a review of radiation oncology emergencies in …
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A REVIEW OF RADIATION ONCOLOGY EMERGENCIES IN
RADIOTHERAPY DEPARTMENT, LAGOS UNIVERSITY TEACHING
HOSPITAL (LUTH)
BY
DR. BOLANLE COMFORT ADEGBOYEGA
(MBBS, IBADAN)
A PART II DISSERTATION SUBMITTED IN PARTIAL FULFILMENT
OF THE AWARD OF THE FELLOWSHIP EXAMINATION IN
RADIOTHERAPY, FACULTY OF RADIOLOGY, NATIONAL
POSTGRADUATE MEDICAL COLLEGE OF NIGERIA
MAY 2017
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CERTIFICATION
This is to certify that the dissertation titled “A REVIEW OF RADIATION ONCOLOGY
EMERGENCIES IN RADIOTHERAPY DEPARTMENT, LAGOS UNIVERSITY
TEACHING HOSPITAL (LUTH)”was carried out by DR. ADEGBOYEGA BOLANLE
COMFORT of the Department of Radiotherapy, Lagos University Teaching Hospital, Idi-
Araba, Lagos State under my supervision.
SUPERVISOR _______________________________
Dr. A. C. Sowunmi FWACS, FMCR
Consultant Radiation Oncology/ Lecturer
Department of Radiotherapy/ College of medicine
Lagos University Teaching Hospital /University of Lagos
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DECLARATION
I hereby declare that this project report titled; “A REVIEW OF RADIATION ONCOLOGY
EMERGENCIES IN RADIOTHERAPY DEPARTMENT, LAGOS UNIVERSITY
TEACHING HOSPITAL (LUTH)” submitted by me to the National Postgraduate Medical
College of Nigeria is a bonafide work undertaken by me in partial fulfilment of the
requirements for the award of fellowship in radiotherapy and that no part of this proposal has
been submitted to any other college for the award of any degree or published any time before.
…………………………………………….
DR BOLANLE COMFORT ADEGBOYEGA
MBBS (IBADAN)
4
Department of Radiotherapy,
Lagos University Teaching
Hospital,
Idi- Araba,
Lagos State
9th of January, 2017.
This is to certify that this dissertation titled “A REVIEW OF RADIATION ONCOLOGY
EMERGENCIES IN RADIOTHERAPY DEPARTMENT, LAGOS UNIVERSITY
TEACHING HOSPITAL (LUTH)” was carried out by DR ADEGBOYEGA BOLANLE
COMFORT of the Department of Radiotherapy, Lagos University Teaching Hospital, Lagos,
in partial fulfilment of the award of the fellowship of Radiotherapy of the National
Postgraduate Medical College of Nigeria.
…………………………………………
DR. M Y M HABEEBU FMCR
HEAD OF DEPARTMENT
Consultant Radiation Oncologist/Lecturer,
Department of Radiotherapy,
Lagos University Teaching Hospital, Lagos
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DEDICATION
This book is dedicated to God Almighty without whom this project would not have been
possible, for His grace and favour, my teachers for putting me through and from whom I
gained experience and my family for their understanding, love and support.
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ACKNOWLEDGEMENT
I wish to acknowledge the Department of Radiotherapy, Lagos University Teaching Hospital,
Idi Araba, Lagos for giving me the opportunity to undergo my training in Radiation and
clinical Oncology.
I express my deep sense of gratitude to my respected and learned supervisors; Prof A.T.
Ajekigbe and Dr. MYM Habeebu for guiding and making necessary corrections with
attention and care when needed.
I owe many thanks to my teachers and consultants at Lagos University Teaching Hospital
namely, Prof. F.A. Durosinmi-Etti, Prof K.K. Ketiku, Prof. A.T. Ajekigbe, Dr. A.C.
Sowunmi and Dr. M.Y.M Habeebu, Dr. O Salako and Dr. Alabi A.O and Prof. M.A Aweda
for their immeasurable contribution and inspiration throughout my training period. The
blessings, help and guidance shall carry me a long way in the journey of life on which I am
about to embark.
I sincerely thank my teachers in other institutions namely Prof. O. B. Campbell, Dr. A. A.
Adenipekun, Dr. R. A. Oyesegun, Dr. Igbinoba, (just to mention a few) for your contributions
to my training. You are all highly appreciated.
I also thank my wonderful colleagues and other members of the department both medical and
non-medical for their support and assistance during my period of training.
It is my privilege to thank my husband Akin Adegboyega for his constant encouragement and
support throughout this residency training, Oreoluwa, Ibukunoluwa and Inioluwa, thank you
for the sacrifices you made and to my mother thanks for being there for me.
Finally, to the Almighty God, without whom all this would have been impossible.
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TABLE OF CONTENTS
Title Page i
Certification ii
Declaration iii
Dedication v
Acknowledgement vi
Table of Contents vii
Abstract 1
Introduction 3
Aim and Objectives 5
Literature Review 6
Materials and Method 21
Results 24
Discussion 36
Conclusion 41
Recommendation 42
Limitations 43
References 44
Appendix I 53
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ABSTRACT
Introduction
Radiation oncology emergencies are acute life threatening conditions due to cancer, its
complications or its treatments which requires the use of radiotherapy. It is common in
metastatic or locally advanced cancer and it requires urgent actions. Prompt diagnosis and
urgent intervention improves survival and outcome. Radiation Oncology emergency cases
accounts for a major component of palliative radiotherapy and a large part of radiotherapy
indications in poor resource setting.
Aim and Objectives:
The objective is to review the pattern, presentation, outcome of radiation oncology
emergencies in the department of radiotherapy, Lagos university teaching hospital.
Methodology:
This is a retrospective review of patients with radiation oncologic emergencies, seen in the
Department of Radiotherapy LUTH Lagos, from 2006-2016. Patient’s bio data, clinical
presentation, histologic findings and treatment records were retrieved using data extraction
forms and subsequently analysed.
Results:
A total of 458 cases of oncologic emergencies were reviewed. The age of patient ranged from
7 to 83yrs. The peak age was in the fourth decade in men and sixth decade in women, mean
age was 52.3yrs and M: F ratio was 1.2:2.
The most common primary cancer sites were breast cancer in 212(46%) patients, prostate
cancer in 96 (21%) patients, gynaecological cancers in 80 (17%) patients and head and neck
cancers in 25(5%) patients. Others were lung cancer, colorectal cancer and renal cell cancer.
Majority of the patients (95%) presented with advanced stage diseases like stage IV in
391(85%) patients, stage III in 45 (10%) patients, stage II in 18(4%) and 4 (1%) was stage I
disease.
Frank and impending myelo compression was the commonest indication seen in 247(53.9%)
of cases followed by raised intracranial pressure in 101(22.1%) patients and tumour
haemorrhage in 98(21.4%) patients.
