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