Palliative Flashcards
what percent of treatments are palliative ?
35-50%
goal of palliative treatmnt
relieve symptoms and maintain quality of life
dose for brain mets
20/5 or 30/10
what type of treatment plan is used for brain mets
linical markup (CMU): requires no simulation
Inferior border is set from a straight line from the supraorbital ridge to the tip of tragus or the lower junction of the ear
SOR to EAM → correct answer for CAMRT exam
This technique covers most of the brain and clears the lens
Borders for brain mets
Inferior: inferior to cribriform plate, cranial fossa and foramen magnum
Anterior: 3 cm posterior to the ipsilateral eyelid
inferior frontal lobe and temporal lobe brain mets
Portal must descend to infraorbital ridge and external auditory meatus
A lens or orbital block should be used
presentation of brain mets
eizures, headaches, focal and motor sensory deficits, gait disturbance, visual or speech changes, changes in memory, personality alterations, nausea and vomiting
medications that brain mets patients should get
for patients with seizures -dilantin is given
moderate dose and high dose corticosteroids (dexamethasone and prednisone) to help with ICP
how long does it take for corticosteroids to take effect
48 hours
diagnostic methods for brain mets
Contrast enhanced MRI → preferred imaging modality
CT and PET with FDG may also be used
If it is a first metastatic lesion, histologic confirmation should be obtained
are primary or metastatic brain tumours more common
metastatic is 10x more common than primary braintumours
what % of cancer patients develop brain mets during some point in their treatment
10-30%
most common primary its that lead to brain mets
lung, breast and melanoma
where do most brain mets occur?
Most brain metastases occur at the junction of the grey and white matter
80% of metastases are found in the cerebral hemispheres, 15% in the cerebellum and 5% in the brainstem
how do most tumours develop into brain mets
usually obtained through vasculature
what % of brain mets are single mets
40-50% are single mets
medial survival for someone diagnosed with brainmets
3 months
prognostic indicator most important in brain mets
karnofskys performance status is most important
treatment for solitary brain mets
sx followed by art dose of 30/10 patient status must also be good
treatment for bulky brain mets
whole brain radiation therapy +temolzomide, these patients are usually not candidate for SRS
Treatment for patients with 1-3 brain mets
WBRT (30/10)followed by SRS
Doses for patients for first treatment of brain mets and reirradiation of brain mets
brain mets can be treated with 30Gy initially then reradiated with 20Gy the second time brain mets often get reradiated
PCI and dose
PCI (Prophylactic cranial irradiation) is often given for patients with SCLC (small cell lung cancer) as there is a high propensity for brain mets DOSE: 25/10
SRS in brain mets
usually used for deep lesions and areas of serious neurologic deficit used for tumours that have progressed after WBRT
SYSTEMIC therapy in brain mets
temozolomide is an oral alkylating agent used in brain mets as there is a great CNS penetration
HBI for bone mets border
upper , mid and low body HBI
HBI (semi body radiation) is used for bone mets and has the borders below: Upper HBI: Covers thorax and abdomen, from the neck to the ischial tuberosities
Midbody HBI: Covers abdomen and pelvis from the diaphragm to the ischial tuberosities
Lower HBI: Top of the pelvis to the inferior portion of the femurs
is the dose higher or lower for upper body HBI vs lower body HBI? Why?
dose is lower for upper body HBI as we need to be aware of the dose limiting structures, the lung is a dose limiting structure in the upper body HBI remember its TD5/5 is 1750
doses in bone mets 8Gy/1fx vs 30Gy/10fx indications and pros and cons
8Gy/1fx is used for patients who prefer not to come back/ travel for treatments and are used for patients with poorer performance status and for patients with a shorter life expectancy CONS: of this treatment regime is that there is a 2-3 x high risk of needing pretreatment and there is a higher risk of flair up brain which can be treated by corticosteroids higher level of pathological fracture than longer treatment fractionations
30/10fx is used for patients with better prognosis, better life expectancy, performance status etc.
