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RC Study > Radiotherapy in Symptom Management > Flashcards

Radiotherapy in Symptom Management Flashcards

1
Q

Radiation : MOA

A
  • ionizing radiation damages DNA
  • Xrays or linear accelerator
  • gamma rays from radioactive source
  • Direct damage to DNA:
    • base deletions, breaks
  • Indirect damage:
    • toxic free radicals from interaction of radiation and water
    • damage to endothelial cells
    • apoptosis
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2
Q

Radical Radiotherapy

A
  • cure
  • minimizing long term damage to normal tissue
  • radiation dose is built up with daily treatment over several weeks
  • can accelerate or hyperfractionate
  • 6-8 weeks in duration
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3
Q

Palliative Radiotherapy

A
  • aim is control of symptoms with minimal acute radiation reaction
  • majority of tumour cells killed (60-80%) in first 1-2 doses
  • short courses, low doses = less acute reaction
  • minimizes late damage to normal tissues
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4
Q

Radiation treatment planning

A
  • Immobilization:
    • face masks, etc
  • Treatment volume dosing
    • CT sim
  • Dosimetric planning
  • Verification
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5
Q

Types of radiation therapy

A
  • External beam radiation (electrons)
    • Xrays
    • linear accelerator
  • Brachytherapy
    • radiactive sources placed directly onto or into treatment area
    • iridium, cobalt
  • Systemic radioisotopes
    • target specific tissue or pathophysiology
    • radioiodine for thyroid cancer
    • strontium for bone mets
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6
Q

Acute side effects of radiation (during treatment - several weeks)

A
  • from loss of epithelial cells
  • skin erythema, desquamation
  • mucositis
  • esopahgitis
  • non infectious cystitis
  • GI irritation
  • skin infection
  • usually recovers in weeks
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7
Q

Late side effects of radiation

A
  • Vascular damage, tissue ischemia
  • Skin
    • atrophy, fibrosis
    • telangectasias, necrosis
  • GI tract
    • stricture
    • bleeding, telangectasias
    • perforation
    • malabsorption
    • enteritis, colitis, proctitis
  • Bladder
    • bleeding
    • strictures
    • fistulae
  • Oral cavity:
    • mucosal atrophy
    • bleeding
    • caries
    • mandibular necrosis
  • Lung:
    • fibrosis
  • Eye:
    • cataract, dry eye
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8
Q

Management of radiation side effects: SKIN

A
  • desquamation rare in palliative doses
  • do not use talcum, gentian violet –> metallic salts increase skin reaction
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9
Q

Management of radiation side effects : MUCOSITIS

A
  • chlorhexidine mouthwash
  • anticandidals
  • NG feeds
  • oral hygiene and dental assessment for curative intent radiation
  • avoid alcohol and smoking
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10
Q

Management of other radiation side effects

A
  • Pneumonitis : steroids and antibiotics
  • GI : nausea management
  • Cystitis : analgesics, rule out infection, flomax, buscopan
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11
Q

Radiotherapy and symptom control : general indications

A
  1. Pain
  • Bone
  • visceral
  • Neuropathic
  1. Local pressure
  • SCC
  • Cranial nerve palsies
  1. Obstruction
  • Bronchus
  • Esophagus
  • SVC
  • Hydrocephalus
  • limb swelling
  1. Bleeding
  • hemoptysis
  • hematuria
  • vaginal bleeding
  • rectal bleeding
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12
Q

Radiation for bone pain

A
  • bone pain
  • pressure on nerves
  • pathological fracture
  • Effective within days to weeks, durable response of months-years
  • Can re-treat with good response
  • Single fraction :
    • more pain flares
    • higher rate of retreatment
  • Multiple fractions:
    • to treat path fracture
    • spinal cord compression
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13
Q

Wide field treatment for bony mets

A
  • multiple sites of disease and pain
  • diffuse
  • Wide field RT: up to half the body at a time
  • Greater toxicity: GI, bone marrow suppression, fatigue, pneumonitis
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14
Q

Radioactive isotopes for bony pain

A
  • isotopes concentrate at bone met sites
  • focal release of beta particles, gamma release
  • Strontium-89
  • Samarium
  • as effective as EBRT, fewer side effects
  • AE : thrombocytopenia, neutropenia
  • analgesia onset - MONTHS
  • Expensive
  • renal excretion, must be continent of urine to prevent contamination

Indications:

  • multiple painful bony mets
  • local radiation not feasible
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15
Q

How does radiation acheive pain control?