Time from onset of symptoms to treatment was < 48hours in 75(16.4%) patients, 72hours to
1 week in 295(64.4%) patients and > 1 week in 88(19.2%) patients.
The commonest radiation doses used was 30Gy in 10 fractions over 2 weeks in 346(75.6%)
patients given in management of spinal cord compression and raised intracranial pressure
cases followed by 15Gy in 3 fractions in 1 week to control bleeding from tumour
haemorrhage and the others had 5-10 Gy in 1-2 fractions for various indications.
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There was improvement of symptoms and survival in 353(77%) of the patients, no
improvement in 52(11%) patients, 5(1.1% had symptoms progression or died but 48(10%)
were either lost to follow up or outcome unknown.
Conclusion; Radiation oncologic emergencies is a common occurrence in resource poor
setting owing to late presentation. The use of radiation treatment has played a prominent role
in reducing morbidity and mortality which may arise from this condition. However,
unavailability or non-functioning of radiotherapy machines continue to be a major challenge
facing the management of these emergencies.
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INTRODUCTION
Oncology emergency can be defined as an acute condition that is caused by cancer or its
treatment which requires rapid intervention to avoid death or severe permanent disability1.
While some oncologic complications are insidious and may take weeks or even months to
develop, others may manifest in a few hours, and quickly lead to severe negative outcomes,
including paralysis, coma and death. Owing to the rising incidence of cancer globally there is
also an expected increase in the incidence of oncology emergencies2. On the average, cancer
incidence rose 0.8% annually in white men and 1.8% in white women2. The patterns among
black men and women were similar to those among whites irrespective of the population
size2.Despite the increasing incidence rate of cancer in the general population, cancer
mortality rates are dropping due to rapid advances in treatment strategies and improvement in
survival of oncology emergencies3.
There are many indications for emergency care in cancer patients which includes the primary
cancer, complications of advanced disease and complications of treatment.
Management of cancer includes: surgery, chemotherapy and radiotherapy others are targeted
therapy and hormonal therapy. These treatment modalities also play a major role in the
management of oncology emergencies. Those managed by radiotherapy are also known as
radiation oncology emergencies.
Oncology emergencies are commonly seen in metastatic and locally advanced diseases 4.
Optimal outcomes in oncology emergencies rely on the recognition of early symptoms and
signs and implementation of appropriate therapy.3
Emergencies in cancer may be broadly classified into 3 viz;
Structural or obstructive emergencies
Metabolic or hormonal imbalance
Secondary to complications arising from treatment effects. 1
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Goals of radiation therapy can either be definitive (aimed at long term control of disease) or
palliative therapy aimed at relieving pain and other clinical signs which overall improves the
quality of life with minimal side effects.
Radiotherapy management of oncology emergencies is an important aspect of cancer care.
Most palliative radiation therapy protocol use fewer fractions, a higher dose per fraction, and
a lower total dose compared to definitive protocols (hypo fractionation). Palliative protocols
are often used when the patient has advanced cancer with metastasis. Those with some other
critical health condition such as hypertension, diabetic mellitus, old age, etc that would limit
life expectancy will also benefit from palliative treatment5.
Common radiation oncology emergencies are; malignant spinal cord compression (MSCC),
Superior vena cava obstruction (SVCO), Raised intracranial pressure in brain metastasis and
uncontrolled tumour haemorrhage.
There is paucity of data on radiation oncology emergencies in our environment thus
necessitating the need to carry out this study to review local data and compare with global
studies.
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AIM AND OBJECTIVES
AIM
To review radiation oncology emergencies managed in the department of Radiotherapy,
Lagos University Teaching Hospital, between January 2008 and December 2016.
OBJECTIVES
1. To determine the prevalence and socio demographic pattern of patients with radiation
oncology emergencies.
2. To describe the pattern of presentation of radiation oncology emergencies in LUTH.
3. To highlight the indication for radiation therapy in patients with oncology
emergencies.
4. To determine the outcome of radiation therapy in oncology emergencies.
.
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LITERATURE REVIEW
Cancer and its treatments may lead to a range of potentially life threatening conditions that
requires urgent actions. These oncologic emergencies can occur at any time during the course
of a malignancy, from the presenting symptom to end stage disease. It is important to have a
good understanding and knowledge of the primary cancer, make prompt diagnosis and early
intervention to improve survival and quality of life even in the setting of terminal illness.
Radiation therapy is vital in the management of some oncology emergencies6. Some of these
emergencies which includes malignant spinal cord compression, raised intracranial pressure,
superior vena cava obstruction and life threatening tumour haemorrhage may allow for
deviation from conventional fractionation and even be an indication for radiotherapy
treatment on weekends and /or scheduled hospital holidays7.
CLASSIFICATION OF ONCOLOGY EMERGENCIES1, 8
Oncology emergencies may be classified into three different groups namely;
Structural or obstructive emergencies; this is the group majorly treated by radiation
oncology and in this group are :-
- Raised intracranial pressure
- Superior vena cava obstruction
- Malignant spinal cord compression
- Tumour haemorrhage
- Bone metastasis/pain
- Obstructions; urinary, gastrointestinal tract, airway.
Metabolic or hormonal imbalance;
- Hypercalceamia
- Hyponatreamia
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- Hypoglycaemia
- Tumour lysis syndrome
- Syndrome of inappropriate Antidiuretics Hormone secretion
Treatment related emergencies;
- Tumour lysis syndrome
- Haemorrhagic cystitis
- Anaphylactic reactions
RAISED INTRACRANIAL PRESSURE
Raised intracranial pressure (ICP) is elevation of the pressure in the cranium. Intracranial
pressure is normally 7-15mmHg. Causes of raised Intracranial Pressure include; brain
tumours, haematoma, abscess, encephalopathy, thrombosis and hydrocephalus1.
Brain tumours may be primary or metastatic. Cranial metastasis affects a quarter of patient
who dies from cancer3 with incidence of about 170,000/year in the US9.
Lung cancer, breast cancer and melanoma are tumours that most commonly metastasize to
the brain; others are renal cancer and colorectal cancer10, 11.
ANATOMY AND PATHOPHYSIOLOGY
The cranium is a rigid bone containing the brain tissue, blood and cerebrospinal fluid. The
Monro- Kellie hypothesis states that the sum of the intracranial volume of any one of the
intracranial contents must be offset by a decrease in one or more of the others or be
associated with a rise in intracranial pressure.
Primary and metastatic brain tumours cause vasogenic oedema which can be due to; Local
production of factors that increase the permeability of tumour vessels e.g. vascular
endothelial growth factors (VEGF) or absence of tight endothelial cell junction in tumour
blood vessels. Most of the metastases are via haematogenous spread.
