Table 1.
PRT Covid-19 Summary: palliative emergencies
| Emergencies | ||||||
|---|---|---|---|---|---|---|
| Reference | Main Prescriptive Indication | Alternative | Additional Statement (if any) | % Consensus Vote* | ||
| A = Agreement (1 + 2) | ||||||
| D = Disagreement (3 + 4) | ||||||
| SA = Strong Agreement (1) | ||||||
| SD = Strong Disagreement (4) | ||||||
| E1 Metastatic Epidural Spinal Cord Compression (MESCC) | ||||||
| QE1a | [9] | 8 Gy/1fx8Gy [Maranzano [19]] | – | • Requires multidisciplinary discussion with neurosurgery, and evaluation of factors including degree of spinal cord compression and presence or absence of spinal instability | A = 100% [SA = 100%] | D = 0% [SD = 0%] |
| • Similar impact on OS and post-RT motor functions than multifractions | ||||||
| • Retreatment is safe | ||||||
| QE1b | Curigliano [16] | – | – | • RT is urgent | A = 100% [SA = 80%] | D = 0% [SD = 0%] |
| QE1c | Thureau [8] | 8 Gy/1fx8Gy | – | • Surgical treatment should theoretically be preferred if possible and for all pt with a life expectancy of more than few months | A = 70% [SA = 30%] | D = 30% [SD = 0%] |
| • Adjuvant RT after surgery for MESCC can be postponed for 4 to 12 weeks | ||||||
| • In cases where surgical treatment is contraindicated or not appropriate, RT should be arranged without delay | ||||||
| • The simplest conformal RT techniques should be used | ||||||
| • MESCC is likely the only instance justifying urgent management of a COVID + patient | ||||||
| QE1d | Simcock [14] | 6-10 Gy/1fx6-10 Gy [ICORG 05–03 [20], TROG 96.05 [21]] | – | • Prefer 3D | A = 80% [SA = 10%] | D = 20% [SD = 0%] |
| E2 Hemostasis (including Hemoptysis) | ||||||
| QE2a | Tchelebi [7] | • Esophageal cancer bleeding: 6–8 Gy/ 1fx 6-8 Gy | – | • Gastric cancer bleeding: RT should be strictly reserved for palliation of symptoms in pts with gastric cancer at the present time | A = 80% [SA = 20%] | D = 20% [SD = 0%] |
| • Gastric cancer bleeding: 6–8 Gy/ 1fx 6-8 Gy (with anti-emetic) | ||||||
| QE2b | [9] | • Pelvic malignancies bleeding: 14.8 Gy/4fx/3.7BID | – | Pelvic malignancies bleeding pt Covid + : Avoid BID | A = 80% [SA = 20%] | D = 20% [SD = 0%] |
| • Pelvic malignancies bleeding, pt Covid + : 20 Gy/5fx4Gy | ||||||
| QE2c | Wu [13] | Hemoptysis: 20 Gy/5fx4Gy | – | Palliative lung radiation should be deferred when possible, otherwise reserved for pt with life-threatening complications such as high-volume hemoptysis | A = 80% [SA = 30%] | D = 20% [SD = 10%] |
| • 17 Gy/2fx8.5 Gy§ | ||||||
| • 10 Gy/1fx10Gy | ||||||
| QE2d | Hahn et al. [63] | Pelvic bleeding: 8 Gy/1fx8Gy | – | – | A = 80% [SA = 40%] | D = 20% [SD = 0%] |
| QE2e | Combs [15] | Bleeding 8 Gy /1fx8Gy (not further specified) | – | – | A = 60% [SA = 30%] | D = 40% [SD = 0%] |
| QE2f | Thomson [6] |
H&N bleeding: o Scenario 1- Early Pandemic—Risk mitigation |
– | – | A = 70% [SA = 30%] | D = 30% [SD = 0%] |
