WBRT+/- steriods

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samysmiley

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Hi team,

I am working with my chair who has just started to work with residents. All of our other attending physicians use steroids in patients about to start WBRT to prevent/mitigate any edema (even in asymptomatic patients). My chair says we do not need to start steroids in asymptomatic patients when they get WBRT. I could not find any evidence to support or refute this. I could find papers on steroids+/- WBRT, but not vice versa. Do you guys have any leads? Thanks for the help.

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I usually dont put pts on steroids unless symptomatic.
 
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Also, a follow-up question. When treating a patient with leptomeningeal disease, do you include the posterior globe? Why or why not?
 
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Don't see a need of routine steroids in WBRT, especially in patients asymptomatic. Symptomatic patients are usually already on steroids when they meet you, and we taper them down or off during treatment as feasible.

Given that we frequently don't do routine steroids in our SRS patients anymore, I'd feel strongly against routinely starting steroids on every WBRT. Certain clinical scenarios (symptoms from brain mets or edema, risk of herniation if edema got any worse, significant non-symptomatic edema on the MRI/CT scan that diagnosed) may be more reasonable.

Leptomeningeal disease doesn't usually factor into whether we cover the posterior globe - that's more for specific histologies, like leukemias with CNS recurrence or primary CNS lymphoma. Others can state specific diagnoses that they would cover the posterior globe in the setting of WBRT.
 
I usually dont put pts on steroids unless symptomatic.

I second this.

Also agree with evilbooyaa. Just need to make sure you're really covering the whole brain including cribiform plate. Some people using bony landmarks I think were covering posterior globe just to make sure they were including the cribiform. I use my simulation CT to ensure complete coverage of the brain / meninges.
 
You don't need steroids in asymptomatic patients. The only patients I may do that, would be the ones who although being asymptomatic have a metastasis in a very unpleasant spot (although most of them are already symptomatic and thus on steroids) = brainstem / cerebellum with mass effect.
 
"This consensus review summarizes the authors’ views on steroid use for metastatic brain disease by indicating that the patient who shows evidence of elevated intracranial pressure, but who does not require immediate surgical attention for either hydrocephalus or impending herniation, should receive 4–6 mg/day of dexamethasone in divided doses and that the routine use of corticosteroids in patients without neurological symptoms is not necessary."

"Dexamethasone is the corticosteroid of choice and twice-daily dosing is sufficient (Good Practice Point). In most cases starting doses should not exceed 4–8 mg/day, but patients with severe symptoms, including impaired consciousness or other signs of increased intracranial pressure, may benefit from higher doses such as 16 mg/day or even more (level B recommendation). An attempt to reduce the dose should be undertaken within 1 week of initiation of treatment; if possible, steroids should be weaned off within two weeks. If complete weaning off is not possible, the lowest possible dose should be looked for. Asymptomatic patients do not require steroids. Steroids may reduce the acute side effects of radiation therapy. All these recommendations are Good Practice Points."

In other words, do whatever you want in the asymptomatic WBRT patient. One may wish to use steroids in symptomatic WBRT patients. Strong feelings either way reflect just that... feelings, not hard data.
 
I skip unless symptomatic.

Steroids aren't benign and I often see patients get edematous, agitated, have insomnia and have their diabetes go out of whack.

I end up putting a lot of my PCI patients on it because they end up with HA after starting tx.
 
I skip unless symptomatic.

Steroids aren't benign and I often see patients get edematous, agitated, have insomnia and have their diabetes go out of whack.

I end up putting a lot of my PCI patients on it because they end up with HA after starting tx.

I second this. I have seen several patients who missed follow up appointments or for whatever reason were unintentionally left on steroids and came back with myelopathy.
 
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A policy of putting all terminally ill cancer patients on dexamethasone may not be a bad idea in general (regardless of brain mets or WBRT). But yes, you have to wean them. I have mixed feelings about my logic for doing so despite the great Dr. Bruera advocating for it in all patients with advanced cancer, but I sheepishly admit I put all newly diagnosed brain met patients on short course dexamethasone with or without symptoms.
Its amazing how much better patients can feel with steroids, especially elderly ones. I have found that elderly pts with breast/prostate ca who get very fatigued during treatment often respond to really low doses. Some of them almost become addicted!
 
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We need to be cautious about just adding on steroids for any palliative RT. Patients may be on immunotherapy or about to start, and we don't want to blunt or diminish a potential immune response. Use sparingly or when symptomatic..
 
I usually start them on 2 mg/day just to prevent the call for (HA, n/v, random symptom x) and tell them to bump it up to 4/day if they get symptoms, or stop it at my first weekly if no symptoms. It's just better to have them leave the sim with the Rx rather than deal with at night when you know a proportion of them will feel crappy (psychosomatic or otherwise) after the first fraction or two.
 
The ACR Appropriateness Criteria have a nice discussion on this topic as well:

"In summary, there is little compelling evidence to support the routine use of steroids in the newly diagnosed patient with brain metastases who has no neurological signs or symptoms. Likewise, there is no compelling evidence that, in the absence of neurological symptoms, steroids should be started simply because the patient is about to start radiation therapy. Steroids cause toxicity and may mitigate the therapeutic effects of systemic therapy for renal cell carcinoma and melanoma. Therefore, any recommendation for steroids must be rendered in light of this fact. For patients with minimal neurological symptoms the panel recommends either starting with 4–8 mg/day or starting with 16 mg/day but tapering after a few days. In all cases, steroids should be tapered as clinically indicated and tolerated (see Variant 4)."
 
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