STEREOTACTIC RADIATION THERAPY Monique Blanchard ANUM Radiation Oncology Epworth HealthCare
Overview Stereotactic radiation therapy at Epworth Healthcare What is stereotactic radiation therapy? Delivery of stereotactic radiation therapy Different types of stereotactic radiation therapy Conditions treated Nursing considerations Overall nursing implications What does the future hold?
Stereotactic radiation therapy at Epworth Healthcare Introduced to the Epworth approximately 3 years ago Clinical trials using stereotactic radiation therapy We are now treating approximately 35 new patients every week with stereotactic radiation therapy
What is Stereotactic radiation therapy Large ablative doses Rapid dose fall off Multiple beams IMRT (intensity modulated radiation therapy) DCA (dynamic conformal arc) Circular arcs Non surgical option for small- medium well defined tumours/ abnormalities. Potential for fewer treatment/ fractions Detailed imaging and 3D treatment planning
Delivery of stereotactic radiation therapy Linear accelerator High definition micro multi-leaf collimators Room based imaging Robotic 6D couch Normally 3D Additional brackets Stereotactic frames
Delivery of stereotactic radiation therapy Immobilization devices Thermoplastic mask Head frame Vacuum bag/cushions
Types of Stereotactic radiation therapy SRS (stereotactic radiosurgery) single high dose stereotactic treatment to tumors/abnormalities in the brain and spinal cord. SRT (stereotactic radiotherapy) - fractionated stereotactic treatment to tumors/abnormalities in the brain and spinal cord. SBRT (stereotactic body radiation therapy) refers to a single high dose or fractionated stereotactic treatment to tumors/abnormalities outside the brain and spinal cord.
Conditions that can be treated with SRS/SRT and SBRT SRS/SRT Benign tumors: Acoustic neuroma Meningioma Pituitary adenoma Malignant tumors: Cerebral metastatic disease Glioma Chordoma Other conditions: Arteriovenous malformations (AVM) Trigeminal neuralgia SBRT Chest (lung and lymph nodes) Abdomen (liver, kidney, adrenal gland, lymph nodes) Pelvis (pelvic recurrence, lymph nodes) Bone (spine and other bony metastases)
Difficulties with finding information about patient care Limited patient and nursing care information Current information medically based Need for nursing learning package and patient information brochures: Nursing responsibility Generalized stereotactic information not sufficient
Acoustic neuroma Benign tumor that develops on the 8 th cranial nerve. Originates from Schwann cells Slow growing Arise spontaneously (later life) / neurofibromatosis Type II (younger patients)
Acoustic neuroma Clinical presentation Early symptoms are often subtle: Gradual loss of hearing in one ear -Cochlear Nerve Often tinnitus / feeling of fullness in the ear Advancing symptoms: Vertigo -Vestibular Nerve Problems with balance/ clumsiness/unsteadiness Facial numbness and tingling, intermittent/constant -Cranial Nerves Facial weakness Swallowing difficulties Visual disturbances -Brain stem compression Headaches /confusion
Goal for treatment Acoustic Neuroma Prevent further tumour growth Preserve cochlear/facial nerve function Maintain/ improve neurological status SRS or SRT Dependant upon tumour size Position/proximity of critical structures Importance of preserving hearing SRS: 14.7G/1/5 SRT: 44G/15/5
Meningioma Usually benign tumour Forms on membranes that cover the brain and spinal cord Typically slow growing and don t spread Symptoms often develop gradually Symptoms related to size and location Cavernous sinus meningioma: A venous pocket below and behind the eye sockets Vital structures (carotid artery, 3 rd,4 th and 6th cranial nerves)
General Meningioma Clinical presentation Headaches Seizures Impairment of brain function Limb weakness Speech problems Visual disturbances Cavernous sinus Trigeminal dysfunction Hearing disturbances
Meningioma Goal for treatment Prevent further tumor growth Maintain or improve neurological status SRS or SRT Dependant upon tumour size Position and proximity of critical structure SRS : 18G/1/5 SRT: 47G/15/5 56G/28/5
Pituitary adenoma Benign tumour that arises from the cells of the pituitary gland Slow growing Non functioning (no hormones) Functioning (excessive hormones)
Pituitary adenoma Clinical presentation Visual disturbances Changes in physical appearance Cognitive difficulties Headaches Nausea and vomiting Light headedness Fatigue Loss of libido Menstrual period irregularities in women
Pituitary adenoma Goal for treatment Tumour control Reduction in secreted hormone SRS or SRT SRS may not be appropriate if: Tumour is within 3mm of the optic chiasm Tumour is wide extending into cavernous sinus SRS: 16G/1/5 SRT: 33G/7/5 56G/28/5
Cerebral metastatic disease Brain metastases spread from primary tumors Clinical presentation Related to location Can include: Headache Seizure Nausea/vomiting Nuchal rigidity Photophobia Cognitive dysfunction Motor dysfunction
Cerebral metastatic disease Goal of treatment Tumor control/cure Preserve healthy brain SRS or SRT Dependent upon tumor size Position and proximity to critical structures SRS: 16-25G/1/5 SRT: 35G/5/5
