Pediatric Palliative Radiation: Single Institution Practice Patterns And End Of Life Outcomes

There are few studies examining the use of palliative radiation therapy (RT) in the pediatric population. This study is one of the largest series reported of palliative RT practice patterns prior to and within 1 month of end of life in pediatric patients from a single institution. A retrospective chart review of patients treated with radiation from 2008-2017 identified patients treated with radiotherapy with palliative intent. Demographic, diagnosis, and treatment parameters were collected for each patient through the electronic medical records. Patients who were deceased at time of review had date of death recorded as date of last follow-up. Patients who were either alive at time of review or who had unknown survivor status had last follow-up visit or last imaging result recorded as date of last follow-up. Of the initial 1,092 patients treated with RT, 108 were identified as having received 227 treatments with palliative intent. Forty-five patients (42%) were female and 63 (58%) were male. The median age at the time of the first course of radiation was 11 years (range 0-25). Central nervous system (CNS) disturbance was the most common indication for palliative radiation (n=50, 46%) followed by pain (n=44, 41%) as the second most common indication. The most common diagnosis was a primary neoplasm of the CNS including the brain, spinal cord, and meninges (n=30, 37%). Patients also presented with metastases (n=23, 21%), neuroblastomas (n=20, 19%), and rhabdomyosarcomas or other connective tissue sarcoma (n=11, 10%). Most patients had a single course of radiation (n=56, 52%) with 1 or more targeted lesions treated with palliative RT. Most were treated with 3D conformal radiation or intensity-modulated radiation therapy (IMRT) (46% and 44%, respectively). Median dose of radiation was 23.4 Gy (range 2.5–50.4) treated in a median of 10 fractions (range 1-37). Forty-four percent were treated under sedation with anesthesia for at least one course of radiation. Few patients had any acute toxicity. The majority of patients also received chemotherapy. The median time from diagnosis to last follow-up was 32.5 months (range 3-242). The median time from last course of RT to date of last follow-up was 3 months (range 0-105), and 25 patients (23%) received RT in the last month of life. Eighty-two (78%) patients were deceased at time of review. Pediatric palliative radiation can be safely administered with anesthesia but given the potentially short interval between treatment and death, further study on the indications for palliation, the optimal radiation dose and fractionation, and the patients most likely to benefit from palliative RT is required. In our study, CNS malignancy and CNS disturbance were the most common diagnosis and indication for palliative RT. Future investigation to identify pediatric patients with primary CNS malignancies who may benefit from early palliative radiation prior to the development of symptoms may have meaningful impact on the end of life.