Emergency radiation therapy in modern-day practice: Now or never, or never again ?

Radiation therapy plays a fundamental role in oncological emergencies such as superior vena cava syndrome (SVCS) and metastatic epidural spinal cord compression (MESCC). These are two examples of critical complications of metastatic cancer in terms of pain and functional impact (respiratory and/or neurological). The aim of this review is to explore the current indications, treatment options and outcomes for emergency radiotherapy regarding to these complications.Regarding SVCS, studies are mostly retrospective and unanimously demonstrated a beneficial effect of radiotherapy on symptom relief. Spinal cord compression remains an indication for urgent radiotherapy, and should be combined with surgery when possible. The innovative stereotactic body radiotherapy (SBRT) showed promising results, however this technique requires small volumes and more time preparation and therefore is often unsuitable for SVCS and MESCC emergencies.This review concluded that radiotherapy has a central role to play within a multimodal approach for SVCS and MESCC treatment. Further prospective studies are needed to confirm the effectiveness of radiation and establish the criteria for selecting patients to benefit from this treatment option.

Symptom relief, prognostic factors, and outcome in patients receiving urgent radiation therapy for superior vena cava syndrome : A single-center retrospective analysis of 21 years' practice.

PURPOSE: Superior vena cava syndrome (SVCS) often results from external vessel compression due to tumor growth. Urgent symptom-guided radiotherapy (RT) remains a major treatment approach in histologically proven, rapidly progressive disease. Despite several publications, recent data concerning symptom relief and oncological outcome as well as potential confounders in treatment response are still scarce. METHODS: We performed a retrospective single-center analysis of patients receiving urgent RT between 2000 and 2021 at the University Medical Center Göttingen. Symptom relief was evaluated by CTCAE score during the RT course. Effects of variables on symptom relief were assessed by logistic regression. The impact of parameters on overall survival (OS) was evaluated using Kaplan-Meier plot along with the log-rank test and by Cox regression analyses. Statistically significant (p-value < 0.05) confounders were tested in multivariable analyses. RESULTS: A total of 79 patients were included. Symptom relief was achieved in 68.4%. Mean OS was 59 days, 7.6% (n = 6) of patients showed long-term survival (> 2 years). Applied RT dose > 39 Gy, clinical target volume (CTV) size < 387 ml, concomitant chemotherapy, and completion of the prescribed RT course were found to be statistically significant for OS; applied RT dose and completion of the prescribed RT course were found to be statistically significant for symptom relief. CONCLUSION: Symptom relief by urgent RT for SVCS was achieved in the majority of patients. RT dose and completion of the RT course were documented as predictors for OS and symptom relief, CTV < 387 ml and concomitant chemotherapy were predictive for OS.

Development and validation of a nomogram for assessing survival in extensive-stage small-cell lung cancer patients with superior vena cava syndrome referred for thoracic radiotherapy: a comparison of upfront vs. consolidative approaches.

PURPOSE: This study sought to design and validate a nomogram capable of predicting outcomes in extensive-stage small-cell lung cancer (ES-SCLC) patients with superior vena cava syndrome (SVCS) based upon the timing of their radiotherapy treatment. METHODS: We retrospectively analyzed data from 175 ES-SCLC patients with SCVS, comparing outcomes between those that underwent upfront thoracic radiotherapy (initial radiotherapy with simultaneous chemotherapy) and those that underwent consolidative thoracic radiotherapy (following 4-6 cycles of chemotherapy). Significant predictors of patient outcomes were identified using a Cox proportional hazard model and were used to construct our nomogram. This model was subsequently validated using receiver operating characteristic (ROC) curves, concordance index (C-index) values, and a risk classification system in order to evaluate its discriminative and predictive accuracy. RESULTS: The overall survival (OS) of ES-SCLC patients with SVCS that underwent chemotherapy (CT), consolidative thoracic radiotherapy (cc-TRT), and upfront thoracic radiotherapy (cu-TRT) was 8.2, 11.7, and 14.9 months, respectively (p < 0.001), with respective progression-free survival (PFS) durations of 3.3, 5.0, and 7.3 months (p < 0.001). A multivariate regression analysis revealed age, gender, ECOG performance status, sites of tumor metastasis, and treatment approach to all be independent predictors of survival outcomes. A nomogram was therefore developed incorporating these factors. C­index values upon internal and external validation of this nomogram were 0.7625 and 0.7959, respectively, and ROC and calibration curves revealed this model to be accurate and consistent. CONCLUSIONS: We found that upfront thoracic radiotherapy in combination with chemotherapy may be associated with a positive impact on outcomes in ES-SCLC patients with SVCS.

Radiation treatment of hemato-oncological patients in times of the COVID-19 pandemic : Expert recommendations from the radiation oncology panels of the German Hodgkin Study Group and the German Lymphoma Alliance.

