Emergency rt for nurse

Emergency RT

Sirentra Wanglikitkoon, MD.

Contents • Brain metastasis

• Spinal cord compression

• SVC obstruction

• Others

• Airway obstruction

BRAIN METASTASIS

• Survival ?

• Symptom ?

• Treatment

• RT

• ?

•Complication?

Epidemiology

• The most common intracranial tumors in adults

Epidemiology

Pathogenesis

• Most common mechanism is hematogenous spread

• Usually located at gray white junction

• Distribution of metastases

• Cerebral hemispheres : approximately 80 %

• Cerebellum : 15 %

• Brainstem : 5 %

Clinical presentation

Prognosis

• Age

• Performance status

• Primary un/controlled

• Pathology

• Metastasis disease

• Number of brain metastasis

•RPA

•GPA

•Diagnosis-specific GPA

Prognosis - RPA

Recursive Partitioning

Analysis

Prognosis - RPA

RPA Median survival

Class I 7.1 months

Class II 4.2 months

Class III 2.3 months

Prognosis - GPA

Prognosis - GPA

Prognosis: Diagnosis-specific GPA

2.8 mo 25.3 mo

A 58-year-old patient with Rt hemiparesis

CT brain: ring enhancing lesions with vasogenic edema at both frontoparietal region. DDx: Brain metastasis

Imaging: CT brain

Imaging: MRI brain

MRI will frequently pick up smaller lesions not seen on CT scans

Significant effect on the patient’s prognosis and treatment course.

Imaging: NCCN 2013

Imaging: NCCN 2013

Investigation

Management

• Symptomatic treatment

• Prevent and control cerebral edema: corticosteroids

• Anticonvulsants

• Specific treatment: local brain

• Radiotherapy • Conventional whole brain RT: Standard treatment

• Stereotactic radiosurgery (SRS)

• Surgical resection

Management

• Symptomatic treatment • Prevent and control cerebral edema: corticosteroids

• Anticonvulsants

• Specific treatment: local brain

• Radiotherapy • Conventional whole brain RT: Standard treatment

• Stereotactic radiosurgery (SRS)

• Surgical resection

Corticosteroids

• Improve edema and neurologic deficits

• Approximately two-thirds of pts Improve

• Should promptly start with dexamethasone 10 mg IV or oral bolus 4-6 mg q 6-8 hrs

• With concurrent PPI

• In asymptomatic pts with little edema and mass effect may be reserved until the first sign of neurologic symptoms.

Anticonvulsants

Management

• Symptomatic treatment

• Prevent and control cerebral edema: corticosteroids

• Anticonvulsants

• Specific treatment: local brain • Radiotherapy

• Conventional whole brain RT: Standard treatment

• Stereotactic radiosurgery (SRS)

• Surgical resection

Whole-brain radiotherapy • WBRT and appropriated steroid use are still standard

treatment of brain metastasis

• Average Median survival of brain metastasis

• Without treatment : approximately 1 month

• With corticosteroids use : 2 months

• With WBRT : 3-4 months

APRIL F. EICHLER,The Oncologist 2007;12:884–898

Whole-brain radiotherapy

• Standard of care in pts with brain metastasis

• Radiographic and clinical response rates: 50-75%

• Standard dose and fractionation: 30 Gy in 10 fractions

WBRT: Dose & fractionation

20Gy/5F = 36Gy/6F = 30Gy/10F,15F = 40Gy/15F,20F

Stereotactic radiosurgery • High dose per fraction

• High conformity

• Rapid dose fall-off

• Minimizing radiation dose to surrounding normal tissue

• Radiation tolerance of normal tissue is volume dependent

• Precisely directed target (usually ≤ 1mm)

• Strictly Immobilization head flame

Stereotactic radiosurgery

Tumor size Max. Dose

< 20mm 24 Gy

21-30 mm 18 Gy

31-40 mm 15 Gy

Maximum tolerated doses of SRS

Int. J. Radiation Oncology Biol. Phys., Vol. 47, No. 2,

pp. 291–298, 2000

Surgical resection

Role of surgery

• Pathology: tissue diagnosis

• Relieving mass effect due to large symptomatic metastases

• Improve local control and survival

Surgery + WBRT vs WBRT alone: Single brain metastasis • KPS ≥70

KPS ≥70

KPS ≥50

WHO≤2

40 wks 15 wks

10 mo 6 mo

NS

Brain complications

• Acute complication

• Acute Encephalopathy

• Late-delayed complication

1. Radiation Necrosis

2. Cognitive Dysfunction

3. Radiation induced brain tumor

Perez 5th edition p 730

Acute Encephalopathy

• Pathogenesis:

• RT open the BBB acutely exacerbate preexisting peritumoral edema

• Onset

• generally most severe following the first radiation dose and gradually lessens in severity thereafter

• Clinical presentation

• nausea and vomiting, drowsiness, headache, and worsening of preexisting neurologic deficits

Acute Encephalopathy

• Management

• Small dose per fraction (<300 cGy)

