Radiation 2012 econference

Transcription

1 Copyright 2012 Oncology Nursing Society. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, without permission in writing from ONS. Saturday, September 8, :45 10:45am Radiation 2012 econference Brandt will discuss oncologic emergencies that are managed with radiation therapy, including malignant spinal cord compression, brain metastases, and superior vena cava syndrome. She'll also address their pathophysiology, clinical presentation, nursing assessment, and treatment. In this interactive session, you'll analyze case studies to learn more about your role in assessing, managing, and preventing complications. Presented by: Jeannine Brant, PhD, APRN, AOCN Oncology Clinical Nurse Specialist and Nurse Scientist Billings Clinic Billings, MT Full Disclosure: Archimedes. Speaker's Bureau Continuing Nursing Education: Participants will receive 1.0 continuing nursing education credits for successful completion of this session.* At the end of this session participants will be able to: 1. Discuss the pathophysiology, clinical presentation, diagnosis, and management of oncologic emergencies sensitive to radiation including malignant spinal cord compression, brain metastases, and superior vena cava syndrome. 2. Describe the role of radiation therapy in the management of oncologic emergencies. Content Outline: I. Overview of Amenable to Radiation Therapy a. Scope of the problem b. Vast array of oncologic emergencies in need of radiation therapy II. Focus on the most common emergencies a. Malignant spinal cord compression i. Pathophysiology ii. Clinical presentation and diagnosis iii. Nursing assessment iv. Management 1. Medications 2. Radiation therapy 3. Nursing management 4. Adverse effects 5. Case Study b. Brain metastases i. Pathophysiology ii. Clinical presentation and diagnosis iii. Nursing assessment iv. Management 1. Medications 2. Radiation therapy 3. Nursing management 4. Adverse effects 5. Case Study c. Superior vena cava syndrome i. Pathophysiology

2 Copyright 2012 Oncology Nursing Society. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, without permission in writing from ONS. Radiation 2012 econference III. ii. Clinical presentation and diagnosis iii. Nursing assessment iv. Management 1. Medications 2. Radiation therapy 3. Nursing management 4. Adverse effects 5. Case Study Implications for Practice a. Level of emergency - when is it really an emergency? i. System issues 1. Policies 2. Weekends and holidays? 3. Staffing * ONS is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC) Commission on Accreditation.

3 Malignant Spinal Cord Compression (MSCC) A compressive indentation, displacement, or encasement of the thecal sac Erosion of vertebral bodies 90% Direct tumor extension 10% Mechanism of injury Interruption of axonal flow or vasculature Inflammatory mediators and cytokines lead to edema Ischemia results in irreversible neuronal injury Location dependent on disease Thoracic for breast and lung Lumbar for prostate Risk of SCC 2.5% - 6% of patients with cancer High risk cancers account for 2/3 cases Breast Prostate Other malignancies: multiple myeloma, NHL, renal cell Multiple synchronous lesions in 1/3 patients Median survival < 6 months Poor outcomes related to: Acute onset and poor functional outcomes Paralysis predicts poor survival cancer diagnosis Halfdanarson, Hogan, & Moynihan, 2006; Halfdanarson, Hogan, & Moynihan, 2006 SCC Clinical Presentation Presentation Back pain 90% Radicular pain Gait disturbance Bowel and bladder dysfunction Increased pain lying Referred pain common Increased pain with vetebral percussion Valsalva maneuver increases pain Late signs: Sensory impairment (numbness, tingling) or loss Motor weakness Cauda equina syndrome Paralysis SCC Diagnosis Diagnosis MRI gold standard T1 and T2 weighted imaging axial, sagital, coronal planes CT scan MRI not available MRI contraindicated Plain radiographs Abnormal in 80% Show bone lesions Limited usefulness Halfdanarson, Hogan, & Moynihan, 2006; Higdon & Higdon, 2006; Colon, 2008; Halfdanarson, Hogan, & Moynihan, 2006; Higdon & Higdon, 2006 Medical Treatment Radiation Therapy MSCC Glucocorticoids Mitigate compression by reducing ischemia Dexamethasone mg stat; then 4-6 mg every 4 hours Higher doses (up to 100 mg) not found to be superior but have more adverse effects Not always indicated if lack of motor deficits or massive invasion Primary treatment for radiosensitive tumors Breast Lymphoma Myeloma Prostate Combined surgery and radiation preferred for eligible patients Indicated for spinal instability Surgery followed 2 weeks later by radiation therapy 87% ambulatory vs 57% with radiation alone Indications for radiation alone Prior decompression Spinal instability subclinical Not a surgical candidate Treatment plan Not well defined 1-2 vertebrae above and below compression 3 Gy x 10 fractions 4 Gy x 5 fractions 1-2 fractions of 8 Gy for palliative therapy ; Patchell et al., 2005; Millender & Wara, 2007