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NATURAL HISTORY AND CLINICAL FEATURES
The effects of brain metastasis can be manifested through two mechanisms viz; Direct
compression and Vasogenic oedema. Common clinical features are due to the tumour size,
site and growth rate of the metastasis. These clinical features include; headache
(throbbing/bursting), nausea and vomiting, behavioural changes and seizures. Others include
focal neurologic deficits, cranial nerve palsies, Papilloedema, Bradycardia(late sign), etc. The
classical triad is; Headache, Vomiting and Papilloedema.
DIAGNOSIS
- Physical examination and history
- Ocular examination – Direct Ophthalmoscopy to examine the eye for papilloedema
- Cranial Tomographic Scan(CT scan) of the head;
- Magnetic Resonance Imaging with contrast enhancement; this is the Gold standards it
can differentiate between neoplastic infection, inflammatory or ischaemic causes13,14.
TREATMENT MODALITIES
Hyperventilation; Controlled hyperventilation is helpful in patients to lower pCo2 which helps
in reducing the raised intracranial pressure.
Intravenous/ oral Steroids: Dexamethasone helps in reducing vasogenic oedema. DOSE –
16mg loading stat dose, then 6-10mg 6hrly to a total of 100mg /day. (Initially parenterally
then orally). Also oral prednisone at 2.5mg/kg.
Osmotherapy (IV Mannitol); may be given as a diuretics along with dexamethasone to reduce
the likelihood of cerebral herniation at 1g/kg 3-6 hrly.
Anticonvulsant phenytoin (initially as intravenous especially in unconscious patients at a
loading dose of 10-15mg/kg slowly in about 200ml of normal saline over 30mins not
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exceeding 50mg/min then maintained at 100mg iv every 6-8hrs. then orally about 1g in 3
divided doses.
Specific treatment modalities
Surgery; involves surgical decompression of operable tumours especially in solitary
metastasis where surgery is the treatment of choice.
Radiotherapy; this has been shown to be efficient in treating brain metastasis
regardless of the primary tumour histology15.
Whole brain radiotherapy (WBRT); this is the treatment of choice in patients with multiple
cerebral metastases. It provides short term relief of neurologic symptoms in 77% of cases 16,
and the dose can be 12Gy in 2 daily fractions on consecutive days, or 20 Gy in 5 fractions
over 1 week or 30Gy in 10 fractions over 2 weeks given in parallel opposed lateral fields17.
Stereostatic Radio surgery (SRS); primary therapy for limited brain metastases given
at 17-18 Gy in a single fraction17. However, it’s a superior mode of treatment for
either single or multiple metastases. Survival rate matches or exceeds those of surgery
+ WBRT or WBRT alone as reported by Patchel et al19 with overall survival of 40
weeks in the surgical group and 15 weeks in the radiation group.
The standard is thus surgery + WBRT which has less loco regional recurrence, better
overall survival and longer maintenance of function.19
Chemotherapy; for chemo sensitive tumours such as germ cell tumours, lymphomas
or small cell lung cancers.
PROGNOSIS
Depends on the following factors;
- Performance status (karnofsky score)
- Presence of systemic disease
- Primary tumour.
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SUPERIOR VENA CAVA SYNDROME (SVCS)
INTRODUCTION/EPIDEMIOLOGY
This is a group of symptoms caused by obstruction of the superior vena cava (SVCO). It is a
medical emergency and is commonly seen in patients with malignant disease within the
thorax20. SVCO previously used to be common as a complication of untreated infections eg
syphilitic thoracic aortic aneurysms; this was before the widespread use of antibiotics21.
William Hunter first described the syndrome in 1757 in a patient with syphilic aortic
aneurysm21. An earlier report in the literature by Schester in 1954 showed 40% of cases due
to syphilitic aneurysm or tuberculous mediastinitis22.
There is a significant change in aetiology factor in the post antibiotic era with malignancy
becoming the commonest cause in 90% of cases23,24, while the rest (10%) is due to non-
malignant causes25 like thrombosis largely due to increased use of intravascular devices like
central vein catheter. 15,000 cases was reported /year in the US with 5-10 % of patients
having right sided malignant intra-thoracic mass lesion26. These lesions include Pancoast
tumour, germ cell tumours, lymphoma, e.t.c.
ANATOMY AND PATHOPHYSIOLOGY
Superior vena cava (SVC) extends from the junction of the right and left innominate veins to
the right atrium its 4-6cm long and 1.5-2cm wide. It is a thin walled, low pressure, vascular
structure located in the middle mediastinum and its surrounded by relatively rigid structures
such as the sternum, trachea, right bronchus, aorta, pulmonary artery and peri-hilar and
paratracheal lymph nodes. The wall of the vessel is easily compressed as it traverses the right
side of the mediastinum27,28.
An obstructed SVC initiates collateral venous return to the heart from the upper half of the
body through four principal pathways viz;
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Azygous venous system
Internal mammary venous system
Long thoracic venous system connection to the femoral vein
Long thoracic venous system connection to the vertebral veins.
Obstruction of the SVC may follow 3 major pathways namely;
Neoplastic invasion of the venous wall
Extrinsic pressure of a tumour mass against the relatively thin walled SVC
Thrombosis of blood within the SVC.
However in some cases both external compression and thrombosis coexist29.
AETIOLOGY
Majority of SVCO results from malignancy, greater than 80% of cases are caused by
malignant mediastinal tumours30, 31, 32. Bronchogenic cancer accounts for 75-80% of all
mediastinal tumours mostly small cell cancers.23,24,30. 2-4% of patients with lung cancer
develops SVCO at some point during the disease26,28. Others are; lymphoma, metastatic
breast cancer, thymomas, mesothelioma and germ cell tumours.
Non – malignant causes33,34; accounts for about 20% of cases and these are; mediastinal
fibrosis, vascular diseases (aortic aneurysm, vasculitis, arterovenous fistula), infections
(histoplamosis, syphilis, tuberculosis), cardiac causes (pericarditis, atrial myxoma)
thrombosis following central vein catethers35,36, post radiation fibrosis in patients with prior
thoracic radiotherapy37.
NATURAL HISTORY AND CLINICAL FEATURES30,38
The rapidity of onset of symptoms and signs from SVCO depends upon the rate at which
complete obstruction of the SVC occurs in relation to the recruitment of venous collaterals.
These symptoms may develop within weeks to months however rapid tumour growth does
19
not allow adequate time to develop collateral flow39. Obstructions can also be partial or
complete. This affects the symptomatology of the disease; it can be asymptomatic in partial
obstruction or gradually worsening symptom over time as tumour increase in size.
Oedema occurs due to narrowing of the lumen of the nasal passage and larynx leading to
dyspnoea (commonest symptoms) in 63% of patients28,35,40, dysphagia41, stridor42, hoarseness
and orthopnea.
Interstitial oedema of the head and neck leads to facial oedema, dilated neck veins, upper
limb oedema and oedema of the neck (collar of stokes)43. Cerebral oedema leads to head
fullness, cerebral ischemia and herniation.