PURPOSE: The coronavirus pandemic is affecting global health systems, endangering daily patient care. Hemato-oncological patients are particularly vulnerable to infection, requiring decisive recommendations on treatment and triage. The aim of this survey amongst experts on radiation therapy (RT) for lymphoma and leukemia is to delineate typical clinical scenarios and to provide counsel for high-quality care. METHODS: A multi-item questionnaire containing multiple-choice and free-text questions was developed in a peer-reviewed process and sent to members of the radiation oncology panels of the German Hodgkin Study Group and the German Lymphoma Alliance. Answers were assessed online and analyzed centrally. RESULTS: Omission of RT was only considered in a minority of cases if alternative treatment options were available. Hypofractionated regimens and reduced dosages may be used for indolent lymphoma and fractures due to multiple myeloma. Overall, there was a tendency to shorten RT rather than to postpone or omit it. Even in case of critical resource shortage, panelists agreed to start emergency RT for typical indications (intracranial pressure, spinal compression, superior vena cava syndrome) within 24 h. Possible criteria to consider for patient triage are the availability of (systemic) options, the underlying disease dynamic, and the treatment rationale (curative/palliative). CONCLUSION: RT for hemato-oncological patients receives high-priority and should be maintained even in later stages of the pandemic. Hypofractionation and shortened treatment schedules are feasible options for well-defined constellations, but have to be discussed in the clinical context.

Radiation Oncology Emergencies.

This article reviews the most common oncologic emergencies encountered by the radiation oncologist, including malignant spinal cord compression, intramedullary spinal cord metastasis, superior vena cava syndrome, hemoptysis, and airway compromise caused by tumor. Important trials evaluating different treatments for these emergencies are reviewed. The role of corticosteroids, surgery, chemotherapy, and radiation therapy in these patients is discussed and patient-specific treatment guidelines are suggested.

Superior vena cava syndrome: A radiation oncologist's perspective.

Superior vena cava syndrome is referred to as a constellation of symptoms and signs caused by obstruction of superior vena cava. It can occur due to both benign and malignant causes with the latter being the predominant. There is a paradigm shift in the approach to manage this condition. It is no longer considered a medical emergency and histological diagnosis is necessary before treatment. This article reviews the causes, symptoms, pathophysiology, and overall management policy which have changed over decades.

Oncologic mechanical emergencies.

Prevalence of cancer and its various related complications continues to rise. Increasingly these life-threatening complications are initially managed in the emergency department, making a prompt and accurate diagnosis crucial to effectively institute the proper treatment and establish goals of care. The following oncologic emergencies are reviewed in this article: pericardial tamponade, superior vena cava syndrome, brain metastasis, malignant spinal cord compression, and hyperviscosity syndrome.

Patient-provider delays in superior vena caval obstruction of lung cancer and outcomes.

This retrospective study investigates the types of delay in the initiation of palliative thoracic radiotherapy for superior vena caval obstruction (SVCO) of lung cancer (LCa) and the effect of treatment delay on patient outcomes. Treatment delays were categorized as patient delay (duration of symptoms), in-hospital delay, and professional delay and were determined in 42 people treated by radiation for palliation of the complicated neoplastic condition between 1981 and 2009. The median period of patient delay was 26.2 days, in-hospital delay was 3.5 days, and professional delay was 1.5 days. The majority (80%) of these individuals were uninsured or underinsured, and 69% presented with locally advanced LCa. The overall response rate was 84%, and the 1-year survival rate was 24%. Despite the longest patient-related delay, symptomatic individuals overall derived palliation from conventional treatment. Improved efforts toward early diagnosis and treatment of patients with SVCO-LCa need to be continued.

Superior vena cava syndrome caused by colon adenocarcinoma metastasis: a case report and review of literature.

Superior vena cava (SVC) syndrome is a critical medical condition that usually results from compression of the SVC by an intrathoracic mass. The majority of contemporary etiology of SVC syndrome are related to mediastinal malignancies and/or to the presence of intravascular devices. Rarely, SVC syndrome has been associated with intraluminal metastasis to this vessel. We describe an unusual case of an 88-year-old woman with stage IIA colon carcinoma diagnosed seven years earlier that was treated with surgical resection, who presented with classical signs and symptoms of SVC syndrome. Imaging studies confirmed the presence of an extensive mass in the SVC and intravascular biopsies showed metastatic colon cancer. She was treated with palliative radiotherapy with good clinical response, remaining asymptomatic eight months after the documentation of metastatic disease. To our knowledge this is the second published case of colorectal adenocarcinoma with intravascular metastasis to the superior vena cava causing SVC syndrome. We discuss the different etiologies and management of this syndrome, and encourage physicians to consider intraluminal metastasis as one of the etiologies.

Palliative radiotherapy--new approaches.

