CAGPO Conference – October 25, 2014
Outline
Goal: To discuss the clinical features and management
of 3 oncologic emergencies
Radiotherapy for Oncologic
Emergencies
Dr. David Palma, MD, MSc, PhD
Radiation Oncologist, London Health Sciences Centre
Clinician-Scientist, Ontario Institute for Cancer Research
1. Spinal Cord Compression
2. Superior Vena Cava Obstruction
3. Brain Metastases
Case History
Case History
 57 year old woman with a history of breast cancer presents with
a 1-week history of band-like numbness across her abdomen
 X-rays show a ‘winking owl sign’
 Over the past day, she reports bilateral leg weakness and is
unable to ambulate
 Calls you for an opinion
MRI
Spinal Cord Compression
 MRI confirms spinal cord compression due to a metastasis to
the thoracic spine
 The tip of the adult spinal cord usually
lies at the L1 level, below this are the
nerve roots of the cauda equina
 Up to 5% of patients with cancer will
develop spinal cord compression
 Most commonly lung, breast, myeloma,
prostate
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Clinical Features
 Early recognition of cord compression is crucial for preservation
of neurologic function
 Diagnosis is often delayed:
• Median history of back pain is 2 months
•
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Median history of neurologic symptoms is 14 days
Back pain (up to 95%), may be radicular
Motor weakness: progressive
Sensory loss
Bladder/bowel: usually urinary retention
Investigations
Pearl #1: Clinical Exam is Crucial
Scenario #1- High Cord Comp
 Inspection
• Dyspneic
• Unsteady posture
 Tone
• Increased in extremities
 Strength
• Decreased in all groups in all limbs
 Reflexes
• Hyperreflexic deep tendon reflexes
 Sensation
• sensory level in upper thorax
 MRI is preferred
 CT does not clearly demonstrate the
cord or epidural space, but can be
helpful for obvious cases
Scenario #2- Low Cord Comp

Inspection
Uncomfortable – unable to stand
Tone/palpation
• increased tone in legs
• ?Decreased rectal tone
Strength
• Decreased in legs [test L3, L4, L5, S1
dermatomes]
Reflexes
• Hyperreflexic deep tendon reflexes in legs
Sensation
• Decreased in legs and peri-anal area [test L3,
L4, L5, S1 dermatomes]
Scenario #3- Cauda Equina
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•
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
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Inspection
?Fasciculations/wasting
Tone/palpation
• Decreased tone in legs
• Decreased rectal tone
• Palpable full bladder
Strength
• Decreased in legs [test L3, L4, L5, S1
dermatomes]
Reflexes
• Hyporeflexic deep tendon reflexes in legs –
may be unilateral, specific e.g. ankle jerks
Sensation
• decreased in legs and peri-anal area [test L3,
L4, L5, S1 dermatomes]
•