DIAGNOSIS40,44
The clinical diagnosis of SVCO is determined by characteristic signs and symptoms. Usually
progressive over weeks then gets better due to collateral veins. However subtle presentation
may require imaging like;
Chest X-ray; may show mediastinal widening, pleural effusion or a mass in the right side of
the chest. Majority of patients, 84% of 86 patients studied34 have abnormal findings mostly
mediastinal widening.
CT scan; neck, chest, lower abdomen, pelvis is the most useful imaging study, it defines the
level and extent of venous blockage, identifies the collateral pathways of venous drainage and
may guide at biopsy45.
MRI; an alternative in patients with contrast dye allergy34.
Venography is the gold standard; it identifies SVCO and the extent of associated thrombus
formation39.
Duplex USS; useful for excluding thrombus in the subclavian, axillary and bronchocephalic
veins especially in patients with indwelling devices.
20
Histologic diagnosis; a prerequisite for appropriate therapy in malignant cases. E.g. samples
gotten from sputum cytology, pleural fluid aspirate, lymph node biopsy, bone marrow
aspirate32.
TREATMENT
Options of treatment of SVCO depends on the underlying aetiology and on the pace of
symptoms progression46,47. Current management guidelines stress the importance of accurate
diagnosis prior to starting definitive therapy. Radiotherapy prior to biopsy may obscure the
histologic diagnosis. Important exceptions however occur in patients with stridor due to
central airway obstruction or coma in cerebral oedema48,49, these patients require urgent
medical treatment.
In the management of SVCO the goal is thus to relieve symptom and to attempt cure of the
primary malignant process. Treatment is thus in phases viz;
- Conservative/Symptomatic management
- Definitive management.
Conservative management
These includes supportive care47,50 and medical management such as;
- Elevation of the head of the bed to relieve cerebral oedema
- Supplemental oxygen
- Bed rest
- Glucocorticoids to relieve oedema especially in steroid sensitive tumours like
thymoma or lymphoma and in patients undergoing radiotherapy32
- Diuretics
- Anticoagulants for thrombosis related SVCO27
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Definitive Management
Radiotherapy is widely advocated as the standard treatment for most patient especially those
caused by radiosensitive tumours. Most of the malignancies causing SVCO are radiation
sensitive thus most patients receive radiotherapy as first line treatment38.
The radiation dose depends on tumour size and the radio-responsiveness of the tumour and
the total radiation dose is up to 30-50Gy. The fractionation schedule can be 2-4 large initial
fractions of 3-4 Gy, then daily dose of 1.5-2 Gy /fraction20. Radiation therapy palliates SVCO
in 70% of patients with lung cancer and in >95% of those with lymphoma20.
Chemotherapy may be preferable to radiation for patient with chemo-sensitive tumours like
lymphoma, SCLC, Germ cell cancer. As reported from MD Anderson Cancer Centre on
management of SVCO secondary to Non-Hodgkin’s lymphoma treated with chemotherapy
alone, radiotherapy and combination showed all patients achieved complete relief of SVC
symptoms within 2 weeks of institution of any treatment option42,48,51.
Surgery; stenting in most patients produce rapid and symptomatic relief within few days. It
may be necessary while the histologic diagnosis is being actively pursued, it may also be
indicated in patients where chemotherapy or radiotherapy has failed 29,34,47,50,52,53.
MALIGNANT SPINAL CORD COMPRESSION
INTRODUCTION
Malignant spinal cord compression (MSCC) is a common complication of cancer that can
cause pain and potentially irreversible loss of neurologic functions. Compression of spinal
cord from rapidly growing mass can result in neurologic compromise. It is a dreaded
complication of cancer and fairly common. It is estimated to develop in about 5% of all
cancer patients54.
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EPIDERMIOLOGY/AETIOLOGY
In a study of spinal cord compression, it was reported that the likelihood of cancer patients
developing cord compression 5yrs before death was 2.5% ranging from 0.2% in pancreatic
cancer and 7.9% in melanoma55. Other studies revealed annual incidence of 3.4% of
hospitalized cancer patients with MSCC56. In the U S alone >20,000 cases of MSCC are
diagnosed annually54.
Metastatic tumour from any primary site can produce MSCC but mostly from tumours that
have tendency to spread to the spinal column. Three most common sites are; Lung cancer,
Breast cancer and Multiple myeloma. Others are; Lymphomas, Prostate cancer and Renal
cancer61,62-64.
ANATOMY
The spinal cord is enclosed by a protector ring of vertebral bones; within this ring is the theca
sac, the outermost layer of which is Dura mater. Between the dura and the bones lies the
epidural space which normally contains fat and the venous plexus. Epidural spinal cord
compression occurs when tumour invades the epidural space and compresses the theca sac. In
adults, the tip of the spinal cord usually lies at the L1 vertebral level.
PATHOPHYSIOLOGY
Vertebral metastases are far more common than MSCC. About 96% of cases occur in
thoracic spine, 30% in lumbosacral spine and 10% in cervical spine57. Studies also suggested
certain tumours have propensity for specific spinal regions like Lung cancer to thoracic spine,
Renal, Prostate and GIT to lower thoracic and lumbar spine58,59.
Approximately 85-90% of cases of MSCC are due to metastatic tumour in the vertebral
bones. The mechanism of metastasis varies60, this includes:
a. Arterial seeding of bone seen in majority of cases
23
b. For pelvic tumour especially prostate cancer - Batson plexus drains the tumour to the
vertebral bones.
c. Pineal tumours travel through neural foramen to epidural space in lymphoma.
NATURAL HISTORY AND CLINICAL FEATURES
The degree of spinal cord compression can range from a minor asymptomatic indentation on
the normal theca sac contour to strangulation of the spinal cord with associated paraplegia.
As tumour grows in the epidural space it encircles the theca sac and obstructs venous plexus
leading to vasogenic oedema and if unchecked leads to spinal cord infarction. The symptoms
are usually;
1. Pain - This is usually the first, present in 83-95% of patient at diagnosis on average
precedes other neurological symptoms by 7 weeks. Usually low back pain with
progressive intensity and may become radicular58,59,62,65.
2. Motor findings – weakness occurs in 60-85% of patient at diagnosis. Increasing
weakness followed by loss of gait function and paralysis66,67.
3. Sensory finding; ascending numbness and parasthesia67.
4. Bladder and bowel dysfunction; usually a late finding like, presenting with features of
urinary retention and or constipation67.
5. Ataxia; gait ataxia in cancer patient raise suspicion of MSCC68.
INVESTIGATION
MRI of the entire theca sac; the gold standard. It can provide an accurate evaluation of
disease extent and involvement of adjacent soft tissue and bone 69.
CT Myelography; roughly equivalent in sensitivity and specificity with MRI70.
