Palliative Care

Eyad Al-Saeed, MD,FRCPCConsultant Radiation Oncology

Prince Sultan Hematology Oncology Center

Brain Metastases

Most common intracranial tumor

( Most common primary (lung,breast,melanoma

Hemorrhagic Metastases( renal cell CA ,

(choriocarcinoma,melanoma

Clinical Presentation

Symptoms%Signs%

Headache49Impaired cognition58

Focal weakness30Hemiparesis59

Mental disturbance32Hemisensory loss21

Gait Ataxia 21Papilledema20

Seizures18Gait Ataxia19

Speech diff12Aphasia18

Sensory disturbance6Visual field cut7

Visual disturbance6Limb Ataxia6

Limb Ataxia6LOC4

Diagnostic Studies

•CT

•MRI

• ?Primary

5a = anterior cerebral artery m = middle cerebral artery fh = frontal horn - lateral ventricle

ph = posterior horn - lateral ventricle cc = corpus callosum

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Cranial structures

1.Hard Palate 2.Nasopharynx 3.Sphenoid air sinus 4.Pituitary gland 5.Frontal sinus 6.Frontal lobe 7.Corpus callosum 8.Septum pellucidum 9.Parietal lobe 10.Fourth ventricle 11.Occipital lobe 12.Cerebellum 13.Sinus Confluence 14.Pons 15.Medulla Oblongata •Spinal Cord

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Prognostic Factors

ClassCharacteristicsSurvival

1KPS 70-100Primary Controlled

Age < 65Mets to brain only

7.1 mo

2All Others4.2 mo

3KPS < 702.3 mo

Treatment

• Steroids•

•improved headache and neurological function•No impact on survival

•Start dexamethason 4mg q 6h if patient has neurological symptoms

•Taper as tolerated •No role for steroids in asymptomatic patients

CONT..

CharacteristicsOptions

Single lesion(1 – 2)

Surgical resection +WBRTWBRT+SRS

SRS alone (with SRS or WBRT for salvage prn)WBRT alone

2-4 lesions (1-2)

WBRT aloneWBRT + SRS

SRS alone (with SRS or WBRT for salvage prn)controversial

4 lesion(1-2)

WBRT aloneWBRT + SRS controversal

SRS alone ( with SRS or MBRT for salvage prn )controversal

class 3WBRT alone

Spinal cord compression

•Anatomy

•Extends from foramen magnum to L1 – L2•Below the termination of the cord it contains the

lumber cistern, an enlargement of the subarachonoid space that surrounds the cauda equina.

•SAS terminates inferiorly at S2 – S3.

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Clinical Presentation

•Pain (90%-95%),usually precedes all other symptoms by several weeks to months

•Weakness is rarely the first symptom (2%)but is fairly common at diagnosis (75%).

•Sensory loss (50%)•Autonomic dysfunction associated with

•unfavorable prognosis and late (50%)•Once neurologic deficits develop, impairment

progresses rapidly .

Diagnostic imaging

(MRI (Gold standard if neurological symptoms

•CT

•Conventional Myelography

•XRay

Treatment

•Steroid to be started immediately and then taper •as tolerated

• Surgery as a first line if •1 -diagnosis unknown or doubtful for malignancy

•2-instability of spine or bony compression of the cord

•3 -previous radiation of the site of compression•4 -progression during radiation

•5 -contra indication of radiation or radiation resistant tumor .

CONT..

•Radiation

•Post op•Alone if multiple levels of compression or

poor performance status patient.

Superior Vena Cava Syndrome

Superior Vena Cava Syndrome is a medical emergency occasionally seen in patients with malignant tumor that requires immediate action

Causes1 -bronchogenic carcenoma 80%

2 -Malignant lymphoma 10 - 18%

3 -Benign 2-3%

Diagnosis

•Biopsy•CT

1 = carina 2 = left main bronchus 3 = right main bronchus4 = right upper lobe bronchus 5 = descending aorta 6 = superior vena cava

Treatment

•1 -Radiation•2 -Chemotherapy in case of Small Cell Lung

Cancer Or Lymphoma

•3 -Steroids•4 ? -Diuretics

Bone Metastases

•Common cause of severe cancer pain

•Good pain control may improve OS

•Sites of mets : Spine (Lumber > Thoracic) > Pelvis > Ribs >femur >Skull

•Primary ( breast, Prostate, Thyroid, Kidney. Lung)

Workup

•Bone scan is the primary imaging modality

•Plain films looking for fracture

•MRI for Spinal cord•Biopsy if unknown primary

Treatment

•1 -Supportive including pain control

•2-Surgery incase of fracture or impending fracture

•3 -Radiation