maximum tolerance dose for upper vs lower HBI
upper HBI MTD is 6Gy (due to the lung) and 8Gy for lower and mid HBI `
most common bone mets presentation
slowly progressive insidious pain that is usually worse at night
presentation of mets in the acetabulum
increase in pain in ambulation or weight bearing
presentation of mets in the ischium or sacrum
increase in pain when seated, less pain when ambulation
what imaging is the best for discovering bone mets
bone scans are most sensitive and specific Tc-99m is most important for screening individuals at risk for bone mets used to indicate osteoblastic (+ bone production) bone activity
what method is best at evaluation neoplastic invasion of bone marrow?
MRI is best at this and it can find invasion of red bone marrow and also is best at determining bone mets from osteoporosis
clinical examination for bone mets? what is done if the clinical exam indicated bone mets?
clinical exam requires HCP to palpate patients body and locate point tenderness which may indicate bone mets. if bone mets is thought then imaging is done
most common site of mets in general is to ____.
bone
what primary sites are most common in bone mets
breast and prostate comprise 70% of the primaries that cause bone mets
most common sites of bone mets
axial skeleton and lumbar spine
how long is the bone life cycle?
120-200 days
3 types of cells that make up bones
Osteocytes: Mature osteoblasts that maintain the bone’s structure
Osteoclasts: Originate from the bone marrow and adhere to the bone
Osteoblasts: Originate from the endosteum and periosteum and build bone by depositing collagen into the extracellular space
types of spread that lead to bone mets
most common is hematogenous followed by direct extension
primaries of breast and prostate cause bone mets in what part of the skeleton and why
in the axial skeleton because they have a high predilection to invade the red bone marrow Metastatic invasion of the bone cortex rarely happens without red marrow involvement → this is why the spine, pelvis and ribs are usually involved before the skull, femora, humeri, scapula and sternum
what 2 worse things can result from bone mets
pathologic fracture and spinal cord compression can result from bone mets
most common causes of pathologic fracture
- osteoporosis
2. bone mets
how long do people live after the diagnosis of bone mets
varies widely depending on the primary tumour
if lung is the primary- 6months
if breast or prostate is the primary- 2-4 months
pain relief to bones of different parts of the body
73% spine mets
88% limb mets
67% pelvic mets
75% mets in other parts of the skeleton
when is XRT used in bone mets when is cx used in bone mets
XRT is used for localized bone mets and Cx is used for diffuse bone mets
HBI for bone mets indications
Used for the palliation of symptoms and adjuvantly to prevent the formation of new bony metastases
Treats about ⅓ of the whole body and is divided into upper, middle and lower HBI
Used for pts with a short life expectancy with multiple symptomatic mets
used to palliate lytic bone mets (lytic = destroy bone think mottled bone) blastic lesion (extra bone is made)
Because of the potential for toxic effects to visceral structures and the difficulties in treatment setup, HBI is not routinely used to palliate multifocal bone mets
which occurs more quickly : the regeneration of peripheral blood counts or the regeneration of bone marrow
regeneration of peripheral blood counts occurs more quickly
the regeneration of bone marrow is influenced by pt age time after XRT, XRT volume and dose and sequencing of chemo
systemic XRT used in the treatment of bone mets
WFRT (Wide field radiation therapy) and radionuclide therapy
indications and contraindications for radionuclide therapy for bone mets
Suitable for pts with multiple bastic, painful mets who have exhausted all other EBRT
Contraindications: pts with poor renal or hepatic function, life expectancy < 6 weeks and urinary incontinence
where do most surgeries to treat bone mets occur
65% are for the femur
why is surgery used in bone mets
most surgery is to prevent OR TREAT pathologic bone fractures
what surgery is used for fractures of the femoral neck
total hip arthroplasty which replaces the femoral neck and the acetabulum or proximal femoral endoprosthesis alone
most common site of spinal cord compression
thoracic spine
prognostic factor most important for spinal cord compression?
patient ambulation
most common presentation of spinal cord compression
back pain that lasts for several weeks
diagnostic methods of spinal cord compression?