4 Nursing Implications Early recognition 90% of ambulatory patients maintain function post MSCC Suspect MSCC with back pain Administer STAT corticosteroids Proper positioning Administer analgesics Plan optimal pain management during radiotherapy positioning on the table Side effect management Steroid side effects Related to location of MSCC Increased Intracranial Pressure (ICP) Results from hematological tumor spread 90% located in the supratentorial region Junction of the gray and white matter Watershed areas of the brain Edema and tumor growth result in increased ICP Occurs in up to ¼ of patients with metastatic cancer Most cancers can metastasize to the brain Common tumor types Breast Melanoma Can also occur with primary brain cancer ICP Clinical Presentation Symptoms General or focal Usually gradual and subtle Headaches in about 50% of patients Tension 77% Worsen with Valsalva, bending over AM headaches that improve during day 36% Acute seizures 10-20% Cushing response a late effect Hypertension with wide pulse pressure Bradycardia Irregular respiratory rate Diagnosis MRI the gold standard Contrast preferred Most specific Computed tomographic scans Noncontrast CT preferred with hemorrhage or hydrocephalus Less sensitive Do not detect metastases in the posterior fossa well Medical Treatment Glucocorticoids Dexamethasone preferred Most lipid soluble Crosses the blood brain barrier more easily Dose example mg IV stat Followed by 4 mg every 6 hours Lower doses sometimes as effective resulting in fewer adverse effects Mannitol and hyperventilation if severe Anticonvulsants Use with seizures Surgery may be an option with focal metastases Radiation Therapy Criteria for radiation therapy Oligometastatic disease Good performance status Well-controlled or minimal systemic disease Whole brain radiation gold standard Improves median survival 3-6 months compared to 1-2 months with supportive care Bottom of field at foramen magnum, inferior to C1 or C2 Use eye block Stereotactic radiosurgery a newer option Dose 4 Gy x 5, 2.5 Gy x 15, 2 Gy x 20 3 Gy x 10 most common ; Millender & Wara, 2007

5 Nursing Implications Frequent neurological assessment Vital signs Be aware of a Cushing response Administer steroids STAT Seizure precautions as needed Side effect management Steroid side effects Neurocognitive deficits 5% symptomatic brain necrosis after stereotactic radiosurgery Superior Vena Cava Syndrome (SVCS) Thin walled SVC easily compressed Compression or obstruction of the superior vena cava Edema and retrograde flow Impaired venous drainage from head, neck, and upper extremities Restricted blood return to the heart Can lead to increased ICP Millender & Wara, 2007 Risk and Diagnosis of SVCS Clinical Presentation High risk malignancies SCLC most frequent Lymphoma Esophageal Right-sided cancers Central venous catheters Thrombus formation on the catheter ; McCurdy & Shanholtz, 2012 CT scan With or without venography MRI scan Chest radiography Contrast venography Localize obstruction Venous ultrasonography IV contrast dye study Identify central vein thrombosis Early Signs and Symptoms Dyspnea Nonproductive cough, usually aggravated with bending forward Dysphagia, hoarseness Chest pain Difficulty buttoning shirt Breast swelling Feeling of fullness in the head Syncope Distended neck and chest wall veins Edema upper extremities, face, neck, fingers Periorbital edema Ruddy face Compensatory tachycardia ; Colon, 2008 Late Signs and Symptoms Life threatening respiratory distress - Stridor Cyanosis face and upper torso Engorged conjunctivitae Mental status changes Tachypnea Orthopnea Stridor Coma Seizures Headache Visual distrubances Dizziness, syncope Lethargy Irritability Medical Treatment Confirm the diagnosis if not already diagnosed with a malignancy Stenting the SVC Decompress occluded vessel Chemotherapy In chemo sensitive tumors Corticosteroids Diuretics Fibrinolytics and anticoagulation For clot formation Intubation with tracheal occlusion Chemotherapy for chemo-sensitive tumors Radiation Therapy Standard treatment Indicated for radiosensitive tumors May take a few weeks for effectiveness Best for well localized tumors that are less chemo-sensitive Only treats tumor within the radiation field Limit 50% of volume of heart <25-40 Gy Limit brachial plexus <60 Gy Dose 3-4 Gy for 2-3 days followed by Gy/fraction 3 Gy x 10, 4 Gy x 5 McCurdy & Shanholtz, 2012; Millender & Wara, 2007

6 Nursing Implications Assess cardiovascular system Elevate HOB 45 о Frequent neurological assessment Administer agents promptly Avoid use of CVCs until etiology of SVCS determined Side effect management Steroid side effects Pneumonitis, esophagitis

7 Radiation 2012 econference Bibliography Colen, F. N. (2008). Oncologic emergencies: superior vena cava syndrome, tumor lysis syndrome, and spinal cord compression. J Emerg Nurs, 34(6), doi: S (07) [pii] /j.jen [doi] Halfdanarson, T. R., Hogan, W. J., & Moynihan, T. J. (2006). Oncologic emergencies: diagnosis and treatment. Mayo Clin Proc, 81(6), doi: S (11) [pii] / Higdon, M. L., & Higdon, J. A. (2006). Treatment of oncologic emergencies. Am Fam Physician, 74(11), Lewis, M. A., Hendrickson, A. W., & Moynihan, T. J. (2011). Oncologic emergencies: Pathophysiology, presentation, diagnosis, and treatment. CA Cancer J Clin. doi: /caac McCurdy, M. T., & Shanholtz, C. B. (2012). Oncologic emergencies. Crit Care Med, 40(7), doi: /CCM.0b013e31824e1865 Millender, L., & Wara, W. M. (2007). Palliative Care. In E. K. Hansen & I. M. Roach (Eds.), Handbook of Evidence-based Radiation Oncology (pp ). New York: Springer. Mitera, G., Swaminath, A., Wong, S., Goh, P., Robson, S., Sinclair, E., Danjoux, C., Chow, E. (2009). Radiotherapy for oncologic emergencies on weekends: examining reasons for treatment and patterns of practice at a Canadian cancer centre. Current Oncology, 16(4), Patchell, R. A., Tibbs, P. A., Regine, W. F., Payne, R., Saris, S., Kryscio, R. J.,... Young, B. (2005). Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet, 366(9486), doi: S (05) [pii] /S (05)