palliative medicine dse-modifying mx report

7/31/2019 PALLIATIVE MEDICINE Dse-modifying Mx Report

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PALLIATIVE MEDICINE

and

MADONNA R. BACORRO, M.D.

SHPM fellow

UP-PGH


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TOPICS FOR DISCUSSION:

Chemotherapy in Palliative Care

Radiotherapy in Symptom Management

Surgical Palliation

Orthopaedic Principles and Management

Interventional Radiology


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The optimal management of cancer requires amultidisciplinary team approach in which palliative

care physicians and surgical, radiation, and

medical oncologists play an important part


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Patients may experience physical, emotional,

psychological, and spiritual distress at any time

during the course of the illness, and involving

palliative care physicians from diagnosis ensuresthat patients are referred for specialist palliative

care when they need it.


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OBJECTIVES:

To understand the respective roles of the

oncologists in the team

To know about the cancers which oncologists

treat and the expectations and side-effects of

their treatments

To be able to recognize patients in our care

who might benefit from cancer treatment and

refer them to an appropriate oncologist


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CANCER

m

utatio

n inherited

Occur by chance

Acquired by exposure tocertain virus or carcinogens


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1) antimetabolites

2) alkylating drugs

3)antitumour antibiotics

4) plant alkaloids


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CYTOTOXIC DRUGS

ANTIMETABOLITES

5-fluorouracil

fludarabine methotrexate

gemcitabine

Cyclophosphamide

ifosfamide Chlorambucil

melphalan


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CHEMOTHERAPY

Most effective when cancer load is:

A) small and growth factor is increased

B) when cytotoxic drugs with different mode of

action are given together (COMBINATION

Chemotherapy)


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Mesothelioma

Prostate


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effectiveness of chemotherapy

the survival time from commencement of treatment the time from commencement of treatment to cancer

progression

the cancer response rate:A) complete remission- which is the proportion of treated

patients whose cancer either becomes undetectable

B) partial remission - reduces in size by at least 50 per cent

C) stable disease- stays the same size

D) progressive disease- continues to grow during treatment

the quality of life.


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TOXICITY OF CHEMOTHERAPY

1) BONE MARROW

2) GIT

3) SKIN

4) KIDNEYS

5) NERVOUS SYSTEM

6) LUNGS

7) HEART


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GIT

Lining of GI is being

shed and replaced after

days of treatment

Nausea,vomiting,mucositis,

diarrhea

Indication for

admission: for hydration

and alimentation

Choices of meds:

a)nausea and vomiting-

domperidone, dexa in

reducing dose,ondansetron for 5-10d

b)Diarrhea

c)mucositis- mouth washif with no infection


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SKIN

Photosensitivity, urticaria, hyperpigmentation,

dermatitis

Alopecia and avulsion of nails

Hand and foot syndrome= 5FU (withdraw)


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To treat or not to treat

1) ComorbiditiEs

2) Blood tests

3) Age

4) Performancestatus

PERFORMANCE

STATUS SCALES

1) Karnofsky Scale

2) ECOG/WHO Scale

Karnofsky scale ECOGa/WHO scale


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TABLE FOR ecog


No complaints; no

evidence of disease

100 0 Normal activity

No restrictions

Able to carry on normal

activity; minor signs or

symptoms of disease

90 1 Restricted but

ambulatory; able to

carry out light work

Some signs or

symptoms of disease;

Normal activity with

effort

80 2 Ambulatory and self-

caring but unable to

carry out light work; up

more than 50% of

waking hours

Cares for self; unable to

carry on normal activityor to do active work

70 3 Limited self-care;

symptomatic, confinedto bed or chair more

than 50% of waking

hours

Requires occasional

assistance but is able to

care for personal needs

60 4 Completely disabled;

totally confined to

bed; may needhospitalization



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TABLE FOR ecog


Requires

considerable

assistance and

frequent medicalcare

50 5 Dead

Disabled; requires

special care and

assistance

40

Severely disabled;

hospitalizationindicated although

death not

imminent

30

Very sick;

hospitalization

necessary; requiresactive supportive

treatment

20

Moribund; fatal

processes

progressing rapidly

10

Dead 0

Serum tumour markers


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Serum tumour markers

used in clinical practice

Immunochemical markers


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Immunochemical markersin common use


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Radiotherapy

in symptom management


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ACUTE EFFECT seen during and may persistfor several weeks after radiotherapy

d/t loss of surface epithelial cells

LATE EFFECTS

rarely


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Acute and late effects of radiation

SITE ACUTE EFFECT LATE EFFECT

1)Skin Erythema Atrophy, fibrosis

desquamation telengiectasia

necrosis

2) GIT Nausea, anorexia stricture

diarrhea perforation

malabsorption

Chronic enteritis, colitis, proctitis

3) bladder Sterile cystitis reduced volume

Telengiectasia, bleeding

Urethral or ureteric stricture

fistula

4) Oral cavity mucositis Mucosal atrophy


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Acute and late effects of radiation

