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Indications for Inpt Radiation Oncology Consultation

Jayden Gracie

Initial Considerations:

  • Is this really cancer? Must have a tissue diagnosis prior to consultation
  • Is problem urgent? Clinic opens at 7:30am, so do not consult until after 7:30am unless emergent
  • Urgent conditions (Inpt consultation indicated, weekend treatment unlikely)
  • Rule of thumb: true emergencies (label consult, 'Urgent,' may treat even on a weekend)
    • Spinal cord compression
    • Airway collapse from mass effect
    • Life-threating hemorrhage from mass
    • Symptomatic brain mets (seizures, FND, etc.)
    • Anaplastic thyroid cancer
    • Pain crisis from bone metastases
    • Requiring rapid turnaround: keloids (post-surgical for keloid prevention), heterotopic ossification)
  • Everything else is generally treated outpt. Order an ambulatory referral for those pts.
  • For pts whose outpt radiation gets interrupted by admission, no need for consult. Page Rad-Onc to close the loop.
  • If in doubt, page Rad-Onc to discuss prior to placing consult.
  • Have non-radiation interventions been discussed with the team/consultants first?
    • Airway compromise: first consult IP/ENT for stent placement/trach
    • Cord compression or symptomatic brain mets: consult Neurosurgery for possible intervention
    • Spinal instability/pathologic fracture: calculate a Spinal Instability Neoplastic Score (SINS). If >6, consult Spine to assess for instability and surgical candidacy. They must have an attested note prior to radiation planning. Not that radiation helps with tumor pain but does not help with instability or pain from the fractures themselves.
    • SVC syndrome: Consult IR for emergent percutaneous stent placement if 4_ points on Kishi scoring system. Engage Med Onc since chemo has a faster effect (especially in SLCL) than radiation (days). Consider surgical consult if concerned for thymoma
  • Is the pt fit enough for radiation? Common precluding factors:
    • Pt is too unstable
    • Cannot lie flat or stay still for 10 min of treatment, 30min-45min for planning (delirium, dyspnea, uncontrolled pain, seizing)
    • Head/neck radiation requires a facemask; claustrophobia should be addressed prior (benzos)

Pre-consultation workup:

  • Brain mets
    • If symptomatic, dexamethasone 10mg IV load followed by 4mg q6 thereafter (with PPI). Rad onc can help with taper plan. Do not stop during active treatments.
    • MRI with and without, labelled 'Cmelak Sequence' in comments section. May also be a 'For Radiation Planning' box.
    • CSF sampling if suspicious of leptomeningeal spread
    • DO NOT stop keppra If already onboard for seizures.
  • Spine mets
    • Damage becomes irreversible around 48 hours from symptom onset. Do not delay treatment and consultation (spine, rad onc, etc.).
    • STAT MRI with and without contrast.
    • Dexamethasone 10mg IV load followed by 4mg q6 thereafter (with PPI). Rad onc can help with taper plan. Do not stop during active treatments.

Logistical Considerations

  • Treatment planning takes several days to plan except in urgent/emergent circumstances.
  • Rad-Onc arranges ALL TRANSPORT for their pts. No need for primary team to do anything.
  • Pts must get a “CT sim” image in Rad-Onc department before starting any treatment.
  • Let Rad-Onc know if pts are going for other procedures/imaging on a treatment day, or if pt is refusing treatment.
  • Radiation plans cannot be transferred into or out of the Vanderbilt system. Let Rad-Onc know a few days in advance if transfers between Vanderbilt centers will be needed.
  • Pts cannot get radiation at 90% SNFs. Radiation must be completed prior to dispo.
  • Most CLCs do not transfer pts back and forth to radiation treatments, so if planning to discharge to CLC, radiation needs to be finished inpt or start after the CLC.
  • In general, most curative RT treatments take several weeks. Most palliative regimens take 1-10d.

Radiation at the VA

  • Pts need prior authorization before Rad-Onc is allowed to see VA pts at VUMC. To obtain PA, consult Med Onc and email Dr. York (medical oncologist at the VA). This may take a couple days. For Emergent cases, you do NOT have to wait on the PA. Rad-Onc can arrange for transport.
  • Rad-Onc attendings do not have access to the VA system. Notes will be in VUMC system.