CT scan of the spine; shows bony disruption not showing spinal cord or epidural space
24
Plain radiography; the easiest study obtainable shows vertebrae body collapse or pedicle
erosion71.
Radionuclide bone scan; more sensitive than plain radiograph, it visualizes the entire skeleton
but not informative about theca sac compression.
TREATMENT
The goals of treatment include the following to control pain, avoid complications,
preservation or improvement of neurologic function72.
The single most important prognostic factor in regaining ambulation after treatment of an
MSCC is pre-treatment neurologic status73. Other factors however includes; degree of spinal
cord block, radio sensitivity of tumour and radiation dose schedule
General principle of treatment thus includes;
- Symptomatic management - high dose glucocorticoids like dexamethasone 10-16mg
stat then 4-6mg 6hrly66,74,75,76.
- Analgesics – opioids and Non Steroidal anti inflammatory drugs (NSAIDS).
- Anticoagulants; due to immobilization to prevent venous thrombosis. Eg
unfractionated heparin, low molecular weight heparin.
- Prevention of constipation; secondary to opiate use, immobilization, autonomic
dysfunction. Ensure bowel regimen which includes intake of high fibre diets and
roughages, use of liquid paraffin or lactulose to ease defecation and enema saponis
when necessary.
Definitive management;
Surgery – surgical decompression and spinal stabilization75. Followed by radiotherapy
increases the likelihood of regaining the ability to walk compared to those treated with
radiotherapy alone in carefully selected patients77.
25
External beam radiotherapy; it was the initial treatment of choice for most patients with
MSCC still used for patients that are not surgical candidates and following surgical
decompression. It is also used as sole treatment in multiple level lesions.
The radiotherapy portal covers the width of the vertebral body and all areas of para vertebral
tumour extend one vertebral body above and below the epidural metastasis. Radiotherapy is
effective for palliation of pain and local tumour control78 approximately 70% of patients
have an improvement in pain and one half of those without spinal instability experience
resolution of back pain following radiotherapy79,80,81
Dose and schedule of treatment varies, ranging from single large fraction like 8Gy which is
recommended for palliation of metastatic bone pain associated with spinal cord compression
or pathological fractures81 to protracted courses like 30Gy in10 fractions to 40Gy in 20
fractions.
Chemotherapy in patients with chemo sensitive tumour like lymphoma or multiple myeloma
chemotherapy is an attractive option because it can also treat tumour deposits elsewhere in
the body.
PROGNOSIS
Factors affecting prognosis include:
- Pre-treatment neurological status
- Radio sensitivity status of the tumour
- Presence of visceral metastases or other bone metastases.
TUMOUR HEAMORRHAGE
INTRODUCTION
Tumour haemorrhage is the commonest oncology emergency in this environment82.
Haemorrhage is the third most frequent cause of cancer death (after organ failure due to
26
tumour invasion and infections). It occurs in 6-14% of patients with advanced cancer 83 and
it’s the immediate cause of death in around 6% of cases83.
PATHOPHYSIOLOGY
Tumour haemorrhage can be due to a number of events occurring solely or a combination
such as local vessel damage or invasion, systemic processes like disseminated intravascular
coagulopathies or platelet abnormalities secondary to liver failure, medications like
anticoagulants, chemotherapy and other forms of management such as radiotherapy, surgery
and concurrent disease like idiopathic thrombocytopenia.
Clinical Presentation
Haemorrhage can present in a variety of ways from occult bleed causing anaemia over weeks
to months(with features like generalized malaise, dizziness, easy fatigability, dyspnoea,
fainting spells) to overt external bleeding from particular anatomical sites like82;
heamatemesis, heamatochezia, melena, haemoptysis, haematuria, epistaxis, vaginal bleeding
and ulcerated skin lesions.
DIAGNOSIS
Detailed history to determine the underlying cause(s) including drug history like use of
NSAIDS and anticoagulants. Past medical history of peptic ulcer disease.
Laboratory investigations include; complete blood count, liver function test and clotting
profile.
Radiological Investigation – Angiography, Endoscopy studies may identify the site of
bleeding if not obvious.
MANAGEMENT
- General resuscitative measures like fluid replacement, volume expander like colloids
and blood transfusion
27
- Packing and Haemostatic agents; this is used with or without pressure in bleeding
from nose, vagina rectum etc.82 This can also be coated with agents that facilitates
haemostasis like acetone in vaginal packing.82
- Vasoconstrictors; epinephrine applied topically in 1:1000 dilution (but its liberal use
is discouraged)89, thromboplastin (available as topical powder), Prostaglandin E2 and
F2 used in intractable haemorrhagic cystitis.83. Formalin 2-4% used as chemical
cautery in intractable rectal and bladder haemorrhage.82
- Systemic treatments like Vitamin K, Anti fibrinolytic agents like trexanemic acid,
dicynone, blood products like platelet concentrates.
- Radiotherapy: External beam radiotherapy or Brachytherapy. This is highly effective
and should be considered for tumour haemorrhage from the vagina, skin, rectum,
bladder and head and neck.
- Single or reduced fraction regimen appear to be as effective as multiple fractions in
achieving haemostasis.82 External beam Radiotherapy may be successful in
controlling bleeding in up to 85% of rectal bleeding and 60% of heamaturia from
bladder cancer83. In cervical cancer, the control of haemorrhage with haemostatic
radiotherapy (external beam and intra-cavitary) was 100% within 12-48hrs post
treatment83. Both 15Gy in 3 fractions and 20Gy in 5 fractions have equal efficacy.
- Surgery; removal of bleeding tissue or ligation of vessels supplying it .this is invasive
and risky thus reserved for early disease or when other methods have failed.
- Interventional radiology; includes intentional occlusion of bleeding artery with either
particles like poly vinyl alcohol, mechanical device like coil, liquids like glue,
alcohol, or injection of other sclerosants.
28
MATERIALS AND METHODS
Study Area
The study was conducted in the Radiotherapy Department of Lagos University Teaching
Hospital, Lagos..The centre is majorly a referral center of the South western and South
Eastern region of Nigeria and occasionally from other parts of the country.
Study Population, Sample Size and Inclusion Criteria
The study included cancer patients who completed prescribed emergency radiotherapy in
Radiotherapy Department, Lagos University Teaching Hospital (LUTH) between January
2008 to December 2016. The time frame was against the initial 10 years study period
proposed but because the LINAC machine did not begin operation till 2008 and records prior
to the period could not be retrieved.
Inclusion criteria
- Patients with histologically confirmed cancer and diagnosis of radiation oncology
emergencies.
- Patients who completed the prescribed treatment
EXCLUSION CRITERIA
- Patients not treated as emergencies
- Those referred for continuation of treatment after commencing emergency
radiotherapy from other centres
- Patients who had incomplete data in their case note or radiation treatment cards were
not available.