MRI and histologic confirmation should be given unless medically contraindicated
combined treatment modalities for SCC?
surgery followed by XRT
indications for surgery in SCC
Surgery should be especially considered for its with fracture, dislocation , paraplegia, radio resistant lesions, absence of steroid response or if there is no histologic confirmation of disease
different XRT plans for different areas of SCC
post field using 4-6MV photons
POP used for tumours approaching mid line
lats used for cervical SCC to spare the oropharynx
tumour dose is usually calculated at to cm for the cervicothoracic sine and at to cm for the lubrosacral spine for SCC
5-6cm for cervicothoracic spine
8-10cm for the lumbrosacral spine
Dose for SCC
30/10+18-30/6-15 = 40-45 Gy or 12-15Gy/3 +18-30/6-15 +40-45
no difference in outcomes between the fractionation schemes
the criteria indicating an impending bone fracture in bone mets
- lesions involving >50% of the diaphysis
- lesions destroying>50% of the cortex
- lesions >2.5 cm in the greater trochanter and the femoral neck region
- lytic lesions located in high stress areas
- involvement of the lesser trochanter, subtrochanteric or subcondylar areas
- Inadequate pain relief despite adequate EBRT being given
contraindications radionuclide therapy in bone mets
not used for patients with SCC, nerve root compression or patients with fractures, patients must also have adequate CBC, must have good renal and hepatic function have a life expectancy of more than 6 weeks and have urinary continence or else they ate not appropriate candidates
what medications can patients not take when they are getting radionuclide therapy for bone mets
patients can not have calcium containing medications when on radionuclide therapy because Ca competes with the radionuclide for uptake
what radionuclide therapy can be given for bone mets
Sr89, Sm153, P32 is rarely used for bone pain relief due to excess myelosupression
half life, tissue penetration and energy of radionuclides used in treating bone mets
Sr89- 1.46 Mev max, .58Mev average, 3-4mm penetration and 50.6 day half life
Sm153-.81Mev max, .29Mev average, 1.7mm penetration, 1.9 days half life
types of visceral mets
visceral mets meaning mets of the internal organs include: Airway obstruction, superior vena cava obstruction, liver mets and gone bleeding
treatment for airway obstruction
Keeping the bronchus with intraluminal brachy with 15-20Gy at 1 cm from the source OR EBRT with 2 8.5Gyfractions a week apart or 10Gy/1fx or 30Gy/10fx which palliates symptoms in 50% of cases
primaries that cause superior vena cava obstruction
SCLC, NSCLC, lymphoma or germ cell tumours, NSCLC is less quick to respond to therapy than the other primaries
is superior vena cava obstruction deadly?
no it is not usually deadly unless there is a complicating factor such as cerebral mets or tracheal obstruction
how is superior vena cava obstruction diagnosed
by percutaneous FNA of the mass under CT or biopsy during flexible bronchoscope with a wang needle
ear;y treatment for superior vena cava obstruction
elevating the head of the bed and diuretics and steroids
XRT in superior vena cava obstruction
XRT is given when the patients condition is stable the patient will be in the supine position the mediastinum m is treated with 30Gy/3Gy/fx to 50Gy in 2.5Gy/fx
median survival for patients with liver mets
4 months
dose for EBRT of liver mets what kind of treatment delivery method is available
28-30Gy/ 2Gy/fx
SBRT can be given for liver mets
what are treatment methods available for gene bleeding
Ferric subsulfate (morsel’s solution) can be sufficient to stop gone bleeding however this can cause vaginal sloughing or a urethral fistula therefore ensure you are applying the solution with the paste on a swab NOT gauze soaked
Palliative EBRT
Intracavitiary bratty can be given
surgery for pathological fracture of the distal femur
managed by a plate and compression screw or with an intercondylar nail and screw
preXRT medications given forgone mets
Pts are recommended to take anti-inflammatory and antiemetic medications prior to their radiation treatments to reduce acute side effects of HBI radiation
Medications are typically dexamethasone and ondansetron an hour before treatment
radiopharmeceuticals are given for what kind of bone mets lesions?
mostly used for blastic bone mets (extra bone production)
what do radoopharmaceuticals do for bone mets ?