| • 8 Gy/1fx8Gy | ||||||
| • 20 Gy/5fx4Gy | ||||||
| • 44.4 Gy/12fx3,7 Gy | ||||||
| o Scenario 2- Late Pandemic—Severe shortage of RT capacity | ||||||
| • 8 Gy/1fx8Gy | ||||||
| • 20 Gy/5fx4Gy | ||||||
| QE2g | Simcock [14] |
Esophageal bleeding: • 12 Gy/4fx3Gy BID [SHARON project [23]] |
Esophageal bleeding: 15 Gy/3fx5Gy [SHARON project]§ |
Esophageal bleeding: • Prefer 3D |
A = 80% [SA = 30%] | D = 20% [SD = 0%] |
| • 18 Gy/3fx6Gy Day (Q) 0, 7, 21 (weekly) (Adapted from other sites) [25] | Pelvic/GI bleeding: | |||||
| Pelvic/GI bleeding: | • Prefer 3D | |||||
| • 20-24 Gy/5-6fx4Gy | • Prefer 3D | |||||
| • 18 Gy/4fx4.5 Gy BID | ||||||
| [SHARON project [23]] | ||||||
| • 14.8 Gy/4fx3.7 Gy BID (Repeat q2-4 wks to total 44.4 Gy in 3 courses) [QUAD SHOT- RTOG 8502 [26, 27]] | ||||||
| • 18-24 Gy/3fx6-8 Gy Day 0, 7, 21 [25] | ||||||
| • 18-24 Gy/3fx6-8 Gy Day 0, 7, 21 [25] | ||||||
| E3 Mediastinal Syndrome | ||||||
| QE3a | Yerramilli [9] |
SVC syndrome Airway Obstruction: • 17 Gy/2fx8.5 Gy (each, weekly) [Sundstrom [31]] |
– | Multidisciplinary discussion may be recommended | A = 100% [SA = 70%] | D = 0% [SD = 0%] |
| • 20 Gy/5fx4Gy | ||||||
| QE3b | Guckenberger | o NSCLC-Early Phase of the COVID-19 pandemic (risk mitigation): | – | Order reported for “NSCLC Early Phase” follows the highest consensus reported in the paper | A = 80% [SA = 50%] | D = 30% [SD = 0%] |
| 2. 8–10 Gy/1fx 8–10 Gy 20 Gy/5fx 4 Gy | ||||||
| o NSCLC -Later phase of the COVID-19 pandemic: (lack of RT resources and need for patient triage) 8-10 Gy/1fx 8-10 Gy | ||||||
| QE3c | Wu [13] | Superior vena cava syndrome: | – | Palliative lung RT should be deferred when possible, otherwise reserved for patients with lifethreatening complications such as superior vena cava syndrome | A = 70% [SA = 40%] | D = 30% [SD = 0%] |
| • 17 Gy/2fx8.5 Gy§ | ||||||
| §(Authors do not specify in text/table but the reference report the schedule as “weekly”) [24] [Rodrigues] | ||||||
| • 10 Gy/1fx10Gy | ||||||
| SCV Syndrome/Lung | ||||||
| QE3d | Simcock [14] | Cancer: | – | Prefer 3D | A = 90% [SA = 30%] | D = 10% [SD = 0%] |
| • 8–10 Gy/1fx8-10 Gy | ||||||
| • 17 Gy/2fx8.5 Gy (weekly) [33] [MRC] | ||||||
§(Authors do not specify in text/table but the reference report the schedule as “weekly”) [Rodrigues [24]]
§ Note: the schedule reported in the paper do not corresponds to Sharon Project schedule
*Consensus Vote: 1 = Strongly Agree; 2 = Agree; 3 = Disagree; 4 = Strongly Disagree
MESCC Metastatic Epidural Spinal Cord Compression; fx fraction; OS overall Survival; RT Radiotherapy; pt patient; BID bis in die; Q schedule repetition interval; QoL quality of life; SBRT stereotactic body RT mets: metastases; wks weeks; PEG percutaneous endoscopic gastrostomy; WBRT whole brain RT; TMZ Temozolamide; mth months; IMRT-SIB Intensity modulated RT—Simultaneous integrated boost