Kavita V. Dharmarajan, T. Jonathon Yang, and Yoshiya (Josh) Yamada
Definition
• Malignant spinal cord compression, brain mets, SVC syndrome airway obstruction, & uncontrolled tumor hemorrhage (eg, gynecologic, bronchial, etc.).
Malignant Spinal Cord Compression
• Definition: Compression of dural sac & contents (spinal cord and/or cauda equina) by extradural tumor mass. Minimum radiographic evidence is indentation of theca at the level of clinical features (Loblaw et al., JCO 2005)
• ESCC (epidural spinal cord compression) scale
W/u: H&P, MRI of total spine (Se 93%, Sp 97%, accuracy 95%); neurosurgical evaluation
Treatment: Start steroids (load w/dexamethasone 10-mg IV, followed by dexamethasone 4–6 mg q6–8 hrs). Start PPI & consider PCP Ppx. (Perez 5th ed.).
Consider radiation, kyphoplasty, and/or surgical resection. Surgical decompression is indicated if spinal instability or bony retropulsion has caused cord compression, or when the pt is symptomatic w/paralysis <2 d. (Lablow et al. JCO 2005)
Radiation dose schedules: 3 Gy × 10 fractions (most common), 4 Gy × 5, 8 Gy × 1, 2.5 Gy ×15. Stereotactic radiotherapy (600 cGy × 5, 800–900 cGy × 3, or 1800–2400 cGy × 1) may be favored for oligomets
• Prognosis: Most important prognostic factor is ambulatory status; predictive factors are time to development of motor deficits (functional outcome better w/slower development of motor deficits before RT), & favorable histology (Hannover et al., IJROBP 2002)
Brain Metastases
• Definition: “Solitary” = one brain met, only site of disease; “Single” = one brain met, other sites of disease
• W/u: H&P, MRI brain w/ contrast
• Prognostic factors: RTOG recursive partitioning analysis (RPA)
• Treatment:
• Steroids (4 mg q6h, only if neurologic sx present).
• Radiation & surgical treatment options based on RPA class
• Radiation dose schedule:
• Acceptable fractionation schemes for whole brain radiation treatment: 3 Gy × 10 (most common); 2.5 Gy × 15; 2 Gy × 20; 4 Gy × 5
• Acceptable fractionation schemes for stereotactic radiosurgery: 17–24Gy × 1
SVC Syndrome
• Etiology: NSCLC (50%), SCLC (22%), lymphoma (12%), met (9%), other (7%)
• Presentation: Dyspnea, ↑venous pressure, ↓ venous return, sx develop over wks to mos
• Proposed grading system
• W/u: CXR, CT scan
• Treatment: (Wilson et al., NEJM 2007)
• Medical management: (1) Elevate head of bed; (2) remove indwelling catheters (risk of thrombosis causing SVC syndrome); (3) consider steroids and/or diuresis
• Radiation treatment: If treating curatively, use 3–4Gy × 2–3 d followed by 1.8–2 Gy fractions up to 60–70 Gy. If treating palliatively, use 3 Gy × 10, 4 Gy × 5, or 2.5 Gy × 15
• Consider endovascular stent for rapid symptomatic relief
• Consider chemotherapy if SVC syndrome is due to SCLC, NHL, or germ cell tumors
Airway Obstruction
• W/u: CT, bronchoscopy
• Treatment:
• Endobronchial stent placement
• Intraluminal brachytherapy
• External beam radiotherapy: Accepted dose schedules: 3 Gy × 10, 9 Gy × 5, 4 Gy × 5, 2.5 Gy × 15
Uncontrolled Tumor Hemorrhage
• Etiology: Gynecologic, GI, pulm, or other malignancies causing tumor erosion of vessels
• W/u: CT, endoscopy/colonoscopy/ERCP (if GI source), bronchoscopy (if pulm source), basic blood tests (CBC, chemistries)
• Treatment:
• Medical management: (1) Transfuse RBCs; (2) vaginal packing (if gynecologic etiology); (3) endoluminal cauterization
• Radiation treatment: If treating gynecologic source of bleeding, use 3.7 Gy BID × 2 d, repeat q2wks × 2 PRN. If nongynecologic source of bleeding, accepted dose schedules are 3 Gy × 10, 4 Gy × 5, or 2.5 Gy × 15