Palliative Treatment Flashcards
1
Q
Palliative Radiotherapy Principles
A
- Quality of Life
o Quality rather than quantity - Pain Relief
o Pain is often the most feared symptom of terminal cancer (two-thirds of patients experience significant pain)
o Pain is very personal, and everyone has a differing pain tolerance - Symptom Relief
o Breathlessness, anorexia, and weakness are also common symptoms
2
Q
Examples of Palliative Intent
A
- SVC Obstruction
o A mass pushes against the superior vena cava and impedes heart function
o Often treated urgently with RT, to reduce mass and alleviate symptoms - Osteolytic Bone Mets
o Eats in healthy bone by ‘lysing’ (cause destruction) bone, causing skeletal dysfunctions
o We want to stop that lytic function of the cells - Brain Mets
o Can disrupt the health function of the rest of the brain, causing confusion and dizziness among other things
o Aim of treatment is to relieve this impediment, effectively restoring normal function to the rest of the organ
3
Q
Palliative Treatment Sites
A
- Can be anywhere, but most common:
o Bone, Brain and Lung - Spinal cord compressions from bone metastases can result in:
o Bleeding complications in the bowel, upper and lower GI tract
o Fungating lesions involving the epidermis
4
Q
Pre-Treatment
A
- Lower T + L spine patient will experience nausea and vomiting
o Important to ensure patient has anti-emetics prescribed and taken prior to treatment
Long list of anti-emetics and all have different actions
Some may not work for some patients
Important to ask about specific symptoms
5
Q
Patient positioning and immobilisation equipment
A
- Assess, stability, immobilise or reproduce
- Patient is often already in extreme pain
o Comfort of the patient is paramount
o Uncomfortable = patient movement - Always consider soft-top
- Site Specific considerations
o Shell – Brain or C-Spine
o Shoulder reproducibility
o Incline – for difficulty lying flat
o Arm position for multi-field lung - General diligence, care and attention to detail
6
Q
Common Anti-emetics
A
- Domperidone – relieve nausea and vomiting
- Metoclopramide – treat heartburn
- Ondansetron/granesitron – prevent nausea and vomiting
- Cyclizine
- Dexamethasone - Is a steroid but has been used to control vomiting
7
Q
Name 5 side effects of dexamethasone
A
vision changes swelling rapid weight gain mood changes nausea
8
Q
Field Arrangements
A
- Minimal for minimal time on couch
- Low doses and low margins
- Critical structures – site specific
o Spinal cord for higher dose lung volumes
o Bowel for lower spines, - Larger margins allow for the reduced stability
o A patient in pain often moves without control
Would require a lower dosage
9
Q
Acute side effects of radiotherapy
A
o Oedema, epithelial irritation, presenting symptoms diarrhoea, nausea, vomiting, increased pain
o Fatigue, mild/moderate skin reactions
10
Q
Long term side effects of radiotherapy
A
o Oedema, growth stunting, fibrosis, cardiac damage, damage to optic chiasm, endocrine dysfunction, myelopathy, Lhermitte’s syndrome, infertility, carcinogenesis
11
Q
Psychosocial Considerations for palliative patients
A
o Terminally Ill o Cultural differences o Great pain o Require reassurance and comfort o Dysfunction and immobility o Impacts on dignity social impediments
12
Q
how to treat side effects
A
o Monitor and medicate
o Antiemetics: dexamethasone for ICP, narcotics painkillers, rest, aqueous cream
o Field shaping and field placement and patient position
o Often greater risks accepted for shorter life expectancy
13
Q
Lhermitte’s Sign
A
- Is a sudden sensation resembling an electric shock that passes down the back of your neck and into your spine and may then radiate out into your arms and legs
- It is usually triggered by bending your head forward towards your chest
- Conditions which can cause LS
o Myelopathy
Subacute combined degeneration from B12 deficiency
o Cervical Spine Inflammation
Can be caused by lupus, an infection or Bechet’s disease
o Transverse Myelitis
A sudden episode of spine dysfunction
Cervical spinal cord tumours
o Spondylosis
Arthritis in the neck, Chemotherapy, Trauma
14
Q
bone mets
A
- At autopsy around 70% of patients who die of cancer are shown to have skeletal mets.
Which primary tumours most commonly metastasise to bone?
- Breast
- Prostate
- Lung
- Any primary site can metastasise to bone
- Radiotherapy with good relief in 80 per cent of cases
- If the bone has already fractured, surgical stabilisation should be performed followed by postoperative radiotherapy
- Must balance symptom relief with sparing of normal tissues to minimise side effects (e.g., small bowel with pelvic treatments)
- Postoperatively, RT the entire prothesis or intramedullary nail should be covered with a margin of normal bone
o This is the area most at risk of residual tumour
15
Q
Types of Bone Mets
A
- Osteolytic
o Deposits in the bone that lyse (cause destruction) to surrounding bone cells
Lyse = destruction of cells or dissolution cells - Osteoblastic
o Cause formation of new bone that is often deformed and weak
o More prone to fracture
16
Q
Areas of Bone Lesions
A
- Osteolytic
o Lung, melanoma, thyroid, kidney colon, breast - Osteoblastic
o Breast, prostate, bladder, stomach
17
Q
Bone Mets: Signs and Symptoms
A
- Depend on site and type (osteolytic or osteoblastic)
- Bone pain and/or pathological fracture.
