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PALLIATIVE MEDICINE
and
MADONNA R. BACORRO, M.D.
SHPM fellow
UP-PGH
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TOPICS FOR DISCUSSION:
Chemotherapy in Palliative Care
Radiotherapy in Symptom Management
Surgical Palliation
Orthopaedic Principles and Management
Interventional Radiology
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The optimal management of cancer requires amultidisciplinary team approach in which palliative
care physicians and surgical, radiation, and
medical oncologists play an important part
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Patients may experience physical, emotional,
psychological, and spiritual distress at any time
during the course of the illness, and involving
palliative care physicians from diagnosis ensuresthat patients are referred for specialist palliative
care when they need it.
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OBJECTIVES:
To understand the respective roles of the
oncologists in the team
To know about the cancers which oncologists
treat and the expectations and side-effects of
their treatments
To be able to recognize patients in our care
who might benefit from cancer treatment and
refer them to an appropriate oncologist
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CANCER
m
utatio
n inherited
Occur by chance
Acquired by exposure tocertain virus or carcinogens
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1) antimetabolites
2) alkylating drugs
3)antitumour antibiotics
4) plant alkaloids
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CYTOTOXIC DRUGS
ANTIMETABOLITES
5-fluorouracil
fludarabine methotrexate
gemcitabine
Cyclophosphamide
ifosfamide Chlorambucil
melphalan
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CHEMOTHERAPY
Most effective when cancer load is:
A) small and growth factor is increased
B) when cytotoxic drugs with different mode of
action are given together (COMBINATION
Chemotherapy)
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Mesothelioma
Prostate
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effectiveness of chemotherapy
the survival time from commencement of treatment the time from commencement of treatment to cancer
progression
the cancer response rate:A) complete remission- which is the proportion of treated
patients whose cancer either becomes undetectable
B) partial remission - reduces in size by at least 50 per cent
C) stable disease- stays the same size
D) progressive disease- continues to grow during treatment
the quality of life.
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TOXICITY OF CHEMOTHERAPY
1) BONE MARROW
2) GIT
3) SKIN
4) KIDNEYS
5) NERVOUS SYSTEM
6) LUNGS
7) HEART
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GIT
Lining of GI is being
shed and replaced after
days of treatment
Nausea,vomiting,mucositis,
diarrhea
Indication for
admission: for hydration
and alimentation
Choices of meds:
a)nausea and vomiting-
domperidone, dexa in
reducing dose,ondansetron for 5-10d
b)Diarrhea
c)mucositis- mouth washif with no infection
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SKIN
Photosensitivity, urticaria, hyperpigmentation,
dermatitis
Alopecia and avulsion of nails
Hand and foot syndrome= 5FU (withdraw)
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To treat or not to treat
1) ComorbiditiEs
2) Blood tests
3) Age
4) Performancestatus
PERFORMANCE
STATUS SCALES
1) Karnofsky Scale
2) ECOG/WHO Scale
Karnofsky scale ECOGa/WHO scale
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TABLE FOR ecog
Karnofsky scale ECOGa/WHO scale
No complaints; no
evidence of disease
100 0 Normal activity
No restrictions
Able to carry on normal
activity; minor signs or
symptoms of disease
90 1 Restricted but
ambulatory; able to
carry out light work
Some signs or
symptoms of disease;
Normal activity with
effort
80 2 Ambulatory and self-
caring but unable to
carry out light work; up
more than 50% of
waking hours
Cares for self; unable to
carry on normal activityor to do active work
70 3 Limited self-care;
symptomatic, confinedto bed or chair more
than 50% of waking
hours
Requires occasional
assistance but is able to
care for personal needs
60 4 Completely disabled;
totally confined to
bed; may needhospitalization
Karnofsky scale ECOGa/WHO scale
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TABLE FOR ecog
Karnofsky scale ECOGa/WHO scale
Requires
considerable
assistance and
frequent medicalcare
50 5 Dead
Disabled; requires
special care and
assistance
40
Severely disabled;
hospitalizationindicated although
death not
imminent
30
Very sick;
hospitalization
necessary; requiresactive supportive
treatment
20
Moribund; fatal
processes
progressing rapidly
10
Dead 0
Serum tumour markers
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Serum tumour markers
used in clinical practice
Immunochemical markers
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Immunochemical markersin common use
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Radiotherapy
in symptom management
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ACUTE EFFECT seen during and may persistfor several weeks after radiotherapy
d/t loss of surface epithelial cells
LATE EFFECTS
rarely
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Acute and late effects of radiation
SITE ACUTE EFFECT LATE EFFECT
1)Skin Erythema Atrophy, fibrosis
desquamation telengiectasia
necrosis
2) GIT Nausea, anorexia stricture
diarrhea perforation
malabsorption
Chronic enteritis, colitis, proctitis
3) bladder Sterile cystitis reduced volume
Telengiectasia, bleeding
Urethral or ureteric stricture
fistula
4) Oral cavity mucositis Mucosal atrophy
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Acute and late effects of radiation
SITE ACUTE EFFECT LATE EFFECT
5) pharynx Dry mouth Telengiectasia, bleeding
Taste loss Dental carries
Mandibular necrosis
6) lung pneumonitis fibrosis
7)CNS Transient demyelination
(Lhermittes sign)
myelitis
Local oedema necrosis
8) eye keratitis cataract
Entropion or ectropion
Dry eye
Indications for radiotherapy in symptom palliation
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Indications for radiotherapy in symptom palliation
Symptom Cause
Pain
Bone pain Bone metastases
Visceral pain Soft tissue metastases
