the residue increases by 1 mm by 2 axes (1 axis and its perpendicular). In any case, we will not be in the urgency of radiotherapy, and the patient will have time to think about it. In the case of a residue regrowth, the surgeon can possibly reinforce a second time but radiotherapy will be necessary after this second intervention.

The question arises more when it is a grade 2, even 3 meningioma.

It is good to do an MRI in immediate surgery in order to have a repository. But, according to hospitals, it is not always possible.

Now, with new radiotherapy techniques, a surgeon can intervene a second time even if post-radic. Indeed, surgical techniques that have progressed, monitoring by MRI being systematic, and radiotherapy being less toxic for the surrounding tissues, access to surgery has become possible, even in post-radical.

There is no more infection if an intervention is practiced after radiotherapy. However, we should expect a longer hospitalization due to slower healing and greater bleeding.

What is important is to have a collegial decision.

After radiotherapy, meningiomas continue to grow in - 10 % of cases

If there is no vital risk with radiotherapy, there is a toxic risk that can go as far as patients (cf. Delphine case).

Recommendations:

- Ask for a second opinion (but no more). In order to be transparent, it should be said to the radiotherapist 1. In the case of meningiomas, radiotherapy is not an emergency.

- Do not accept blurred speeches. The radiotherapist must be clear and precise in his explanations and the probable side effects expected

- Do not hesitate to ask questions to which the radiotherapist must answer with just as many details. Do not hesitate to insist when the answer is blurred.

How is the choice of surgery/radiotherapy when the location of meningioma is problematic?

- When a meningioma is very poorly placed to intervene surgically, it is just as poorly placed to do radiotherapy. However, this does not mean that the radiotherapist will not be able to treat it.

- There are meningiomas placed in 'risk' places that threaten fragile parties. These are mainly the meningiomas of the cerebral trunk, the optic nerve, the optical chiasma, the marrow, the magnum foramen, the occipital hole, the cavernous sinuses, the longitudinal venous sinus etc ... The surgical gesture is then as much feared as the radiotherapeutic gesture especially if it is stereotaxy.

- Before making a decision, the benefit/risk must be measured. See if there are annoying symptoms, the age of the patient etc. Take into account that it is often the largest meningiomas that grow the least because their progression is slow. If it takes place it is over several years (meningioma, if it grows, it is slowly.)

Seeing if it's worth taking the risk of late and disabling toxicity for the patient's daily life.

- The recommendation is to make regular MRIs. When a symptom is triggered (like a visual symptom for example), it is rediscovered. If the surgeon cannot intervene, the radiotherapist will then take over.

- The radiotherapist will then decide on the dose, fractionation, machine, number of session, total dose, etc. It's really a à la carte 'decision.

- The objective is to ensure the most prolonged local control of meningioma. This means that meningioma will not disappear, but it will no longer grow. Meningioma is sterilized and not burned (which would be dangerous because the place where it is located must remain as functional as possible).

- In 85 to 90% of cases, you get stability over 10 years minimum. If the disease resumes, it is necessary to take into account developments in medicine and surgery over a decade. And also take into account the progress of surgical techniques and the technicality of radiotherapy machines as well. (Soon the "zap", a sort of gammaknife without cobalt)

Can we treat a young person in the same way as an elderly person (the 2 having the same meningioma)?

- No because it is not the same disease.

- Generally, we do not develop meningioma at 20 years old. If this occurs, it is, a priori, because of a radiotherapy treatment that the patient would have had much younger, and which would be linked to another brain tumor, herself healed, like a meédulloblastoma.

- When we discover a meningioma on an 80 -year -old person, we can say that the disease has been there for a long time and that it will not evolve or little and that it will not harm the quality of life of the person on what remains to live.

Retain that the category of meningiomas due to progestins is a separate disease.

Technology is evolving. It makes it possible to treat or even retirement patients. Does this development make it possible to lower the toxicities of radiotherapy?

The answer is not obvious.

Meningioma is a benign disease (read here: non -cancerous) but very annoying.

Meningioma is a mening disease. To no longer have any risk of redoing meningioma, this mening is necessary to remove.

A patient who has meningioma, is more likely to make others.

A treated meningioma can re -evolve more than 10 years later. But it is still necessary that the patient is still alive. And in 10 years the technology evolves greatly, so the care also. Technology must go hand in hand with the training of nursing teams that will use it. You have to be master of these new technologies before using it.

When you have a range of machines and technology, it becomes possible to adapt the treatments and choose the ad hoc machine for the patient's individual situation.

It should also be taken into account that people living longer and longer, we will have to treat more often and even several times the same meningioma. This therefore increases toxicity because it is always the same brain that is irradiated.

In any case, you always have to weigh the profits/risk balance because it is different for each case.

The association thanks Delphine and Adeline, for the transcription of exchanges and Dr. Dhermain for her listening and her benevolence.