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Vol. 67, No. 1 2016
Northeast Florida Medicine
DCMS online
. org
Palliative Care
cell lung cancer) can impair blood return to the right
atrium from the head and upper extremities. With tumors
that are rapidly proliferating, impairment of blood return
from tumor compression can outpace collateralization and
lead to backup of blood in the upper torso. If uncorrected,
SVC syndrome is fatal. Management of SVC syndrome
is multidisciplinary, and may require urgent initiation of
chemotherapy, radiotherapy, anticoagulation, endovascular
stenting and thrombectomy.
32
Airway occlusion from tumor bulk can also occur and lead
to partial or total collapse of lung. Endobronchial stenting,
chemotherapy and external beam radiotherapy, as well as
endobronchial brachytherapy, have been employed to restore
airway integrity.
33
Esophagus
Unresectable or metastatic esophageal cancer will very
commonly progress and cause symptoms such as dysphagia
and bleeding. This is one instance when palliative radiation
is frequently given in prolonged courses (50 Gy in 25 frac-
tions) to maintain durable tumor control. Approximately
70 percent of patients will receive some degree of palliation
with EBRT alone, and 54 percent are able to swallow solid
foods until their death.
34
Another study treated 49 patients
with Stage III-IV disease using concurrent chemo-radiation
and found a 91 percent improvement in initial swallowing
function.
35
Sixty-seven percent had improvement that
lasted until death.
36
Therefore, combined and protracted
chemo-radiation should be considered in patients with a
good performance status who are deemed candidates to
receive chemo-radiation. In patients with a poorer KPS,
shorter RT courses may be utilized.
Pelvis
Advanced pelvic tumors may arise frommultiple primary
sites including prostate, bladder, rectum, anus, uterus and
cervix. All of these tumors have the ability to cause bleeding,
genitourinary obstruction, gastrointestinal obstruction and
pain. Given the wide variety of tumor types and prognoses,
multiple treatment regimensmay be recommended. Formany
advanced malignancies, a combination of chemotherapy
and full course radiation may be recommended for durable
response because pelvic disease progression invariably causes
a large decline in quality of life.
37
For patients with a short
life-expectancy or with more urgent presentations (acute
bleeding), shorter palliative doses are commonly used.
Technology
Perhaps radiation oncology has benefited more than
any other field in cancer care from the development of the
modern computer. Until very recently it was not possible
to combine large and complex image data sets taken of the
patient’s disease process using MRI, CT and PET scanning
in a dynamic way that is imperceptible to the patient while
they undergo treatment. With the most recent generation
of linear accelerators it is now considered standard to
superimpose and modify the patient’s radiation care plan
onto daily images taken just prior to treatment. In terms of
radiosurgery, the field has been able to modify and improve
the standard tool of the trade, the linear accelerator, in order
to deliver both high quality image-guided radiation and
radiosurgery. Figures 1-4 provide four examples of modern
palliative radiotherapy images. In the past, a standard ra-
diation department needed to have multiple machines in
order to carry out its daily functions, an example being the
gamma knife to deliver brain stereotactic radiation and a
cyberknife and/or novalis to deliver body radiosurgery. At this
point most commercially available radiation therapy systems
Figure 2:
Figure 1:
Figures 1-4:
Four examples of modern palliative radiotherapy.