Neuropathic pain Bone metastases
Soft tissue primary or metastases
Intrinsic tumour in nerve tissue
Local pressure
Spinal canal compression Extradural metastases
Bone metastasesCranial nerve palsies Skull base bone metastases
Meningeal metastases
Obstruction
Bronchus Intrinsic bronchial tumour
Extrinsic lymphadenopathy
I d f d h ll
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Indications for radiotherapy in symptom palliation
Oesophagus Intrinsic bronchial tumour
Extrinsic lymphadenopathy
Superior vena cava Primary mediastinal tumour
Primary lung or oesophageal tumour
Metastatic mediastinal lymphadenopathy
Hydrocephalus Malignant meningitis
Primary or metastatic brain tumour
Limb swelling Metastatic lymphadenopathy
Bleeding
Haemoptysis Primary bronchial tumour
Metastatic bronchial or lung tumour
Haematuria Primary tumour in kidney, ureter, bladder,prostate
Vaginal bleeding Primary tumours of vagina, cervix or uterus
Metastases in vagina
Rectal bleeding Primary anal or colorectal tumours
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SIDE EFFECTS OF RADIATION:MOST COMMON SYMPTOMS MANAGEMENT
1) MILD SKIN REACTIONS Aqueous cream
2) NAUSEA Metoclopromide, 5 -HT antagonists
3) RADIATION-INDUCED ACUTE DIARRHEA Dietary advice,loperamide, Codeine
Phosphate
4) RADIATION CYSTITIS Alpha-blocker, K citrate, cranberry juice
5) OROPHARYNGEAL MUCOSITIS Or, prophylactic anti-candidal
preparationsal hygiene, chlorhexidine
mouthwash
6) DENTAL CARRIES AND OSTEONECROSIS
OF THE JAW
Dental hygiene, for local relief of pain
7) PNEUMONITIS (dry cough and dyspnea) Systemic steroids and antibiotics for 2-3
wks
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Surgical palliation
Ricardo J. Gonzalez, MD
Assistant Professor of SurgeryUniversity of Colorado
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Palliation
Relieve symptoms for patients beyond cure whennonsurgical measures are not feasible, noteffective, or not expedient
Palliation means patient should be better at thecompletion of the procedure or treatment
It is axiomatic that one cannot palliativelyimprove an asymptomatic patient using a
scalpel.
R. G. Martin, 1982
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GASTRO INTESTINAL MALIGNANCIES
PALLIATIVE PROCEDURES
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Orthopedic principles
and
management
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Skeletal metastases
principles of treatmentare:
1) pain relief
2) preservation/restoration of skeletal integrity
3) preservation/restoration of function
4) elimination or prevention of neurologic
compromise.
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main role of the orthopaedic surgeon
treatment of the complications of skeletal
metastases
Pain -- commonest form of presentation of
skeletal metastases , occurring in two-thirds
of patients with radiographically detectable
lesions
-- may develop before the lesion becomesdetectable on radiographs
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orthopaedic surgeons role
not usually involved in the treatment of
painful skeletal metastases but he may be
involved in their diagnosis as patients with
bone pain are frequently referred initially
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Magnetic resonance imaging --the most
sensitive method of detecting early
metastases, especially in the spine
skeletal scintigraphy-- still probably the
investigation of choice in assessing the degree
of skeletal dissemination
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The orthopaedic surgeon is usually not involved
in the treatment of the painful uncomplicatedlesion although he may have made the
diagnosis but becomes involved when one of
the following complications arise
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Facts:
commonest site of pathological fracture is in
the femur
three aspects to the treatment of pathological
fractures.
1) The orthopaedic management
2) localized irradiation
3) the treatment of the causative tumour
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Harrington classification
Class I: The lateral cortices and superior and
medial acetabular walls are structurally intact
Class II: The medial wall is deficient.
Class III: The lateral cortices and the medial
and superior acetabular walls are deficient.
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indications for endoprosthetic replacement in the
management of skeletal metastases are:
resection of a solitary metastasis, usually secondary
to renal carcinoma, with the aim of achieving a
wide margin of healthy tissue around the tumour
transcervical femoral fractures
some metastases or pathological fractures involving
the epiphysis or metaphysis of long bones, where
other forms of treatment are not practical
and some failures of previous fixation
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Multiple fractures
Some patients present with several
pathological fractures and each must be
treated on its merits. This may require the
stabilization of several fractures
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Contraindications to surgery
terminally ill patient
a high risk of fixation failure due to the extent
of bone destruction
presence of infection
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I t ti l di l i l d
Procedure Examples of indications
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Interventional radiological proceduresDrainage Malignant obstruction of renal and biliary tract,
pleural effusions, ascites
Dilation/stenting Malignant gastrointestinal, biliary, ureteric andairway obstruction, superior or inferior vena
caval obstruction, etc.
Feeding Venous accessHickman lines peripherally-
inserted central catheter (PICC) lines
Percutaneous gastrostomy
Extraction Retrieval or resiting of venous lines
Infusion Regional, selective infusion of chemotherapeutic
agents
Embolization Hormone producing metastases, primaryhepatocellular carcinoma, skeletal metastases,
etc.
Neurolysis Coeliac ganglion in pancreatic cancer
Vertebroplasty Vertebral metastasis, osteoporosis
Tumour ablation Liver, renal, bony, and soft tissue tumours
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REFERENCE:
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THANK YOU!!!