- Patients who had incomplete radiation treatment.
29
Study Design
This is a retrospective study of patients with histologically confirmed cancers presenting with
oncologic emergency managed by radiotherapy.
Data Collection
Case notes and radiation treatment cards of radiotherapy emergency cases treated at the
Department from Jan. 2008- Dec. 2016 were retrieved from the medical records department
for data collection using questionnaires. Data on the patients demographic status like age,
sex, smoking and alcohol history,site of primary disease, presenting complaints,duration of
symptoms, stage at presentation, histological types and treatment modalities were obtained
from the case notes. Others included treatment such as treatment field, dose received and
chemotherapy combination, response to treatment, follow up till date/ demise were also
collected and analysed.
The Linear Accelerator (LINAC) 6Mv/15Mv machine was used for radiotherapy treatment
Data Management and analysis
The data obtained were analysed using the statistical Package For Social Science version 16.0
(SPSS ver 16.0). Analysis was done using percentages, frequencies,counts, charts.
ETHICAL CONSIDERATION
Ethical clearance to conduct the study was obtained from the Health Research and Ethics
Committee of the Lagos University Teaching Hospital (LUTH) Lagos.
1. Confidentiality of data: Serial number and initials, and not names of patients were
used. The records of patients were kept confidential and no third party had access to
them. The data extraction forms and data collected were protected and made
accessible to the researcher only.
30
2. Beneficence: The study is expected to be of benefit to patients, because its findings
will be communicated to the stakeholders involved in providing care and support
services to patients.
31
RESULTS
During the study period of January 2008 to December 2016, a total of 2270 cancer patients
had radiotherapy in this department, of which 458[20%] were emergency cases.
The ages of patients seen were between 7 and 83years with the mean age of 52.3years and
peak age being the fourth decade in men and sixth decade in women (figure 1).
Mean = 52.3 N=458 Figure 1:
Age distribution of patients treated for radiotherapy
emergencies
Freq
uen
cy
32
Figure 2: Frequency distribution of the sex of the patients with radiotherapy emergencies
The sex distribution of the patients was 31% male and 69% female with ratio M: F 1:2.2. The
commonest age distribution of the females was 41-50 years and 61-70 years for males.
(Figure 2
Freq
uen
cy
33
Figure 3; frequency distribution of cancer sites
CRC denotes Colorectal cancer
CUP denotes carcinoma of unknown primary
RCC denotes Renal cell carcinoma
STS denotes soft tissue sarcoma
The commonest primary cancer site was Breast accounting for 212 (46%), followed by
prostate cancer in 96 patients (21%). Others were Gynecological cancers in 80 patients
(17%), head and neck cancers in 25 patients (5%), Lung cancer was 9 cases (2%), and
bladder cancer in 8 patients (2%). Others include Colorectal, bone and soft tissues and renal
cell cancer. (fig 3)
Freq
uen
cy
34
Figure 4: Frequency distribution of previous treatment by patients with oncology
emergencies.
At presentation, 105(23%) of these patients had not had any prior treatments before
presenting as emergencies while 353(77%) had prior treatments like chemotherapy in
103(22%), surgery in 68(15%) patients, Hormonal in 13(3%) patients. Others had various
combination therapies like surgery and chemotherapy in 116 (25%) patients, surgery,
chemotherapy and radiotherapy in 21(5%) patients and other combinations. (figure 4)
No previous treatment
35
Table 1; frequency distribution of prior treatment in the various cancer patients
PRIOR TREATMENT
PRIMARY
CANCER SITE CHEMOTHERAPY HORMONAL NIL RADIOTHERAPY SURGERY
COMBINATION
THERAPY
GRAND
TOTAL
Bladder 3 0 3 0 1 1 8
Bone 1 0 0 0 0 0 1
Breast 69 0 13 0 10 120 212
Cervix 4 0 58 1 3 10 76
CRC 3 0 0 0 1 3 7
CUP 1 0 0 0 0 0 1
Endometrium 0 0 1 0 3 0 4
Head/Neck 7 0 3 0 3 12 25
Lung 7 0 2 0 0 0 9
Others 4 0 0 0 2 3 9
Prostate 2 12 24 1 42 15 96
RCC 0 1 0 0 1 1 3
STS 2 0 1 0 2 2 7
Grand Total 103 13 105 2 68 167 458
Majority (69 of 103) of the patients who had prior chemotherapy were breast cancer cases
while hormonal therapy was only recorded in prostate cancer.
Of the 105 patients without prior treatment, 58(85%) presented as tumour hemorrhage, 15
with features of myelocompressions and the rest as other complaints (table 1).
36
Figure 5; frequency distribution of stages of cancer at presentation
The commonest stage presenting as emergency was stage IV disease in 391(85%) patients,
45(10%) patients was stage III, 18(4%) presented in stage II while only 4(1.1%) patients were
in stage I.( figure 5)
Freq
uen
cy
37
Figure 6; Frequency distribution of indications for emergency radiotherapy
Overall, frank and impending myelocompression was the commonest indication for
emergency radiotherapy in our Centre accounting for 53.9% (247 patients) of all cases seen;
raised intracranial pressure was seen in 101(22.1%) patients, closely followed by tumor
hemorrhage in 98(21.4%) patients. Less frequent indications for emergency radiotherapy
were superior vena cava obstruction, fungating tumors and obstructive uropathy. Figure 6
38
Table 2; frequent metastatic sites and emergency presentatgtvkfk987koc8ccion patterns
Common Metastatic Sites / Emergency Presentation Patterns
Frequency
Metastatic Site BRAIN
CHEST
WALL
SPINE/
BONES HEAMORRHAGE SVC OTHERS
Grand
TOTAL
Bladder 0 0 8 0 0 0 8
Breast 80 5 128 0 0 0 213
Cervix 1 0 0 75 0 0 76
Crc 0 0 6 0 0 0 6
Cup 1 0 0 0 0 0 1
Endometrium 0 0 0 4 0 0 4
Head/Neck 10 1 14 0 0 0 25
Lung 4 2 2 0 2 0 10
Prostate 3 0 92 0 0 0 95
RCC 0 0 3 0 0 0 3
STS 1 0 6 0 0 0 7
Others 2 0 6 0 0 1 9
Grand Total 102 8 265 79 2 1 457
%
Primary
Cancer Site
22% 2% 58% 17% 0% 0% 100%
The commonest cause of the tumor hemorrhage was cervical cancer in 66(67.4%) patients,
10(10.2%) was due to head and neck cancers, 8(8.2%) from breast cancer, 7(7.1%) from
prostate/urinary bladder.