A
  • not clear
  • tumour shrinkage may not occur
  • osteoclast activation?
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16
Q

Pain flare after radiation

A
  • first few days
  • 1-2 days duration
  • dexamethasone
  • opioids
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17
Q

Radiation for pathological fracture

A
  • if surgery not indicated or possible
  • Post operative internal fixation
    • prevents progression
  • if widespread disease, limited prognosis, good pain control –> no RT
18
Q

Radiation for SCC

A
  • Dexamethasone 4 mg qid
  • Lymphoma and SCLC - primary treatment is chemo
  • Surgery first if:
    • good PPS
    • solitary mets
    • single level cord compression
    • extensive vertebral collapse into spinal canal
  • Radiation post op
  • primary radiotherapy is surgery not indicated or wanted
19
Q

Radiation for Brain mets

A
  • Dexamethasone 4-8 mg daily
  • Solitary brain met - surgery or SBRT and post op RT
  • WBRT for mutiple diffuse mets
    • palliation of headache, motor and sensory loss, confusin in 80%
    • median survival < 6 months
  • brain mets = widespread advanced disease
  • Need careful patient selection and discussion of goals of care

Acute toxicity WBRT : alopecia x2-3 months

Long term toxicity WBRT : neurocog impairment

20
Q

Meningeal carcinomatosis and RT

A
  • Pre terminal event
  • survival few weeks if untreated
  • multifocal radiculopathy, cranial neuropathy, headache, backache
  • raised ICP
  • breast, lung, leukemia, lymphoma
  • WBRT and whole spinal RT extends prognosis from weeks to maybe short months, all taken up with treatment
  • Skull case for CN or spinal cord nerve roots for sx control may be indicated
21
Q

Brain mets RT decision algorithm

A
  • Good PPS
    • multiple mets
      • WBRT
    • solitary /oligomet
      • surgical?
      • non surgical - radiosurgery, WBRT
    • lymphoma, SCLC, germ cell tumour
      • chemotherapy
  • Poor PPS
    • supportive care
22
Q

Other neurological symptoms that may benefit from Radiation

A
  • Cranial nerve palsies - skull base effective
  • Peripheral nerves - lumbosacral nerve roots, apical lung tumours, brachial pleus, lymph nodes
  • Choroidal and orbital mets
  • Cerebral lymphoma - HIV, WBRT role in question
23
Q

Obstructive symptoms : SVCO

A
  • Occlusion by external compression
  • intraluminal thrombosis
  • direct invasion of vessel
  • Lung cancer, lymphoma
  • Presentation:
    • headaches
    • somnolence
    • dizziness
    • edema
    • dysphagia
    • dyspnea
    • cough
    • hoarseness
    • engorgement and dilation of facial veins
    • facial edema
24
Q

SVCO management general

A
  • steroidse
  • SVC stent
  • Chemo for SCLC germ cell, lymphoma
  • Radiotherapy
25
Q

Bronchial obstruction

A
  • central airway obstruction
  • bronchial carcinoma, extrinsic compression by mediastinum LN, lymphoma
  • dyspnea, cough
  • Treatment
    • intrinsic tumours
      • bronchoscopy with laser or cryo
      • stent
    • Extrinsic tumours
      • chemo
      • radiation
      • stent
      • endobronchial radiation
26
Q

Dysphagia and Radiation

A
  • extrinsic compression from esophageal tumour, hypopahrynx, stomach, thymus, thyroid, meadistinal LN
  • Radiation:
    • useful
    • swallowing improved 80%
    • 2 weeks for efficacy
    • esophagitis AE
27
Q