SITE ACUTE EFFECT LATE EFFECT

5) pharynx Dry mouth Telengiectasia, bleeding

Taste loss Dental carries

Mandibular necrosis

6) lung pneumonitis fibrosis

7)CNS Transient demyelination

(Lhermittes sign)

myelitis

Local oedema necrosis

8) eye keratitis cataract

Entropion or ectropion

Dry eye

Indications for radiotherapy in symptom palliation


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Symptom Cause

Pain

Bone pain Bone metastases

Visceral pain Soft tissue metastases

Neuropathic pain Bone metastases

Soft tissue primary or metastases

Intrinsic tumour in nerve tissue

Local pressure

Spinal canal compression Extradural metastases

Bone metastasesCranial nerve palsies Skull base bone metastases

Meningeal metastases

Obstruction

Bronchus Intrinsic bronchial tumour

Extrinsic lymphadenopathy

I d f d h ll


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Oesophagus Intrinsic bronchial tumour

Extrinsic lymphadenopathy

Superior vena cava Primary mediastinal tumour

Primary lung or oesophageal tumour

Metastatic mediastinal lymphadenopathy

Hydrocephalus Malignant meningitis

Primary or metastatic brain tumour

Limb swelling Metastatic lymphadenopathy

Bleeding

Haemoptysis Primary bronchial tumour

Metastatic bronchial or lung tumour

Haematuria Primary tumour in kidney, ureter, bladder,prostate

Vaginal bleeding Primary tumours of vagina, cervix or uterus

Metastases in vagina

Rectal bleeding Primary anal or colorectal tumours


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SIDE EFFECTS OF RADIATION:MOST COMMON SYMPTOMS MANAGEMENT

1) MILD SKIN REACTIONS Aqueous cream

2) NAUSEA Metoclopromide, 5 -HT antagonists

3) RADIATION-INDUCED ACUTE DIARRHEA Dietary advice,loperamide, Codeine

Phosphate

4) RADIATION CYSTITIS Alpha-blocker, K citrate, cranberry juice

5) OROPHARYNGEAL MUCOSITIS Or, prophylactic anti-candidal

preparationsal hygiene, chlorhexidine

mouthwash

6) DENTAL CARRIES AND OSTEONECROSIS

OF THE JAW

Dental hygiene, for local relief of pain

7) PNEUMONITIS (dry cough and dyspnea) Systemic steroids and antibiotics for 2-3

wks


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Surgical palliation

Ricardo J. Gonzalez, MD

Assistant Professor of SurgeryUniversity of Colorado


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Palliation

Relieve symptoms for patients beyond cure whennonsurgical measures are not feasible, noteffective, or not expedient

Palliation means patient should be better at thecompletion of the procedure or treatment

It is axiomatic that one cannot palliativelyimprove an asymptomatic patient using a

scalpel.

R. G. Martin, 1982


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GASTRO INTESTINAL MALIGNANCIES

PALLIATIVE PROCEDURES


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Orthopedic principles

and

management


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Skeletal metastases

principles of treatmentare:

1) pain relief

2) preservation/restoration of skeletal integrity

3) preservation/restoration of function

4) elimination or prevention of neurologic

compromise.


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main role of the orthopaedic surgeon

treatment of the complications of skeletal

metastases

Pain -- commonest form of presentation of

skeletal metastases , occurring in two-thirds

of patients with radiographically detectable

lesions

-- may develop before the lesion becomesdetectable on radiographs


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orthopaedic surgeons role

not usually involved in the treatment of

painful skeletal metastases but he may be

involved in their diagnosis as patients with

bone pain are frequently referred initially


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Magnetic resonance imaging --the most

sensitive method of detecting early

metastases, especially in the spine

skeletal scintigraphy-- still probably the

investigation of choice in assessing the degree

of skeletal dissemination


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The orthopaedic surgeon is usually not involved

in the treatment of the painful uncomplicatedlesion although he may have made the

diagnosis but becomes involved when one of

the following complications arise


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Facts:

commonest site of pathological fracture is in

the femur

three aspects to the treatment of pathological

fractures.

1) The orthopaedic management

2) localized irradiation

3) the treatment of the causative tumour


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Harrington classification

Class I: The lateral cortices and superior and

medial acetabular walls are structurally intact

Class II: The medial wall is deficient.

Class III: The lateral cortices and the medial

and superior acetabular walls are deficient.


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indications for endoprosthetic replacement in the

management of skeletal metastases are:

resection of a solitary metastasis, usually secondary

to renal carcinoma, with the aim of achieving a

wide margin of healthy tissue around the tumour

transcervical femoral fractures

some metastases or pathological fractures involving

the epiphysis or metaphysis of long bones, where

other forms of treatment are not practical

and some failures of previous fixation


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Multiple fractures

Some patients present with several

pathological fractures and each must be

treated on its merits. This may require the

stabilization of several fractures


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Contraindications to surgery

terminally ill patient

a high risk of fixation failure due to the extent

of bone destruction

presence of infection


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I t ti l di l i l d

Procedure Examples of indications


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Interventional radiological proceduresDrainage Malignant obstruction of renal and biliary tract,

pleural effusions, ascites

Dilation/stenting Malignant gastrointestinal, biliary, ureteric andairway obstruction, superior or inferior vena

caval obstruction, etc.

Feeding Venous accessHickman lines peripherally-

inserted central catheter (PICC) lines

Percutaneous gastrostomy

Extraction Retrieval or resiting of venous lines

Infusion Regional, selective infusion of chemotherapeutic

agents

Embolization Hormone producing metastases, primaryhepatocellular carcinoma, skeletal metastases,

etc.

Neurolysis Coeliac ganglion in pancreatic cancer

Vertebroplasty Vertebral metastasis, osteoporosis

Tumour ablation Liver, renal, bony, and soft tissue tumours


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REFERENCE:


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THANK YOU!!!

palliative medicine dse-modifying mx report

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