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SHADOW PRESENTATION

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Created on October 15, 2024

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Transcript

ByJayavignesh Sekar PGY-2

Morbidity & Mortality

index

Clinical Presentation

Differential Diagnosis

case

Treatment

Radiation Plan

Data

Future Directions

Questions

MD, 60 years old female from China initially had trouble urination and fever

4/29/19

Reports vaginal bleeding in February 2019

Diagnosed in China with a benign tumor on biopsy

Small Cell Carcinoma of Cx- diagnosed in the USA

Pelvic Exam: 6cm mass in the cervix with b/l parametrial involvement PET/CT 5/2/19 : cervical mass (8 x 7.5 with SUV 7.5) possibly extending into LUS and hypermetabolic bilateral external iliac lymphadenopathy. (2.8 x 1.8 cm with SUV 8.9)

Cervical Carcinoma

cT2bN1Mo - IIIC

Case - Treatment

OTV

7/26/2019

Plan

Planned for CCRT + brachy

No bladder or bowel complications during treatment, Transfused for anemia at the end of treatment

Completed 5936/28fx + 4 cycles of CE + 2800/4 HDR brachy

Case - Follow up

Rpt PET/CT 03/2020: further decrease in size, Clinically NED, also no bladder or bowel dysfunction

Post treatment PET/CT 10/2019 showed decreased FDG activity with resolution of b/l pelvic nodes

06/2020: complained of intermittent bright red streaks of blood in stool and upon wiping

08/2020: Developed Dysuria, Hematuria, low back pain, frequency

Differential Diagnosis

  • Infection
  • Radiation/Chemo Proctitis
  • Diverticulitis
  • Stones/Cancer
  • Hemorrhoids
  • Radiation/Chemo Cystitis
  • Trauma, obstructive uropathy
  • Anal Fissures

Presentation

  • Dysuria
  • Change in bowel habits
  • Tenesmus
  • Hematuria
  • Bleeding PR, pain
  • Frequency, urgency
  • Reduced capacity, sphincter dysfunction
  • Incontinence

CTCAE v5 Cystitis

Grade 2

Grade 1

Moderate hematuria; moderate increase in frequency, urgency, dysuria, nocturia or incontinence; urinary catheter placement or bladder irrigation indicated; limiting instrumental ADL

Microscopic hematuria; minimal increase in frequency, urgency, dysuria, or nocturia; new onset of incontinence

Grade 3

Grade4

Life-threatening consequences; urgent invasive intervention indicated

Gross hematuria; transfusion, IV medications, or hospitalization indicated; elective invasive intervention indicated

Grade 5

Death

CTCAE v5 Proctitis

Grade 2

Grade 1

Symptomatic (e.g., rectal discomfort, passing blood or mucus); medical intervention indicated; limiting instrumental ADL

Rectal discomfort,intervention not indicated

Grade 3

Grade4

Life-threatening consequences; urgent invasive intervention indicated

Severe symptoms; fecal urgency or stoolincontinence; limiting self care ADL

Grade 5

Death

Follow up

Colonoscopy 08/2020 & 11/2020: Multiple angiectasia or rectum and sigmoid - Argon coagulation of rectal angiectasia

Follow up

01/2021 Cystoscopy showed trigone and floor of bladder with significant erythematous and bullous changes and necrotic tissue -- appears consistent with radiation cystitis

04/2021 Cystoscopy showed radiation cystitis and struvite stones

Developed severe thickening of bladder, contraction and R HUN

Follow up

Continued on Hyperbaric O2 60 sessions - near resolution of pelvic pain

She was started on Hyperbaric O2

07/2021: Developed Dysuria, Hematuria, low back pain, frequency

Complicated by renal stones - had L UR scopy and lithotripsy to remove the stone

Clinically NED with vaginal Stricture, PAP negative so far, no bladder or bowel dysfucntion

Treatment Plan

HDR brachy

Treatment Plan

HDR brachy

Treatment Plan

HDR brachy

Treatment Plan

IMRT

Treatment Plan

IMRT

Treatment Plan

IMRT

Treatment Plan

Directives
  • Radiation proctitis after EBRT + Brachy

Data

  • Radiation cystitis
Total EQD2

Rectum:65-70Gy for D2ccBladder: 80-90Gy for D2cc

  • Vaginal stricture

+info

  • Treatment options

Treatment options

Treatment options

Hyperbaric oxygen therapy

  • First used in 1980s
-Rationale to proposal was it reverses the vascular radiation induced pathophysiology, through oxygen tension.
  • Prospective Data with 40 patients – Bevers RFM, Lancet 1995, Short Term Results
-75% had no hematuria for at least 3 months after - 17% had occasional slight hematuria -7.5% did not respond. -Bladder preservation in 90% of patients.
  • Long Term Results – 11 patients, 28-64 treatments, Del Pizzo, Urology 1998
-F/U of 5.1 years –8/11 patients asymptomatic with 2.5 year follow-up-Cystoscopy post treatment showed decrease telangiectasias

Treatment options

Literature

grade 3-4 chronic GI and GU toxicities, the incidences were 4.1% and 2.7%, respectively

Systemic Immune-Inflammation Index (SII), platelet-to-lymphocyte ratio (PLR), and PAR could stratify patients who need extra intervention and nursing care to prevent bladder radiation damage and improve patients' quality of life.

Future Directions

  • Prospective studies for CCRT related toxicities
  • MRI brachy planning
  • LDR vs HDR, planning techniques
  • Predictive models?
  • Radiation attenuation agents

Questions?

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Cystitis

After Cervical Cancer Radiation

7–9.8% patients for RTOG 1-2 and in 1.3–14.5% patients for RTOG 3-4 after 3 years.

  • 5–10% of patients undergoing pelvic radiotherapy will develop Late urinary complications

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Proctitis

After cervical cancer radiation

Brachytherapy alone 8-13%, 20% if combination therapy

  • 5-11% after pelvic radiation

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