Oncological emergencies in radiotherapy




"ONCOLOGICAL EMERGENCIES IN RADIOTHERAPY "

               In radiotherapy, oncological emergencies are acute medical situations in cancer patients that require urgent intervention,where radiotherapy is often used for quick symptom relief and management to prevent serious complications, morbidity or death.

INDICATIONS:

  • Malignant spinal cord compression (MSCC).
  • Superior vena cava obstruction.
  • Massive hemorrhage / Bleeding tumors.
  • Brain metastasis / Raised intracranial pressure.
  • Bone metastasis.

1.Malignant spinal cord compression (MSCC)

           Spinal cord compression occurs when the malignant growth compress the spinal cord.
           Cancer that spread to the bone and spinal cord such as lung , breast , myeloma , lymphoma, and prostate.

Symptoms:

  • Autonomic dysfunction  
  • Sensory deficit  
  • Back pain  
  • Weakness  
  • Bladder and bowel dysfunction

Management :

         EBRT can be delivered in many different dose and fractionation regimens,
  • 20 Gy in   5 fractions
  • 30 Gy in 10 fractions
  • 8   Gy in   1 fraction
        RT is given to spinal cord to relieve a debilitating pain and preserve neurological functions.

2.Superior vena cava obstruction 

           Superior vena cava syndrome (SVCS) is the obstruction of blood flow through the superior vena cava.

           SVC usually caused by lung cancer or lymphoma.

Symptoms:

  • Dyspnea 
  • Facial swelling  
  • Arm swelling 
  • Cough 
  • Chest pain 
  • Cyanosis
  • Venous distention of neck and chest wall

Management :

           Radiation therapy - palliative rt for SVCS is exerted by decreasing the extrinsic pressure on the SVC by surrounding or invading malignant masses and effectively preventing SVC recurrence.
  • 30 Gy in 10 fractions.
  • 20 Gy in 5 fractions .

2D-BORDERS:

        UPPER                    - Suprasternal notch 

        LOWER                  - 8 to 10 cms from upper                                                        border

        LEFT LATERAL    - 3 cm lateral to mid line
 
        RIGHT LATERAL - 5 to 7 cms lateral to 
                                                mid line
 
    (Field borders should be verified with Ct-simulation)

3.Massive hemorrhage / bleeding tumors

         Radiotherapy can be used to stop tumor bleeding through a technique is called HEMOSTATIC RT.

            Tumor that causes significant hemorrhage either externally or internally, due to invasion of blood vessels.

Common sites of bleeding tumors,

  • Cervical cancer - vaginal bleeding 
  • Gastric cancer - upper GI bleeding
  • Rectal / Anal cancer - Rectal bleeding 
  • Head and neck cancers - Oral cavity and oropharynx bleeding.

Management:

              HEMOSTATIC RT given to the bleeding tumors .
             Shrinking the tumor.
             Damaging tumor vessels.
             Inducing fibrosis.
             Bleeding stops and prevent recurrence.
  • 20 Gy in  5  fractions.
  • 30 Gy in 10 fractions.
  •   8 Gy in   1 fractions.
             

4.Brain metastasis

                Brain metastasis refers to the spread of cancer cells from a primary tumor located outside the CNS (central nervous system) to the brain.
                They are usually arise via hematogenous spread .
                 Cancer that spread to the brain such as, lung cancer, breast cancer, renal cell carcinoma, melanoma .

Symptoms:

  • Headache 
  • Neurological deficit 
  • Seizures

Management: 

  • WBRT (Whole Brain Radiation therapy) 

                 It is currently the standard treatment of brain metastasis.
                 It improves survival over supportive care and neurological functions. 
                 Dose - 30 Gy in 10 fractions.

         Superior - Skin fall off
         Inferior - Cranial base
         Anterior - Skin fall off
         Posterior - Skin fall off


  • SRS (Stereotactic Radio Surgery)
                Lesion less than 2- 5 mm.
                Dose- 25 Gy in 5 fractions (SRT).

5.Bone metastasis 

               Bone metastasis is a hematogenous spread of malignant cells from a primary tumor to the bone , resulting in structural and functional disruption of bone .
                  Cancer that spreads to the bone such as breast , lung , prostate cancers ....

Clinical presentation:

  • Pain (most common symptoms)
  • Reduced mobility
  • Spinal cord compression (in vertebral metastasis)

Management:

                PALLIATIVE RT is given to the affected spine.
                Dose - 30 Gy in 10 fractions.

For example,

             Affected spine segment - L2 to L4 
    (L1 and L5 also included in the target - Adequate coverage , setup uncertainty and safer margin CTV → PTV).  

Conclusion:

           Rt can preserve neurological functions, control bleeding and relive distressing symptoms like severe pain , obstruction etc...
           Palliative and supportive cancer care.
           Improvement in quality of life.

                        
              

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