1. Oncologic Emergencies

2. Spinal Cord Compression
Immediate treatment to reduce risk of permanent neurological damage- Transverse Myelitis
Treatment is required for tumors that involve spinal cord and result in spinal cord compression.

3. Pathology Can arise in three places Spinal vertebra- Most common
Paravertebral Tissue
Epidural Space

4. 95% spinal cord compressions are due to mets
Primary spinal cord malignancies are rare
Tumors that arise from metastasis usually originate in lung, breast, or lymphomas, myeloma, sarcoma, prostate, and kidney
20% present with multiple sites of mets

5. Symptoms
Pain- Radiating back pain often weeks or months prior to onset of neuro symptoms
Weakness- Leg weakness in 75% of patients
Sensory deficits- Paraplegia and paralysis- (late symptom)
Autonomic disorders- Loss of bowel and bladder sphincter- (Early symptom)

6. Diagnostic Work Up History and Physical- Neurological assessment
High suspicion in cancer patients with back pain for early diagnosis
Radiographs- Reveal bony abnormalities
MRI- Study of Choice CT

7. Treatment Multidisciplinary
Corticosteroids- Dexamethasone- use high dose with rapid tapering
Surgery
Radiation Therapy

8. Surgery Indications for Surgery: Unknown primary
Progression during course of radiation
Recurrence in irradiated field in which spinal cord had previously reached tolerance
Not for paraplegic patient or one with diffuse mets

9. Surgical Decompression
Removal of the vertebral body when there is an anterior compression
Laminectomy- when there is posterior compression

10. Radiation Therapy Treatment of choice
Radiation should follow surgery unless cord tolerance has been met
Done alone or post-op
Treatment should begin immediately

11. Technical Aspects Patient prone
Determine upper and lower extent of tumor volume from images
Single posterior treatment port used with 3-4cm margin above and below lesion
Tumor dose calculated at depth of 5-6cm
Lateral simulation film taken to determine depth of treatment

12. Field Borders Superior- 3 cm above cord compression
Inferior- 3-4 cm below cord compression
Lateral – 7-8 cm wide depending on lateral extent of tumor

13. Dose Rapid onset- Use large initial dose
3-4 Gy x 3
Cord tolerance Gy/fx preferable when possible
Total dose varies with histology
Lymphoma Gy
Carcinoma – Gy

14. Severity of Pretreatment Outcome
Less than 20% of patients with paraplegia at time of diagnosis become ambulatory
Sever dysfunction prior to treatment, little chance of improvement
Early diagnosis is best hope!

15. Rapidity of Onset Slowly progressive neurological symptoms
Better prognosis
Optimal treatment is within 48 hours
The more rapidly the compression develops the less time to relieve compression before it becomes irreversible

16. Histological
Lymphomas and myelomas are associated with a better prognosis than carcinomas

17. Other Factors Upper vs. lower T Spine Presence of bony abnormalities
Lower better prognosis
Presence of bony abnormalities
Worse prognosis
Duration of pretreatment dysfunction
Worse prognosis with increased duration

18. Side Effects of Radiation
Acute
Transient Radiation Myelopathy (Any disease of the spinal cord) usually mild
Late
Delayed or irreversible myelopathy with symptoms of:
Ascending Parethesias
Motor Paralysis
Disturbances of bowel and bladder function

19. Superior Vena Cava Obstruction
Tumors that infiltrate mediastinum and compress SVC
Can cause life threatening complication

20. Anatomy
SVC is major venous channel for return of blood to heart from upper thorax, head and neck, and upper extremities
Surrounded by anterior mediastinal structures and encircled by numerous lymph nodes

21. Pathology Causes of SVC:
Lung Cancer- Small Cell most common followed by Oat Cell and Squamous Cell
Lymphomas- Non Hodgkin’s
Metastasis- Most frequent from breast cancer
Benign causes- Thyroid goiter

22. Obstruction of SVC May occur:
Secondary to extensive compression by tumor or lymph nodes
Direct invasion of tumor into vessel wall with or without associated thrombosis

23. Clinical Features Obstruction of venous drainage in upper thorax
Dyspnea
Facial Swelling
Cough
Chest pain
Dysphagia
Venous distention of neck and thorax causing:
Cyanosis, Tachypnea, Upper extremity edema

24. Diagnosis Chest X-ray CT of chest Verification of Histology
Sputum cytology
Bronchoscopy with biopsy
Supraclavicular nodal biopsy

25. Radiation Therapy Treat immediately for symptomatic patients
Patient treated supine, may require a slant board or treatment chair due to respiratory distress

26. Treatment Portals Include primary tumor with 2-3 cm margin Mediastinal
Hilar
Supraclavicular
Measure separation daily to decrease in edema

27. Dose Initially high 3-4 Gy for 2-3 days.
Conventional fractionation 1.8 –2.0 Gy /fx
Total dose depends on histology
Lymphoma Gy
Carcinoma Gy

28. Chemotherapy Used with radiation therapy for chemo responsive tumors:
Oat Cell
Germ Cell
Lymphoma
Palliative
Systemic control

29. Additional Treatment Steroids Diuretics for edema
Anticoagulants for thrombosis

30. Palliative Results Good relief in 2-3 days
2/3 show signs of response in 1-2 weeks of initial treatment
Survival poor- Most have lung cancer
80% of patients with lymphoma have complete response

31. Airway Compression
Cancer of the lung, trachea, and esophagus may cause compression of trachea, main stem bronchi or carina

32. Symptoms Hemoptysis- Coughing up blood Dyspnea- Difficulty breathing
Stridor- Abnormal high pitch sound caused by obstruction

33. Treatment Cryotherapy Laser therapy Surgical resection
External beam radiotherapy
Brachytherapy (HDR)
Long term survival- Poor