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Practical Approach
 Give 10 mg IV dexamethasone and 4 mg IV/PO q6h
 Would this patient be a radiation therapy and/or surgical
candidate?
•
Yes-> call radiation oncology or neurosurgery on call to discuss case
 Potential treatment plan exists
•
-> call radiology to ask for urgent MRI
Pearl #2: Start Steroids While Awaiting MRI
Treatment
 The most important predictor of neurologic status after treatment is
neurologic status before treatment
 Usually about 1/3 ambulatory at time of treatment
 Goals:
• pain control
•
•
avoid complications from local progression
preserve neurologic function
Pearl #3: Surgery if Possible
RCT: Spinal Cord Compression
•
•
•
•
•
Patchell RCT: Primary Endpoint
101 patients with MESCC, nonchemosensitive
One neurological sign or symptom
Not paraplegic for >48h
MESCC in one single area (can be
contiguous)
Life expectancy > 3 months
Lancet 2005
Lancet 2005
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Patchell RCT: Other Endpoints
External Beam Radiotherapy
•
•
•
Usually a short course of radiotherapy (10 fractions
or fewer), either after surgery or alone
Most patients experience pain relief and maintain
neurologic function
Stereotactic radiotherapy is an option at some
centres but not yet evaluated by rigorous trials
Lancet 2005
Treatment Algorithm
Prognosis
 Median survival is short: approximately 6 months
 Better in patients with:
• Fewer metastases, no organ mets
•
•
•
•
Slow progression of neurologic symptoms
Radiosensitive tumors
Ambulatory at treatment
Long interval since original diagnosis
Case 2
Imaging
 A 54 year-old man with a history of lung cancer resected 2 years
ago, presents with a 5-day history of facial edema, bilateral arm
edema, and shortness of breath
 CXR reveals a mediastinal mass
 Found to have tumor recurrence in the mediastinum,
compressing and invading the superior vena cava
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SVCO - Anatomy
SVCO - Histology
 Non-malignant: Thrombosis, Infection, Fibrosis
SVCO - Presentation
SVCO - investigations
 Imaging:
• Often abnormal chest-xray
•
CT usually sufficient for diagnosis
 Histology
• 60% of patients have no history of cancer
•
Often bronchoscopy, mediastinoscopy,
EBUS, VATS
SVCO - Treatment
 Goals:
• Improve symptoms, treat underlying disease
 SVCO is an oncologic emergency for some patients
• Patients with stridor due to airway obstruction, severe
laryngeal edema, or cerebral edema
•
In others, after assessment in ER/cancer centre, there is
often time for a full diagnostic work-up
Pearl #4: SVCO treatment is histology-based
AND there is usually time to get histology
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Grading Severity
SVCO - Treatment
 Treatment depends on histology
• Steroids – only helpful for lymphoma, or if edema
 Chemotherapy for sensitive tumors
•
•
Lymphoma, SCLC, germ cell tumors
Clinical response is usually rapid
 Radiation Therapy
• 60-80% rate of resolution by 2 weeks
 Endovascular stents
• For severe cases
Algorithm
Case 3
 A 58-year old man presents with a
3-day history of headache, nausea,
and right-sided weakness
 His medical history is remarkable
for stage I NSCLC lung cancer
treated 4 years prior with surgery
Brain Metastases
Overview
 Brain metastases occur in 10-30% of patients
with cancer
 Comprise the majority of intracranial tumors
 As therapy for primary tumors improves and
patients live longer, rates of brain metastasis are
increasing
 Primary sites:
•
•
•
•
•
•
Lung 50%
Breast 15%
Melanoma 10%
Colon/rectum 5%
Other primary 10%
PUK 10%
 Some tumors almost never metastasize to brain:
prostate, esophagus, oropharynx, and nonmelanoma skin cancer
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Overview
Treatment
 Most common site of metastasis is at grey/white junction
• Some tumors have unique distribution
 Can present with nearly any neurological symptom
• Headaches
• Seizures
• Altered mental status
• Nausea/vomiting
• Motor/sensory deficit
 Without treatment, survival is about 4 weeks.
 Goals:
• Improve neurological status
•
Long-term tumor control
 Symptomatic:
• Steroids to reduce edema
•
Anticonvulsants
 Don’t forget about issues around driving
Management
 Symptomatic Treatment
• Corticosteroids
•
•
•
•
•
reduce vasogenic edema by stabilising the BBB
Usually administered QID, but the biological half-life is 3654 hours. BID or QD dosing is reasonable.
Sx improvement in 6-24hrs, max effect in 3 days.
70% of patients will respond.
Anti-convulsants
• A 1999 meta-analysis concluded that there is no benefit
with prophylactic use of anti-convulsants for brain
metastases.
Management
 Dependent upon:
• Location, size and number of metastases
•
Patient age, performance status, neurological status
Extent of extracranial disease
Previous response of tumor to therapy
•
Modalities available:
Surgery
•
•
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•
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Stereotactic Radiosurgery
Radiotherapy
Chemotherapy/hormone therapy (limited)
Solitary Brain Metastases

In the setting of a solitary brain metastasis, surgical resection or
stereotactic radiation improves survival compared to just providing
palliative whole brain radiotherapy
 For patients with 2-3 metastases, surgery or stereotactic radiation
may improve quality of life and reduce the risk of neurological death
Pearl #5: For a solitary brain met, ablation or
resection improves survival
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Multiple Brain Metastases
Prognosis
 70% of patients have multiple mets
 WBRT alone is standard (increases survival to 3-6 months)
 Surgery can be considered if one lesion is large and life-threatening
Kaal et al, Lancet Neurol 2005:4:289
Treatment Algorithm
Whole Brain Radiotherapy
 First published experience of WBRT in Cancer 1954 by Jen-Hung
Chao.
Most common treatment
today is:
2 opposing lateral radiation
beams
Dose:
3000/10 (2000/5)
Whole Brain Radiotherapy
Hippocampal Sparing: the next generation?
 50% of patients will improve in neurological
functioning, 70-80% will improve or remain
stable.
Response rates for individual symptoms will vary:
headache 80%; cranial nerve palsies much lower
• Responses occur in 2-4 weeks.
•
Nevelsky JACMP 2013
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The Bottom Line (on one slide)
1. Spinal cord compression requires a detailed neurologic
examination to guide imaging, early initiation of steroids, and
advocating for early MRI and assessment by neurosurgery and
radiation oncology
2. For patients with SVCO, there is usually sufficient time to
obtain a proper diagnosis and plan. Treatment depends on
histology and severity of symptoms
CAGPO Conference – October 25, 2014
Radiotherapy for Oncologic
Emergencies
Dr. David Palma, MD, MSc, PhD
Radiation Oncologist, London Health Sciences Centre
Clinician-Scientist, Ontario Institute for Cancer Research
3. Some patients with brain metastases are long-term survivors.
Treatment decisions are based on number of metastases and
overall RPA prognostic score.
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