Of the 102 patients with raised intracranial pressure, 80 were from breast cancer, 10 from
head and neck cancers with brain extension, 4 patients had lung cancer as their primary, 3
from prostate cancer and the rest from other sites. Table 2
39
Figure 7; Frequency distribution of time to presentation
Time from onset of symptoms to treatment was between 24-48hrs in 75 patients (16.4%),
72hrs to 1 week in 295 (64.4%) patients and more than 1 week in 88(19.2%). Figure 7
Majority (80%) of the early presenter (<48hrs) were due to tumor hemorrhage, 10(13.3%)
was due to raised intracranial pressure but most of those that presented after 1 week of onset
of symptoms were either due to impending or frank myelocompression as seen in 47(53.4%)
patients and raised intracranial pressure in 34(38.6%) patients.
Freq
uen
cy
40
The commonest radiotherapy doses given in 75.6% of the total patient treated was 30 Gy in
10 fractions which was mostly due to myelo-compression in 242 (52.8%) patients and raised
intracranial pressure in 98 (21.4%) patients. Some (11/2.4%) however had 20-25 Gy in 5-10
fractions also due to above indication. Those treated for tumor hemorrhage 78 (17.1%)
patients received 15 Gy in 3 fractions while the rest received 5-10 gy in 1-2 fractions.
.
41
Figure 8; frequency distribution of treatment outcome
There was complete/ partial response in 353 (77%) patients as evidenced by cessation or
improvement of symptoms like tumor hemorrhage, improvement in power or gait in those
with cord compression. There was also significant pain control in those with impending
myelo compression). However, there was no response in 52 (11%) patients and 5 (1.1%) had
disease progression or died. The remaining 48 (10%) were either lost to follow up or outcome
unknown. Figure 8
Freq
uen
cy
42
Definition of Terms
Complete Response(CR); Complete resolution or dissapearance of signs and symptoms of
Disease after radiotherapy treatment.
Partial Response (PR); This is greater than 50% reduction in signs and symptoms after
radiotherapy treatment.
No Response (NR); This is reduction in signs and symptoms of less than 50% or progression
of the disease after radiotherapy treatment
43
DISCUSSION
Radiotherapy is an important treatment option for the emergencies in oncology being very
effective for symptom relief and improving overall survival in these patients.
The study results showed that oncologic emergencies is a common occurrence in our center
as it is in most developing countries and it accounts for 20% of the new cases seen within the
review period implying that 1 in every 5 new patients will present with emergency. This is
higher than the result in an earlier study in the northern part of the country by Adewuyi et al4
where it is found in 1 in 9 patients. The rising incidence could be attributed to increasing
cancer incidence in the general population as revealed by an earlier study by Dinse et al4
where he reported increase in cancer incidence in the United States from 1975. Also
Abdulkareem F85 reported cancer incidence in Nigeria with the upward trend.
However, a study done by Christian E et al83 in Germany showed that it only represent 3.1%
of all radiotherapy indications. Which could be attributed to screening, early detection,
advances in management modalities and availability of funds/ health insurance among other
things in developed countries as opposed to resource poor countries.
The sex distribution of M:F = 1.2:2 revealed female preponderance which is in accordance
with a previous study in the South-West part of the country which revealed that cancer
incidence is higher in females than males due to high incidence of breast cancer compared to
prostate cancer as shown by studies by Ketiku KK84 and Abdulkareem85. So also in this
study 46% of the patients had breast cancer while prostate cancer was the primary
malignancy in 21% of patients. Other cancer cases were cervical cancer in 80 (17%) patients,
head and neck cancers in 25(5%) patients. So breast cancer is confirmed to be the commonest
cancer seen in the general population in Nigeria86,87.
44
Ninety-five percent of the reviewed cases presented late as either metastatic or locally
advanced disease which is similar to the pattern of presentation in the northern part of the
country by Adewuyi et al4, in which about 80% of the patient were stages III and IV. This
when compared to studies in developed countries presents a gloomy picture of expected poor
result following treatment unlike in developed countries where early presentation improves
their outcome and reduces emergency rates.
Fear of unknown, illiteracy, traditional and cultural beliefs were reasons proffered for late
presentation in a study conducted earlier in our Centre by Ajekigbe et al88.In this study, 87%
of cancer patients presented in stages 3 and 4 and 13% presented with stages 1 and 2. Other
reasons that were implicated included poverty, denial, alternative medicine usage and
inadequate facilities in the environment89.
This study showed that the commonest indication for emergency radiotherapy treatment was
malignant spinal myelo-compression which accounts for 53.9%, followed by raised
intracranial pressure in 22.1% and tumor hemorrhage in 21.4%. Other indications like SVCO
and obstruction only contributed minimally. This is somewhat similar to reported studies in
literature that reported the commonest indication being malignant myelo-compression though
closely followed by SVCO because of higher incidence of lung cancer in the developed
countries as opposed to the pattern in this environment54, 83,90. However the study findings
are contrary to the earlier study in the northern part of the country that showed the
commonest indication for emergency radiotherapy to be tumor hemorrhage. This could be
due to higher incidence of cervical cancer in the Northern part of the country which could be
as a result of early marriage and low socioeconomic status in that environment when
compared to the compared to the South-Western part of Nigeria.4
Breast cancer accounted for 84% of the cases of raised intracranial pressure, 10% from head
and neck cancers, 4% from lung cancer and 3% from prostate cancer and this is comparable
45
to reported studies where lung cancer, breast cancer and melanoma were the commonest to
send secondaries to the brain and this further corroborates the pattern of cancer prevalence in
our environment where breast cancer is the commonest malignancies seen in the general
populace86,87.
At presentation, 105(23%) of the patients had no prior treatment while the rest had some
forms of treatments like chemotherapy, hormonal therapy, surgery either as monotherapy or
combination therapies. However when compared to the study in the Northern part of the
country by Adewuyi et al4; 64.3% of cases seen were not on any treatment. This wide
variation between the North and South could be due to low socioeconomic status in the North
and also high incidence of tumor hemorrhage especially bleeding cervical cancer as this is the
most commonly seen oncologic emergencies over there and 85% of those without prior
treatment in this index study are also due to tumor hemorrhage mostly from cervical cancer.
According to the literature; the interval between the onsets of symptoms to definitive
treatment is a major prognostic factor determining the outcome and effectiveness of the
treatment72. Christian E et al83 reported the median time interval between presentation and
beginning of radiotherapy as 2hrs and the latest being 36hrs. The pattern in our environment
however is far from this as 64.4% of the patients didn’t start radiotherapy until after 72hrs to
about 1 week from onset of symptom, 19.2% presented after 1 week and only 16.4 %
presented and were treated between 24-48hrs of onset of symptom and this is also similar to
the study by Adewuyi et al4 where 82% of the patients were treated after 1 week of symptoms
onset. Reasons for delay in this environment include extremely few radiotherapy centers with
its attendant frequent breakdowns, low man power, poverty, ignorance etc.