Most cancer patients will require radiation therapy some time during their disease. Thirty percent to 50% of all radiation treatments are palliative, either to alleviate symptoms or prophylactic to prevent deterioration of quality of life from local progressive disease. Radiotherapy is a locally effective tool. It typically causes no systemic and mostly mild acute side effects. We will provide an overview of principles, decision-making, and new developments in palliative radiation therapy.

Severe valvular toxicity and pericarditis early after radiation therapy in a patient treated for Hodgkin's lymphoma.

Hodgkin's disease can be cured in most cases by radiotherapy. However, it can increase the risk of cardiotoxicity. Here, we report a patient with Hodgkin's disease and superior vena cava syndrome who was treated with chemotherapy in combination with radiotherapy. Four months after the initiation of this therapy, she developed progressive dyspnea. Pleural and pericardial effusion, severe mitral regurgitation, moderate aortic insufficiency, and mild tricuspid regurgitation were detected in echocardiography, which suggested heart failure. The patient was then treated with intrapericardial drainage and received dopamine and diuretics for congestive heart failure; she responded well to this treatment and was discharged in good condition. After high-dose mediastinal radiation, cardiologic screening is recommended in order to identify patients with radiation-induced heart disease and to assess their need for treatment and follow-up.

Radiotherapy in oncological emergencies--final results of a patterns of care study in Germany, Austria and Switzerland.

Radiotherapy (RT) is an important treatment option for emergencies in oncology. A multicenter patterns of care study (PCS) was conducted in all RT institutions in Germany, Austria and Switzerland. In 2003 a standardized structured questionnaire was sent to all RT institutions. Number and type of staff involved, number of patients, over time distribution and expense, treatment indications and concepts of emergency RT were assessed. In addition, treatment outcome for the different indications was evaluated. The PCS was structured and analyzed according to the model for quality assessment set up by Donabedian in three major components: structure, process and outcome. One hundred and forty institutions (70%) answered the questionnaire. For the baseline of 2003 a total of 3244 emergency radiotherapy indications with a mean of 28 per institution were reported. Forty percent of all institutions provide a special 24 h service at night or weekends. Seventy percent of the emergency indications were irradiated between Monday and Thursday, 30% between Friday and Sunday. Ninety percent of all emergencies were referred to RT between 8 a.m. and 6 p.m., 10% between 6 p.m. and 8 a.m. The applied doses for emergency RT ranged between 2 Gy and 8 Gy (median: 3.5 Gy). Time expense was reported with a median of 90 min. The outcome analysis based on the treatment results of 1 033 patients: There was an improvement of myelocompression in 50% of the cases, vena cava superior compression in 70%, bronchial obstruction in 70% and bleedings in 80%. A clear dose-response relationship could not be established, but single doses of over 3 Gy in vena cava superior syndrome exhibited a significant advantage. This study represents the largest database in literature on emergency RT. RT was shown to be fast, time sparing and a very effective treatment option for special oncological emergencies.

Retrospective analysis of the superior vena cava syndrome in irradiated cancer patients.

BACKGROUND: A carcinoma is the underlying cause of superior vena cava syndrome (SVCS) in 95-97% of patients. The aim of our study is to retrospectively analyse the outcome of patients after local radiotherapy compared to literature data. PATIENTS AND METHODS: In 35 consecutively registered patients, irradiated because of SVCS, different primary carcinomas (lung, breast, head-and-neck, Non-Hodgkin's lymphoma) were ascertained. Distant metastases had already been diagnosed in 33 patients. Chemotherapy had previously been given in seven patients. RESULTS: In 30 patients, radiotherapy obtained a reduction of symptoms within 5-9 days. However, in seven patients, radiotherapy had to be stopped early because of local progress and tumor induced complications. Local recurrences were observed in six patients. The 1-year overall survival rate was 15.6%. Survival rate depended significantly on the performance status (p < 0.004). CONCLUSION: Based on literature data our results are comparable regarding the incidence, the radio-oncological procedure and the response to treatment. These data confirm that radiotherapy is the standard treatment in most patients suffering from SVCS. However, it should be determined if endovascular stenting, which is more frequently considered in the last few years in patients with a tumor induced SVCS, may be a useful option as a simultaneous or sequentially given treatment to optimize the palliative effect.

Malignant lymphoma presenting as a cardiac tumor and superior vena caval syndrome successfully treated by haploidentical stem cell transplantation.

A 16 year-old male with B-cell non-Hodgkin's lymphoma presenting as a cardiac tumor and superior vena caval (SVC) syndrome received a haploidentical stem cell transplant (SCT) from his mother after conventional and salvage chemotherapy. He received additional radiation therapy for the residual tumor and is alive and well on day 640 after transplantation. Malignant lymphoma presenting as a cardiac tumor, including primary cardiac lymphoma, is rare. Although many reports have shown the poor prognosis of cardiac lymphoma, our case suggests that allogeneic haploidentical SCT might be useful for the treatment of aggressive cardiac lymphoma.