Calcium and phosphorus analogs preferentially accumulate in bone
A beta emitter or low dose gamma source will allow for localized treatment where the radiopharmaceutical accumulates
Radiation is deposited directly at the involved area
This minimizes side effects and has an excellent therapeutic ratio
Is used in combination chemotherapy and radiation therapy
types of primaries that lead to bone mets from most to least common
Breast
Lung
Prostate
Myeloma
what primaries are more commonly osteoblastic bone mets and which are most commonly osteolytic bone mets?
bone mets with breast and lung primary are most often osteolytic myeloma is also purely osteolytic in nature
prostate primaries are most commonly osteoblastic
N.B. most of the mets have a combination of both osteolytic and osteoblastic features but they are classified by what feature is most prominent
how often does pathologic fractures occurs in bone mets
in 8-30% of cases
What bones/ parts of the bones are most likely to have pathological fractures?
proximal part of long bones are more likely to have bone mets than the distal parts of bones femoral neck and head are the most likely place for pathological fractures because of the propensity for mets and because they are weight bearing bones
what causes esophageal obstruction
it could be due to late stage esophageal cancer or due to mets
how is esophageal obstruction classified
it could be a mild obstruction up to a complete obstruction where the patient can not even swallow their own saliva
treatment for esophageal obstruction (in general)
sx +xrt
what is the treatment for a complete esophageal obstruction
a complete obstruction requires immediate surgery and is sometimes followed by XRT the surgery could have a stent placed to allow the patient to have food and beverages passed through
bratty therapy for esophageal obstruction dose
Dose of 15 Gy at 1 cm or 18 Gy /3 fx or 16Gy/2 fx which all presented similar results
when is brachytherapy used in esophageal obstruction
Brachytherapy may be useful following insertion of a stent , laser therapy or cryotherapy
brachytherapy for esophageal obstruction instructions
- NG tube passed into stomach through area where tumor is
- X rays are taken to better localize the tumor and to help define the treatment length
- Dwell times are calculated, conventionally 1 cm from the source
- Treatment is delivered by inserting HDR catheter into afterloading machine
- Following treatment the NG tube can be removed and pt can be discharged
hemoptosysis is usually from what primary cancer
hemoptysis is coughing up blood and is usually from a lung primary
can also be caused by XRT of the pulmonary artery or because of a small endobronchial lesion
diagnostic methods in hemoptysis
Testing may be performed using chest x-ray and/or CT, endoscopy and lab testing
different degrees of hemoptysis
minor and major hemoptysis
surgeries used for major hemoptysis
Embolization via bronchial artery angiography
BUT emergency Sx may be used as a last resort
The goals are to prevent aspiration and exsanguination
surgeries for minor hemoptysis
may be treated with surgical intervention (e.g. removal of tumour and anticoagulants may be used)
treatment of hemoptysis as a result of endobronchial lesions
may be improved or relieved entirely with endoscopic laser fulguration in conjunction with EBRT, conventional low-dose brachytherapy or high-dose rate afterloading brachytherapy
XRTdoses for hemoptysis
30-40Gy in 10-15fx
primary sites that can cause hemorrhage
H&N and gone cancer also bladder and rectum cancer
how often do advanced cancers have bleeding
in 6-10% of cases
treatment for hemoptysis
Packing of gauze is typically performed to stop or slow the bleeding
Palliative doses are extremely effective at stopping bleeding
The mechanism by which XRT achieves hemostasis is unknown but is thought to affect tumour microvasculature and/or cause release of certain cellular products that improve blood clotting
Packing of gauze is typically performed to stop or slow the bleeding
Palliative doses are extremely effective at stopping bleeding
The mechanism by which XRT achieves hemostasis is unknown but is thought to affect tumour microvasculature and/or cause release of certain cellular products that improve blood clotting
most common primary site that causes skin mets
breast cancer
other sites: melanoma and lung cancer
is skin mets common or uncommon
is very rare compared to many other mets sites