There is no ideal dose and fractionation for oncologic emergencies but according to the
literature, the total dose is tailored to the disease setting, life expectancy and performance
status of the patients.1,3,30,31. The commonly used dose and fractionation in our center is 30Gy
46
in 10fractions over 2 weeks and this was used for 75.6% of the cases treated especially the
skeletal and cranial irradiations. 24.6% received 15Gy in 3fractions mostly as hemostatic
doses in tumor hemorrhage and SVCO. 11 patients however had 5-10Gy in 1 or 2 fractions
for cases like spinal irradiations and fungating tumor with outcomes compared to those that
received 30Gy in 10 fractions for same indications.
Alongside the teletherapy, these groups of patients with oncologic emergencies had
supportive therapies to further improve the outcome ranging from analgesics following the
World Health Organization (WHO) ladder for those with pains.
Those with cord compression raised intracranial pressure had high dose corticosteroids.
Other modalities of treatments included site packing with or without adrenaline for bleeding
tumors. Parenteral or oral trexamin and blood transfusion were also employed in hemorrhage
management.
In some instances also there were co managements with other units like the nephrologist to
manage the renal impairment usually by hemodialysis.
All these measures are strongly recommended in the literatures 23,32,62,45.
This study showed significant improvement in symptoms [palliative measures] in 353
patients (77% of cases) most especially in those with tumor hemorrhage and SVCO. This
further corroborates the fact that radiotherapy plays a major role in the management of SVCO
and tumor hemorrhage. There was also significant pain and symptomatic relieve in 60% of
those with MSCC following radiotherapy irrespective of the dose fractionation. This finding
was supported by Donato V et al91 study on the various dose fractionation showing 73.3%
relief in patient that had 30Gy in 10fractions, 66.6% in those that received 20 Gy in
5fractions and 70 % relief in those that had 8 Gy in 1 fraction.
In 2005, Patchell et al19 reported the critical role played by radiation therapy in the treatment
of MSCC, including in patients who have undergone surgical decompression. The percentage
47
of ambulatory patients was significantly higher in the group treated with surgery plus
radiation compared with those who had surgery alone (84% vs 57%), also the median
survival (126 days vs 10days).
There was little or short term improvement in 52 patients (11%) and these were cases of
raised intracranial pressure and some MSCC. Chargari et al 16 report supported this revealing
that 70% of patients with brain metastasis had only short term relief.
In addition, 5 patients died during or shortly after treatment essentially due to renal
impairment in pelvic malignancies and disease progression in those with raised ICP.
About 10% of the patients were either lost to follow up or outcome unknown due to
improper/ inadequate documentations in their case files. This is one of the major problems
faced in this environment regarding patient care and follow up.
48
CONCLUSION
Increasing cancer burden is a global challenge because of its associated morbidity and
mortality. The prevalence was seen to have increased over the years with majority of the
patients presenting with advanced/ metastatic diseases.
Oncologic emergencies incidence arising commonly in patients with metastatic disease is
increasing as cancer therapies improves with the attendant median survival of such patients.
Radiotherapy has been used to treat these conditions effectively and safely in time past till
now leading to improved quality of life and longer survival time. Therefore palliative
radiotherapy continues to be a mainstay of treatment of cancer patients with advanced
diseases.
Oncologic emergencies can threaten the life of almost any patient with a malignancy as it
spans the chronological spectrum of a diseases natural history, all clinician should be familiar
with the modes of their presentation as well as understand the methods for their prompt
assessment and treatment.
49
RECOMMENDATIONS
There should be more enlightenment programme to create more awareness and
educate the populace about cancer.
The community health workers, religious leaders and media should be engaged in
enlightenment programmes to dispel the myth about cancer and ensure early
presentation.
The government should ensure funding of quality controlled population based
screening programmes in all geopolitical zones in the country which will ensure that
women above 50 years have access to yearly mammogram, sexually active women
have PAP smear and men above 50years have annual PSA evaluation at subsidized
rates or totally free screening.
Government and private organizations should invest in establishing more radiotherapy
centres preferably in every state to cater for the increasing burden of cancer in
developing nations and to ensure prompt treatment.
Health insurance scheme should cover cancer management to allow for subsidised
cancer treatments availing more patients the benefit of best of care.
Training and continuing medical education of health givers especially the General
Practitioners on cancer management and early referrals to specialist to ensure proper
management of cancer in Nigeria.
50
LIMITATIONS
Being a retrospective study, some case notes and treatment cards were not available
for study. Also some information was not supplied in the files for analysis.
Many patients were lost to follow up making it difficult to determine the overall
survival of these patients.
There were incessant breakdowns of the radiotherapy machine during the study period
which necessitated patient’s referral to other radiotherapy centres.
51
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APPENDIX 1
DATA EXTRACTION FORM
1. Serial Number…………………………………..
2. Hospital Number………………………………..
3. Age (Years)………………………………………………
4. Sex……………………………………………
5. Referral Centre
6. Primary cancer site
7. Primary cancer histology………………….
8. Primary cancer stage…………………….
9. Duration of illness (a) <1 Year… (b) 1-2 Years….. (c) 2-5 Years…. .(d) >5 Years……
10. Prior treatment received for primary cancer
- Surgery……
- Chemotherapy………
- Radiotherapy……
- Surgery and Chemotherapy…….
- Surgery and Radiotherapy………………………….
- Chemotherapy and Radiotherapy…………………..
- Surgery, Chemotherapy and Radiotherapy…………….
- Hormonal therapy…….
- Others……
- Nil…………
11. Metastatic site / Presenting complains
12. Site of symptoms (a) Brain………. (b) Vertebra/Spinal cord…… (c) Lung…
(d) Bone……… (e) Lymph node….. .. (g) Others………
61
13. Cause of presenting symptoms (a) Primary disease… (b)Metastatic disease…
(c) Recurrence/Residual
14. Duration of symptoms (a) <24 hours…. (b) 24-48 hours…. (c) 48-72 hours….. (d) >72 hours...
15. Indication (s) for emergency radiotherapy (a) Pain……. (b) tumour fungation…….
(c) Bleeding……
(d) Myelocompression……… (e) Increased intracranial pressure..........
(f) Superior vena cava obstruction…… (g) Obstructive uropathy…….
(h) Gastrointestinal obstruction……… (i) Bronchial obstruction…….
(j) Others………………..
16. Radiation fields used (i) 1………… (ii) 2……… (iii) 3………….. (iv) 4…………
17. Total treatment dose………………………..
18. Number of fractions………………………..
19. Dose per fraction……………………………
20. Duration of treatment………………………..
21. Adjuvant medications (a) Analgesics……… (b) Steroids………(c) Others…… (d) Nil…….
22. Effect of treatment on symptoms (a) improved…. (b) Not improved…
(c) Worsened… (d) Unknown
23. Follow up (a) absence of new complaints (b) presentation of new complaints
(c) recurrence (d) lost to follow up
62