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Palliative Care Eyad Al-Saeed, MD,FRCPC Consultant 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 % Headache 49 Impaired cognition 58 Focal weakness 30 Hemiparesis 59 Mental disturbance 32 Hemisensory loss 21 Gait Ataxia 21 Papilledema 20 Seizures 18 Gait Ataxia 19 Speech diff 12 Aphasia 18 Sensory disturbance 6 Visual field cut 7 Visual disturbance 6 Limb Ataxia 6 Limb Ataxia 6 LOC 4 Diagnostic Studies CT • MRI • ? Primary • a =5anterior cerebral artery m = middle cerebral artery fh = frontal horn - lateral ventricle ph = posterior horn - lateral ventricle cc = corpus callosum 6 Cranial structures 7 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 16.Spinal Cord 8 Prognostic Factors Class Characteristics Survival 1 KPS 70-100 Primary Controlled Age < 65 Mets to brain only 7.1 mo 2 All Others 4.2 mo 3 KPS < 70 2.3 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.. Characteristics Options Single lesion (1 – 2) Surgical resection +WBRT WBRT+SRS SRS alone (with SRS or WBRT for salvage prn) WBRT alone 2-4 lesions ( 1-2) WBRT alone WBRT + SRS SRS alone (with SRS or WBRT for salvage prn) controversial 4 lesion (1-2) WBRT alone WBRT + SRS controversal SRS alone ( with SRS or MBRT for salvage prn ) controversal class 3 WBRT 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. • • 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 Causes 1- bronchogenic carcenoma 80 % 2- Malignant lymphoma 10 - 18% 3- Benign 2-3% Diagnosis Biopsy • CT • 1 = carina 2 = left main bronchus 3 = right main bronchus 4 = 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 •