Arteriovenous malformation (AVM) Abnormal cluster of blood vessels within the brain or spine Excessive blood flow Potential for hemorrhage/stroke More commonly found in the brain Usually congenital
Arteriovenous malformation (AVM) Clinical presentation Many are asymptomatic If symptomatic - Symptoms can include: Headache (generalised) Seizures Haemorrhage (acute onset of severe headache) Difficulties with movement/co-ordination Difficulties with speech and communication Abnormal sensations (numbness, tingling) Memory and thought related problems
Arteriovenous malformation (AVM) Goal of treatment Reduce long term risks SRS or SRT Dependant upon size of AVM Position and proximity to critical structures SRS: 20G /1/5 SRT: 50/10/5
Trigeminal neuralgia Chronic neuropathic pain condition Affects the trigeminal/5 th cranial nerve Can be associated with a variety of conditions Clinical presentation Abrupt, searing, electric- shock like facial pains Most commonly involves the lower face and jaw Typified by attacks and can be progressive
Trigeminal neuralgia Goal for treatment Lasting pain relief SRS Single fraction SRS: 70-90G/1/5
Indications for SRS/SRT Small to medium tumors/abnormalities Residual/recurrent tumors Inoperable tumors/abnormalities Risk of surgery too high Over production of hormones not controlled by medication (pituitary adenoma) Treatment of multiple metastases Pain relief when medication fails (Trigeminal neuralgia)
Overall effects SRS/SRT Pre-existing symptoms may increase Benign tumors May take months to years (Good and Bad) Acoustic neuroma - possible hearing loss Pituitary adenoma - hormonal balance Malignant tumors Less overall edema than conventional external beam Abnormalities AVM- may take several years to close TN may take 6-12 weeks. Possible re-treat.
ACUTE SIDE EFFECTS SRS/SRT Acoustic Neuroma Meningioma Pituitary adenoma Cerebral metastases AVM Headache/Nausea/vomiting Neurological Disturbances Visual disturbances Hearing disturbances Facial disturbances Balance disturbances Pain flare Hair loss Skin reaction Fatigue Trigeminal Neuralgia = may occur = rarely occurs = does not occur
SBRT SBRT similar to SRS/SRT Treats tumours outside the CNS Greater combined dose can be given Fewer treatments Less damage to surrounding tissues Single or fractionated
SBRT CHEST Lung & lymph nodes Goal for treatment Tumor control/cure Minimize pulmonary symptoms SBRT 26/1/5 (lung) 48/4/5 (lung) 50/10/5 (nodes) ABDOMEN Adrenal & lymph nodes Goal for treatment Tumor control/cure Minimize gastritis SBRT 24/3/5 (adrenal/kidney) 50/10/5 (nodes)
SBRT PELVIS Pelvic recurrence & lymph nodes Goal for treatment Tumor control/cure Minimize bowel/ bladder symptoms SBRT 50/10/5 (nodes) BONE Spine & boney areas Goal for treatment Tumor control/cure Decrease/eliminate pain Minimize neurological effects SBRT 14/1/5 25/5/5 (spine) 50/10/5 (boney area)
Indications and overall effects for SBRT Indications Small to medium localized tumors Oligometastatic disease up to 3-5 Inoperable tumors Overall effects Less overall edema than conventional external beam Potential for faster tumor control/cure Faster and more durable pain relief
ACUTE SIDE EFFECTS OF SBRT CHEST ABDOMEN PELVIS BONE LUNG NODES ADRENAL NODES RECURRENCE NODES BONE Oesphagitis Chest wall/rib pain Pneumonia like symptoms Nausea/Vomiting Reflux Abdominal pain Loss of appetite Diarrhea/rectal discomfort Bladder discomfort/frequency Pain flare Hair loss Skin reaction Fatigue = may occur = rarely occurs = does not occur
Nursing considerations Site Condition type Benign/malignant/abnormality Number of # SRS/SRT/SBRT Time on machine Sedation/ pain relief Pre-meds Every patient is different Common potential for side effects Individual side effects Less face to face nursing assessment
Nursing implications Up to date nursing education Assessment and management of side effects Consistent pre treatment assessment and education Individualized site specific side effects Reporting and management of side effects Comprehensive patient information Condition specific information Follow up Phone call
What does the future hold? Treatment of movement disorders Treating other areas of the body Change in how we are educating and providing nursing care Continued development of nursing learning packages Comprehensive patient information
References "Complications of Radiosurgery." Aboutcancer.com. Web "Conditions and Treatments." Betterhealth.vic.gov.au. Web "Diseases and Conditions." Mayoclinic.org. Web Patient information leaflets. uhb.nhs.uk. Web "Radiosurgery." Irsa.org. Web Shinohara, Eric. "Radiation Therapy: Which Type Is Right for Me." Oncolink.org.22 Apr. 2016. Web. "Stereotactic radiation." RT Answers. Astro, Web. "Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiotherapy (SBRT)." RadiologyInfo.org. Web Smink, Karen A., and Susan M. Schneider. "Overview of Stereotactic Body Radiotherapy and the Nursing Role." Clinical Journal of Oncology Nursing 12.6 (2008): 889-93. "What-to-expect/stereotactic-radiotherapy." Radiation Oncology Victoria.