Hypofractionated external beam radiotherapy as retreatment for symptomatic non-small-cell lung carcinoma: an effective treatment?

PURPOSE: To evaluate prospectively the efficacy, toxicity, and duration of the palliative effect of retreatment with external beam radiotherapy in symptomatic patients with recurrent non-small-cell lung cancer. METHODS AND MATERIALS: Twenty-eight symptomatic patients with local recurrence of non-small-cell lung cancer underwent repeated treatment after previous radiotherapy (equivalent dose, 46-60 Gy). Reirradiation consisted of two fractions of 8 Gy on Days 1 and 8 with two opposed beams using 6-18-MV photon beams at the site of pulmonary recurrence. The physician scored symptom resolution. RESULTS: Relief of hemoptysis and superior vena cava syndrome could be obtained in all assessable cases (100%). Treatment was less effective for coughing (67%) and dyspnea (35%). The overall median duration of this palliative effect was 4 months. Palliation in almost all patients lasted more than one-half of their remaining life span. The Karnofsky performance score improved in 45% of assessable cases. One patient had Grade 2 esophagitis. Complications consisted of tumor-related fatal hemoptysis in 5 patients (17%) and 1 death from bronchoesophageal fistula (4%). CONCLUSION: External beam hypofractionated reirradiation can be effective as a palliative treatment for local complaints in non-small-cell lung cancer. The complication rate of reirradiation was acceptably low.

Double-flash, large-fraction radiation therapy as palliative treatment of malignant superior vena cava syndrome in the elderly.

Rapid control of symptoms is mandatory in cancer-induced superior vena cava syndrome (SVCS), but older patients often do not tolerate aggressive approaches. In order to maximize symptom relief and minimize treatment-related discomfort of aged patients in poor health we adopted a short-course, large-fraction radiation therapy (RT) schedule. Twenty-three consecutive patients aged over 70 who were suffering from solid-malignancy-related SVCS were enrolled. A total dose of 12 Gy was given in two 6-Gy fractions, 1 week apart, mainly in an out-patient setting. Completion of therapy to give up to 37-40 Gy was planned in the best-responding patients. Symptom relief was experienced by 8 patients as early as 4-5 days after the first fraction. The overall response rate was 87%. Despite some mild systemic side effects (chest pain, fever) reported by 5 patients (22%), overall toxicity was negligible. Short-course, double-flash RT stands as an effective and safe tool in the palliative treatment of malignant SVCS in older patients. Fractions larger than 6 Gy can be avoided in order to minimize side and toxic effects.

Radiation therapy for oncological emergencies.

AIMS AND BACKGROUND: Radiation therapy holds a fundamental role in oncological emergencies such as superior vena cava syndrome, spinal cord compression and endocranial hypertension. The purpose of our study was, by comparing schedules of treatment, to confirm the efficacy of hypofractionated radiation therapy. METHODS: From January 1994 to December 1998, 43 patients with superior vena cava syndrome, 37 patients with metastatic spinal cord compression and 108 patients with endocranial hypertension secondary to metastasis were treated at our institution. In the group of patients with superior vena cava syndrome, radiotherapy schedules were: 4 Gy x 5 to a total dose of 20 Gy (23 patients) and 3 Gy x 10 to a total dose of 30 Gy (20 patients). In the group of patients with spinal cord compression, radiation schedules were: 3 Gy x 10 to a total dose of 30 Gy (15 patients); 4 Gy x 5 to a total dose of 20 Gy (12 patients); a single fraction of 8 Gy in 10 cases, repeated after 1 week in 7 responder cases to a total dose of 16 Gy. 5 out of 37 patients were underwent to laminectomy plus stabilization of the spine and post-operative radiotherapy. In the group of patients with endocranial hypertension, radiotherapy schedules were: 6 Gy x 2 to a total dose of 12 Gy (53 patients), repeated after 4 weeks in 34 responder patients and 3 Gy x 10 to a total dose of 30 Gy (55 patients). RESULTS: The patients with superior vena cava syndrome, revaluated after 4 weeks at the end of treatment, obtained a partial remission of symptomatology in 73.9% with 20 Gy and in 75% with 30 Gy. The patients with spinal cord compression obtained symptomatic relief in 73.3% with 30 Gy, in 66.6% with 20 Gy and in 70% of cases treated with 8 Gy. The patients with endocranial hypertension obtained symptomatic relief in 64.1% with 12 Gy and in 63.3% with 30 Gy. CONCLUSION: Histology, pretreatment and performance status were important prognostic factors for the response to therapy. Our results demonstrated no significant difference among different schedules of radiotherapy and confirmed the importance of radiotherapy for oncological emergencies: it improves the quality of life and, in responding patients, is associated with a longer survival time.