Urinary tract obstruction

A
  • nephrostomy, ureteric stsents or TURP most appropriate
  • radiation alternative if procedure impossible or inappropriate
28
Q

Limb edema and radiation

A
  • venous obstruction, lymphatic obstruction, post radiation
  • radiation helpful for axillary, inguinal or pelvic lymphadenoapthy
29
Q

Hydrocephalus

A
  • Obstructive hydrocephalus from primary or secondary tumours
  • Posterior fossa or midbrain tumours obstructing aqueduct or 4th ventricle
  • leptomeningeal disease

Treatment:

  • IV shunt
  • if not feasible, palliative radiation
30
Q

Hemoptyis and radiation

A
  • radiation effective 80% control
  • no survival advantage
  • pulmonary mets more difficult to treat
    • harder to ID site of hemorrhage
  • may require bronchosopcy to localize site
31
Q

Hematuria and radiation

A
  • must localize bleeding on cysto or CT for treatment planning
  • Causes of hematuria:
    • tumour bladder
    • cystitis
    • late complication of pelvic rad
    • tumour anywhere in GU tract
  • RT:
    • hemostasis in inoperable tumours
    • failure of conservative managemnt (TXA, irrigation, etc)
    • SE: diarrhea, nausea, vomiting
32
Q

Uterine and vaginal bleeding : radiation

A
  • uterine tumours
  • local infiltration of advanced bladder or rectal ca
  • Radiation helpful
33
Q

GI Bleeding and radiation

A
  • large bowel lesions can be radiated
  • stomach and small bowel difficult
34
Q

Chest wall and skin lesions - Bleeding

A
  • locoregional recurrence in breast can
  • skin nodules
  • primary skin cancers

Treatment

  • radiation can control growth, bleeding and prevent fungation
  • skin nodules reponsive to RT
35
Q

Fungating skin lesions -radiation

A
  • Occurs with superficial tumours
  • most common is breast chest wall recurrence
  • metastatic LN in neck or groin

Treatment

  • radiation best when skin is intact
  • can still treat once fungation has occured
  • antibiotics, analgesics, antibiotics, skin care
36
Q

Kaposi’s sarcoma

A
  • AIDS
  • very radiosensitive - RT can lead to complete regression
  • presentation :
    • multiple purplish skin plaques
    • also in oral cavity and GI tract
37
Q

Liver mets

A
  • inoperable mets: stereotactic RT helpful
  • useful if:
    • good PS
    • normal bilirubin
    • not stomach or pancreas cancer
  • liver mets = terminal phase advanced cancer
  • liver has limited tolerance to radiation
38
Q

Splenomegaly and radiation

A
  • hematologic malignancies (leukemia, NHL, MDS)
  • splenectomy preferred management
  • radiation in advacned disease or poor PPS
  • consider if symptomatic from bulk or hypersplenism (thrombocytopenia and anemia)
  • may precipitate pancytopenia
39
Q

Acute radiodermatitis : treatment

A
  • Erythema, edema 1-2 weeks post RT
  • desquamation, ulcers
  • Treatment:
    • no prophlyaxis
    • wash with mild soaps, avoid deodorants, shaving
    • moisturizers
    • no benefit to steroids
40
Q

Chronic radiodermatitis : treatment

A
  • Vascular
  • dermal atrophy 4-6 months
  • dermal thinning 1 year
  • skin necrosis and ulcers

Treatment:

  • emollients
  • prevention of trauma
  • radiation ulcers are treatment resistent
  • goal is to prevent infection and pain
  • hydrocolloids useful for ulcers
41
Q

Radiation recall

A
  • inflammatory reaction triggered by sytotoxic chemo in previously radiated areas (skin)
  • radiation could have been days or years prior
  • Presentation
    • well circumscribed erythema in previous rad field
    • gemcitabine, anthracyclines, taxanes
  • treatment
    • stop chemo
    • steroids, NSAIDS

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