treatment skin mets
Treatment normally includes systemic therapy but local treatment may include Imiquimod cream, photodynamic therapy and excision
XRT is not commonly used as the condition is systemic
how is nodal mets diagnosed
by PET or CT scan
early stage nodal mets treatment
arly stage locoregional metastases are usually treated with XRT and/or Sx to tumouricidal doses
Microscopic nodal metastases are usually treated to 45Gy
Specific doses and techniques are discussed under each organ site
late stage nodal mets treatment
Advanced stage nodal metastases are usually treated with palliative XRT doses and/or systemic therapy
spinal cord compression definition
SCC develops when the spinal cord is compressed by a tumour or where the tumour has invaded one or more vertebrae and the spine collapses
is SCC CONSIDERED an oncologic EMERGENCY
yes
definition of an oncologic emergency
condition caused by cancer that can cause death or severe/permanent disability if not treated immediatelyNormally treated on the same day as they are Dx (usually within hours and at most 24hrs)
Is SCC life threatening
it is an emergency but it is rarely life threatening
most common technique used for treating SCC
4-6MV single post field most common
Opposed fields can be used if treatment volume approaches midline
Lateral fields can be used for cervical spine to spare oropharynx
presentation for SCC
Back pain These patients often exhibit bone pain Paraparesis or paraplegia Sensory loss Bladder or bowel disturbances
Diagnostic methods used in SCC
MRI → most informative study
If it is a first metastatic lesion, histologic confirmation should be obtained
Imaging such as CT would clearly demonstrate the SCC and the vertebra will look darker and may even be collapsed in extreme situations
Most common site of SCC
70% thoracic spine
20% lubrosacral spine
10% cervical spine
what primary tumours spread to what part of the spine in SCC
Lung and breast cancer metastasize to the thoracic spine
colon and pelvic tumours metastasize to the lumbrosacral spine
how long is patient survival from diagnosis for SCC
7months
most important prognostic factor for SCC
Patient ambulation patients who are ambulatory survive 8-9 months and non ambulatory patients survive 1 months
combined modality treatment for SCC
Includes corticosteroids, XRT, neurosurgical interventions (laminectomy) or a combination laminectomy +XRT has a better outcome than either method alone
tx of choice in SCC
xrt
XRT indications in SCC
Usually used prophylactically but can also be used after it happens too
XRT can be used alone for patients who are ambulatory and XRT can be used for non ambulatory patients who respond to steroids
most common treatment dose for patients with SCC
30/10
Patient set up for patients T and L spine SCC
pts lie in the prone position, preferably, if not supine is okay too for direct spinal XRT
Patient set up for patients with C spine SCC
usually treated with the patient in the supine position with lateral POP (never a direct PA)
Borders for SCC treatment fields
~8 cm wide → 4 cm for width of vertebra +2cm margin on either side)
Length is calculated depending on the number of vertebrae to be treated → typically the physician will treat 1-2 vertebrae above and below the compressed spinal vertebrae
Each vertebra is ~2 cm in height
Superior and inferior borders are always placed at intervertebral spaces and never through vertebral bodies
indications for surgery in SCC
Used for pts with acute-onset paraplegia, radioresistant lesions, absence of steroid response, no histologic proof of metastatic cancer
Laminectomy has been recommended for prompt reduction of tumour volume in an attempt to provide rapid relief
Systemic treatment for scc
Dexamethasone usually provides pain relief and improves neurologic symptoms
most common primary tumours that lead to paediatric SCC
Neuroblastoma, Ewings Sarcoma, Wilm’s Tumor, neuroblastoma being the most common primary tumor
What causes paediatric SCC
Caused by neural foraminal invasion causing a “dumbell tumor”
treatment for paediatric SCC
Chemotherapy can be used exclusively to allow for complete recovery
Emergency surgery can be used in cases with rapid neurologic progression at diagnosis
Radiation is reserved for pts who require palliation after disease progression after chemotherapy or surgery
is SVCO an oncologic emergency
yes superior vena cava obstruction is an oncologic emergency
signs and symptoms of superior vena cava obstruction ?
