Emergency rt for nurse

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Emergency rt for nurse

  1. 1. Emergency RT Sirentra Wanglikitkoon, MD.
  2. 2. Contents • Brain metastasis • Spinal cord compression • SVC obstruction • Others • Airway obstruction
  3. 3. BRAIN METASTASIS
  4. 4. • Survival ? • Symptom ? • Treatment • RT • ? • Complication?
  5. 5. Epidemiology • The most common intracranial tumors in adults
  6. 6. Epidemiology
  7. 7. Pathogenesis • Most common mechanism is hematogenous spread • Usually located at gray white junction • Distribution of metastases • Cerebral hemispheres : approximately 80 % • Cerebellum : 15 % • Brainstem : 5 %
  8. 8. Clinical presentation
  9. 9. Prognosis • Age • Performance status • Primary un/controlled • Pathology • Metastasis disease • Number of brain metastasis • RPA • GPA • Diagnosisspecific GPA
  10. 10. Prognosis - RPA Recursive Partitioning Analysis
  11. 11. Prognosis - RPA RPA Median survival Class I Class II Class III 7.1 months 4.2 months 2.3 months
  12. 12. Prognosis - GPA
  13. 13. Prognosis - GPA
  14. 14. Prognosis: Diagnosis-specific GPA 2.8 mo  25.3 mo
  15. 15. Imaging: CT brain A 58-year-old patient with Rt hemiparesis CT brain: ring enhancing lesions with vasogenic edema at both frontoparietal region. DDx: Brain metastasis
  16. 16. 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.
  17. 17. Imaging: NCCN 2013
  18. 18. Imaging: NCCN 2013
  19. 19. Investigation
  20. 20. 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
  21. 21. 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
  22. 22. 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.
  23. 23. Anticonvulsants
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. WBRT: Dose & fractionation 20Gy/5F = 36Gy/6F = 30Gy/10F,15F = 40Gy/15F,20F
  28. 28. 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
  29. 29. Stereotactic radiosurgery Maximum tolerated doses of SRS Tumor size Max. Dose < 20mm 24 Gy 21-30 mm 18 Gy 31-40 mm 15 Gy Int. J. Radiation Oncology Biol. Phys., Vol. 47, No. 2, pp. 291–298, 2000
  30. 30. Surgical resection Role of surgery • Pathology: tissue diagnosis • Relieving mass effect due to large symptomatic metastases • Improve local control and survival
  31. 31. Surgery + WBRT vs WBRT alone: Single brain metastasis • KPS ≥70 40 wks 15 wks KPS ≥70 10 mo 6 mo WHO≤2 NS KPS ≥50
  32. 32. 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
  33. 33. 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
  34. 34. Acute Encephalopathy • Management • Small dose per fraction (<300 cGy) • Routine use of corticosteroids in pts with peritumoral edema
  35. 35. For Nurse • Prognosis • Observe neuro sign • Observe RT complication • Dexamethasone • DM • PPI • Infection
  36. 36. Spinal cord compression
  37. 37. 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%
  38. 38. Introduction • Location of the site of compression • cervical spine 4-15% • thoracic spine 59-78% • lumbosacral spine 16-33% • multiple sites 50%
  39. 39. Pathophysiology Paraspinal mass into neural foramen Continued growth vertebral bone metastasis Destruction of vertebral cortical bone Spinal cord compression
  40. 40. Spinal cord compression Epidural venous plexus compression Spinal cord edema Increased vascular permeability and edema Decreased capillary blood flow White matter ischemia
  41. 41. 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%
  42. 42. Imaging Plain film • False negative 10-17% • might not detect paraspinal masses J Clin Oncol 23:2028-2037
  43. 43. Imaging MRI (Whole spine) • Method of choice • Accuracy 95% • sensitivity 93% • specificity 97 %
  44. 44. Goals of treatment • Pain control • Avoidance of complications • Preservation or improvement of neurologic function
  45. 45. Prognosis • Time from start of any symptoms to development of motor deficits • Pathology and primary cancer • Pretherapy ambulatory status
  46. 46. Management •Corticosteroid •Surgery •RT
  47. 47. Corticosteroid • Must be started as soon as possible (even before radiographic diagnosis) • PPI for GI prophylaxis
  48. 48. Corticosteroid • Sorensen et al, 1994 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% RCT • Vecht et al, 1989 Comparison: Dexa 100 mg vs 10 mg IV oral 16mg/d Conclusion : no differences on pain, ambulation, or bladder function
  49. 49. Corticosteroid • Dexamethasone dose: loading dose 10 mg iv then 4-6 mg q 6 – 8 hrs then tapering
  50. 50. 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
  51. 51. 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
  52. 52. 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
  53. 53. • 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
  54. 54. For nurse • Early detection: Patient with bone metastasis  developed weakness • Prevent bed sore • PM&R
  55. 55. Superior Vena Cava Syndrome (SVC) with Malignancy Causes
  56. 56. 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
  57. 57. 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
  58. 58. Clinical manifestation
  59. 59. 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
  60. 60. 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
  61. 61. Management • Considered treatment of cancer and relief symptoms of obstruction • Current management guidelines stress the importance of accurate histologic diagnosis prior to starting therapy
  62. 62. Supportive treatment • Head should be raised to decrease head and neck edema • Avoid intramuscular/intravascular injections in arms • Glucocorticoids • Diuretics
  63. 63. Management Chemo-responsive tumor: SCLC, lymphoma , germ cell tumor • Initial chemotherapy is treatment of choice for patients with symptomatic SVC syndrome • Rapid clinical response
  64. 64. 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
  65. 65. 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)
  66. 66. Airway obstruction

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