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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

Questions

Data

Differential Diagnosis

Radiation Plan

Clinical Presentation

Future Directions

Treatment

case

index

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

cT2bN1Mo - IIIC

Small Cell Carcinoma of Cx- diagnosed in the USA

Diagnosed in China with a benign tumor on biopsy

Reports vaginal bleeding in February 2019

4/29/19

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

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

OTV

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

7/26/2019

Planned for CCRT + brachy

Plan

Case - Treatment

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

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

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

Case - Follow up

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

Differential Diagnosis

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

Presentation

Grade 2

Grade4

Grade 5

Grade 3

Grade 1

Life-threatening consequences; urgent invasive intervention indicated

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

CTCAE v5 Cystitis

Death

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

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

Grade 2

Grade4

Grade 5

Grade 3

Grade 1

Life-threatening consequences; urgent invasive intervention indicated

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

CTCAE v5 Proctitis

Death

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

Rectal discomfort,intervention not indicated

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

Developed severe thickening of bladder, contraction and R HUN

04/2021 Cystoscopy showed radiation cystitis and struvite stones

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

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

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

Follow up

HDR brachy

Treatment Plan

HDR brachy

Treatment Plan

HDR brachy

Treatment Plan

IMRT

Treatment Plan

IMRT

Treatment Plan

IMRT

Treatment Plan

Directives

Treatment Plan

  • Radiation proctitis after EBRT + Brachy
  • Treatment options
  • Vaginal stricture
  • Radiation cystitis

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

Total EQD2

Data

+info

Treatment options

Treatment options

  • 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

Hyperbaric oxygen therapy

Treatment options

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.

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

Literature

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

Future Directions

Questions?

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

Cystitis

After Cervical Cancer Radiation
  • 5–10% of patients undergoing pelvic radiotherapy will develop Late urinary complications

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

Proctitis

After cervical cancer radiation
  • 5-11% after pelvic radiation

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