SOB, dyspnea, face/arm edema
Veins are swollen and those close to the skin may appear bulging across the chest, arms, head and neck
primary cancer most commonly associated with SVCO
lung cancer
how is SVCO diagnosed?
usually from FNA with CT guidance or transcranial biopsy with bronchoscopy
patient care for SVCO patients
many of these patients require oxygen and a lot of significant physical support is needed
patient position for treating SVCO with XRT
Many of these pts will be be able to lie prone for treatment, and some cannot maintain an orthopnea position and must be treated in a full upright position with gantry angles at 270 and 90 degrees for an AP/PA POP to the chest
How long does it take for XRT to improve with SVCO
3 days after the start of XRT and 2 weeks for patients to achieve complete releif
XRT dose for SVCO
Mediastinum is treated with doses ranging from 30-50 Gy in 3 Gy or 2.5 Gy fx, respectively
Early treatment for SVCO
Early treatment: elevation of head and diuretics accompanied with steroids
main primaries related to liver mets
Colorectal
Esophogeal
Stomach
Pancreatic
presentation related to liver mets
anorexia Early Satiety Weight loss Nausea Epigastric pain Jaundice Fever Most patients present with multiple metastatic deposits in the liver
when is chemo agents used (adjuvant) neoadjuvant for liver mets
given neoadjuvantly to downsize the tumour in hopes of resecting it
how is chemo administered for liver mets
arterial or hepatic infusions are better than oral agents
chemo agents used for liver mets
Targeted agents such as cetuximab or bevacizumab are used
These combination of these agents have changed the goal of chemotherapy from palliation to prolonged survival
SIRT for liver mets indications
selective internal radiation therapy Used for patients with diffuse liver mets
SIRT for liver mets procedures
Uses Yttrirum 90 (a radioactive source) tiny microspheres are put down a tube into the hepatic vein straight to the liver
dose pf EBRT for liver mets
Doses of 21 Gy/ 7fx or 30 Gy/ 15fx has proven to provide symptomatic relief
median survival for liver mets
4 months
indications for surgery for liver mets
Is best indicated with pts with clear resection margins, low levels of carcinoembryonic antigen, a single liver metastatic deposit, and node negative disease
other treatments for solitary liver mets
Radiofrequency Ablation
Microwave coagulation therapy
Transarterial chemoembolization
Stereotactic body radiotherapy
most common type of mets
bone mets
bone mets are usually in one bone or multiple bones?
multiple bone
As cancer cells damage the bones, calcium from the bones is released into the blood. This can lead to problems caused by high blood calcium levels, called
hypercalcemia
what subtype of cancer causes bone mets?
adenocarcinoma (breast, prostate,lung thyroid, kidney
most common location of bone mets
spine
when do we treat bone mets with XRT
only we treat the bone mets if its symptomatic
mechanism of pain relief with bone mets XRT
radiotherapy inhibits the normal cells release of chemical mediators of pain called prostaglandins and also prevents further bone destruction, reduces size of tumour and enables reabsorption of bone to take place
How do biophosphonates work for bone mets?
inhibitors of bone resorption
effective in reducing morbidity in terms of pain, fractures ad hypercalcemia
what radoopharmaceuticals used for bone mets
P32
SR89
How do radoopharmaceuticals work for bone mets
follow the metabolic pathways of calcium in bone, as they decay they emits radiation
most common primaries for brain mets
lung cancer, breast, melanoma, kidney, colon cancer