• Routine use of corticosteroids in pts with peritumoral edema

For Nurse

• Prognosis

• Observe neuro sign

• Observe RT complication

• Dexamethasone • DM

• PPI

• Infection

Spinal cord compression

Introduction

• 5-14% of all cancer patients

• 1/3 survival beyond 1 yr

• Most common cancer

• breast cancer 29%

• lung cancer 17%

• prostate cancer 14%

Introduction

• Location of the site of compression

• cervical spine 4-15%

• thoracic spine 59-78%

• lumbosacral spine 16-33%

•multiple sites 50%

Spinal

cord compression

Continued growth

vertebral bone metastasis

Paraspinal mass into

neural foramen

Destruction of vertebral

cortical bone

Pathophysiology

Spinal cord compression

Epidural venous plexus compression

Spinal cord edema

Increased vascular permeability and edema

Decreased capillary blood flow

White matter ischemia

Clinical manifestations

• Bone pain 88-96% : earliest symptom

• Muscle weakness 76-86%

• Sensory loss 51-80% : examined spinal sensory level is typically 1-5 levels below the actual level of cord compression

• Bowel or bladder dysfunction 50-60%

Imaging

Plain film

• False negative 10-17%

• might not detect paraspinal masses

J Clin Oncol 23:2028-2037

Imaging

MRI (Whole spine)

• Method of choice

• Accuracy 95%

• sensitivity 93%

• specificity 97 %

Goals of treatment

• Pain control

• Avoidance of complications

• Preservation or improvement of neurologic function

Prognosis

• Time from start of any symptoms to development of motor deficits

• Pathology and primary cancer

• Pretherapy ambulatory status

Management

•Corticosteroid

•Surgery

•RT

Corticosteroid

•Must be started as soon as possible (even before radiographic diagnosis)

•PPI for GI prophylaxis

Corticosteroid

• Sorensen et al, 1994

• Vecht et al, 1989 Comparison: Dexa 100 mg vs 10 mg IV oral 16mg/d Conclusion : no differences on pain, ambulation, or bladder function

RCT Dexa (before RT) 96 mg IV then oral 96mg/day

then 10 day taper No Dexa

3-mo ambulatory rate 81% 63%

6-mo ambulatory rate 59% 33%

Corticosteroid

• Dexamethasone dose: loading dose 10 mg iv then 4-6 mg q 6 – 8 hrs then tapering

Surgery

Advantage • Immediate cord decompression and provoids an

opportunity to stablize spine

Indication • Spinal instability or bony compression

• Single site of cord compression

• Neurologic progression during or after RT

• Unknown primary site

• Radioresistant tumors

Patchell, 2005 - Surgery within 24 hr - Single area of spinal compression

Surgical plus RT All/walk entry (50)

RT alone All/walk entry (51)

Combined ambulatory rate 84% (42/50) 57% (29/51)

Retained ability to walk 122 days 13 days

Walk at entry 94% (32/34) 74% (26/35)

Retained ability to walk 153 days 54 days

Unable to walk at entry 62% (10/16) 19% (3/16)

Retained ability to walk 59 days 0 days

J Clin Oncol 23:2028-2037 Lancet 2005; 366: 643–48

Radiation

Volume of treatment

• Superior-inferior

• To cover 1 level of upper and lower spine, if definite level from MRI

• Lateral

• Adequate margin vertebral body

Radiation dose

• Commonly use 30 Gy in 10 Fx

• Compared short course (8Gyx1F, 4Gyx5F) vs long course (3Gyx10F, 2.5Gyx15F, 2Gyx20F)

• Better local control in long course (81%vs61%)

• Improve motor not different

• Long course prefer to favorable expected survival

For nurse

• Early detection: Patient with bone metastasis developed weakness

• Prevent bed sore

• PM&R

Superior Vena Cava Syndrome (SVC) with Malignancy Causes

Introduction

• Syndrome results from any condition that leads to obstruction of blood flow through the SVC

• Obstruction by

• invasion or external compression of SVC by adjacent pathologic structure eg, right lung, LN or mediastinal structures

• thrombosis of blood within the SVC

Introduction

Causes of SVC obstruction

• Malignancy 60-80%

• NSCLC 50%

• SCLC 25%

• Lymphoma

• Metastasis tumor at mediastinum

• Benign 20-40%

• Thrombosis due to using intravascular devices

• Infection

Clinical manifestation

Imaging

• Chest X-ray: 25% negative

• CT scan with contrast

• Most useful image shows level and extent of blockage

• Venogram

• Only when an intervention (placement of a stent or surgery) is planned.

• MRI

• Patients cannot tolerate contrast medium

• PET-CT

• For design radiotherapy field

Definite diagnosis Pathology

• Minimal invasive procedures

• Sputum cytology

• pleural fluid cytology

• biopsy SPC

• More invasive procedures

• Bronchoscopy

• Mediastinoscopy

• Video-assisted thoracoscopy

• Thoracotomy

• Percutaneous transthoracic CT-guided biopsy

Before RT

Management

• Considered treatment of cancer and relief symptoms of obstruction

• Current management guidelines stress the importance of accurate histologic diagnosis prior to starting therapy

Supportive treatment

• Head should be raised to decrease head and neck edema

• Avoid intramuscular/intravascular injections in arms

• Glucocorticoids

• Diuretics

Management

Chemo-responsive tumor: SCLC, lymphoma , germ cell tumor

• Initial chemotherapy is treatment of choice for patients with symptomatic SVC syndrome

• Rapid clinical response

Management

Radiation therapy • RT complete relief of symptoms within two weeks

• 78% in SCLC and 63% in NSCLC

• Target: gross disease and adjacent nodal region

• Dose: lymphoma is recommended conventional Fx

SCLC/NSCLC are recommended hypofractionation

Management

Endovascular stenting • For True emergency condition

• stridor due to central airway obstruction

• coma from cerebral edema

• Recommend emergent treatment with endovascular stenting followed by radiation therapy (RT)

Airway obstruction