- Severe weakening of the bone.
- Osteoblastic lesions are slightly more prone to fracture.
- Cord compression – tumour mass compressing the cord itself.
- Hypercalcaemia: another debilitating symptom caused by bone mets
o Excessive excretion of calcium >weakness, nausea, vomiting, dehydration, polyuria, anorexia, lethargy and constipation…
o More advanced and untreated cases, confusion, psychosis and seizures, then coma and death.
18
Q
Field Techniques – Bone Mets
A
- Depending on site and critical structure
o Single field
o Parallel opposite
o Direct fields
19
Q
Patient positioning bone mets
A
- Upper Cervical Spine Area
o Supine, lateral fields to avoid mouth, chin raised, shoulders down - Lower Cervical, Thoracic, Lumbar Spine
o Prone if possible, posterior field prescribed as peak dose or to a depth - Torso, Limbs
o Supine, anterior/posterior opposed fields
o Opposed tangential fields to ribs to minimise lung dose or direct electron field
20
Q
Spinal Cord Compression symptoms
A
o Pain
o Weakness of legs, bladder or bowel dysfunction (complete paraplegia)
o Should be treated quickly to prevent permanent damage.
21
Q
Spinal Cord Compression – Common Symptoms
A
- Common features (thoracic area)
o Back pain, sensory disturbance in the lower limbs, bladder or bowel dysfunction and leg weakness - Common features (lumbar spine)
o Nerve pain in the back and legs, occasional paraplegia
22
Q
Spinal Cord Compression Diagnosis
A
- Emergency MRI required whole spine
- Clinical signs can appear to be out of keeping with the vertebral level involved
23
Q
Spinal Compression Considerations
A
- All patients suspected SC Compression should be given high dose of steroids Eg. Dexamethasone 16 mg daily (Barrett, Dobbs, Morris, & Roques, 2009 , p.63)
- Treatment options o Spinal decompressive surgery o Postoperative XRT o Chemotherapy o XRT
- Indications for Surgery
o Unknown primary tumour
o Unstable spine or vertebral displacement
o Relapse following spinal radiotherapy
o Neurological symptoms which progress during radiotherapy
o Relatively radio-resistant tumour
o Paralysis of rapid onset.
24
Q
Spinal Cord Compression: Dose Fractionation Schedules
A
LOOK AT TABLE, I WILL PUT IN NUMBERS LATER
25
Parallel Opposed Pair
- Beam from anterior directly opposed to posterior beam
| - Equal weight
26
DMAX distances for varying beam energies
LOOK AT TABLE, I WILL PUT IN NUMBERS LATER
27
Brain Mets
- 1/3 of all brain lesions are mets
- Originates from:
o Lung (35%)
o Breast (15%)
o Melanoma (8%)
o Plus renal cell, colorectal
28
Brain Mets – Symptoms at Presentation
- ICP & headaches
- Focal neurological damage
- Convulsions
- Personality changes
29
Brain Mets – Consideration
- Principle treatment for ICP is dexamethasone.
o Cannot be used for long periods without complications.
o Will usually be continued during XRT
o May cause side effects
Stomach irritation, vomiting, headache, dizziness, insomnia, depression, anxiety, acne, increased hair growth, easy bruising, irregular or absent menstrual periods
- Surgery may be an option (small-localised deposits, patient in good condition)
- Breast Cancer Mets are also radiosensitive
o Whole brain irradiation is indicated, though not prophylactically
- Blood brain barrier WBI is it useful for chemotherapy.
30
Whole Brain Dose Fractionated Schedules
- Radiotherapy
- NSCLC & Breast 1o radiosensitive
- PCI (Prophylactic Cranial Irradiation)
- 20Gy in 5#
- 30Gy in 10#
- 12Gy in 2# (offer advantages to the patients QOL, plus more economical
31
Other Treatment Options: Brain Mets
- Stereotactic radiosurgery:
- Growing in popularity (Gamma Knife and Cyber Knife)
- Small-localised deposits not suitable or agreeable for surgery,
- Often treated with high doses to small volumes
32
Whole Brain Side Effects
- Raised intra-cranial pressure symptoms
- Nausea
- Vomiting
- Seizures
- Coma
- Death
33
Treatment Symptoms: Brain mets
o Complications: confusion, memory loss, long-term neurological morbidity (if the patient lives long enough).
o Can be severe - treatment considered mostly for patients who have shown good response to chemo or previous RT.
34
Brain Met Considerations (SCL)
- Small Cell Lung (SCLC) is especially prone to brain mets
o ~2/3 patients at autopsy shown to have brain mets.
o Also highly radiosensitive - RT is commonly given electively.
35
Brain Met Considerations (PCI)
- PCI – prophylactic cranial irradiation (whole brain)
o In one recent study: to reduce brain met incidence 40% to 10%, & improve survival at 1yr from 13.3% to 27.1%.
o PCI preventative RT to the brain to kill cells that may have already spread there but are unable to be seen yet with scan – small cell ca – respond well to XRT 30 in 10#.
