Keywords
Anesthesia - chemotherapy - distraction techniques - pediatric - radiotherapy
Introduction
Treatment of pediatric cancers is challenging and involves a multidisciplinary approach.
Younger children usually <12 years of age have apprehension and anxiety regarding
diagnostic and therapeutic procedures performed on them. Therefore, it becomes necessary
to give them sedation or general anesthesia to successfully perform the recommended
procedure. A proportion of pediatric tumors, especially solid tumors require radiotherapy
as an integral part of their management. Radiotherapy is delivered in daily fractions
usually over a period of 4–6 weeks. Patients need to be immobilized to achieve accurate
delivery of planned radiotherapy dose. Any movement during radiotherapy delivery can
be proved to be deleterious. Young children can be intimidated by the radiotherapy
room, machine, and the staff. Therefore, to alleviate their anxiety and immobilize
them, either sedation or general anesthesia is needed daily during the next few weeks.
However, this leads to increased occupancy of radiation machine, thereby decreasing
in the number of patients treated in that machine. Furthermore, there is an inherent
risk in the daily delivery of general anesthesia/sedation. Hospitals in resource challenge
settings may not have availability of an anesthetist/anesthetic equipment in radiation
department or facilities to monitor a child during and after anesthesia. The study
looks at the delivery of radiation to young children without the use of sedatives
or general anesthesia.
Subjects and Methods
The study included children <12 years of age with malignancies treated at the radiotherapy
department in our institute from January 2015 to June 2017. The data were collected
retrospectively by evaluating the patients’ case records. Before initiation of planned
radiotherapy treatment, the parents were counseled regarding the treatment and the
need for immobilization. The treating radiation oncology consultant met the children
and their parents and decreased their anxiety and fear. The children were made to
visit the department multiple times and visualize the procedure starting from immobilization
to treatment execution.
During immobilization and simulation, parents were made to stand by the side of the
child with the provision of adequate shielding techniques. Parents were not allowed
to be present during treatment execution. All treatment decisions were made based
on multidisciplinary tumor board. None of the children were given any sedative before
immobilization/treatment. Immobilization was done using mold/Vac-Lok. Children were
also not kept nil by mouth before radiotherapy delivery.
Radiation was delivered using linear accelerators (VARIAN CLINAC 600 and 2100). To
alleviate anxiety, children were treated in the same machine and by the same team.
During the delivery of radiation, children were monitored using closed-circuit television
and two-way audio communications. Precise delivery of radiotherapy and adequate immobilization
were confirmed by pre- and post-treatment images. Supports on the sides were provided
in the couch and straps were made available to prevent any falls.
Results
During the study, 50 children received radiotherapy in our institute. Among 50 children,
44 children were treated without anesthesia/sedation and 6 children required anesthesia.
The mean age of children treated without anesthesia was 5.56. Among 44 children, 26
(59%) were male and 18 (41%) were female. The malignancies include acute lymphoblastic
leukemia (25%), ewing’s sarcoma (16%), rhabdomyosarcoma (14%), lymphoma (11%), Wilm’s
tumor (11%), neuroblastoma (10%), brain tumours (5%), primitive neuroectodermal tumor
(2%), retinoblastoma (2%), nasopharyngeal carcinoma (2%), and fibromatosis (2%) [Table 1]. Among the 6 children who received general anesthesia, 5 out of 6 were initially
tried for treatment without general anesthesia. However, it was not successful. We
did not find any discrepancy between the planned and the executed treatment. [Table 2] provides treatment details and patient characteristics.
Table 1
Distribution of pediatric malignancies
|
Malignancy
|
Number of children (n=44), n (%)
|
|
ALL – Acute lymphoblastic leukemia; RMS – Rhabdomyosarcoma; PNET – Primitive neuro
ectodermal tumor
|
|
ALL
|
11(25)
|
|
Ewing’s sarcoma
|
7(16)
|
|
RMS
|
6 (14)
|
|
Lymphoma
|
5 (11)
|
|
Wilm’s tumor
|
5 (11)
|
|
Neuroblastoma
|
4 (10)
|
|
Brain tumors
|
2 (5)
|
|
PNET
|
1 (2)
|
|
Retinoblastoma
|
1 (2)
|
|
Nasopharyngeal carcinoma
|
1 (2)
|
|
Fibromatosis
|
1 (2)
|
Table 2
Patient and treatment characteristics
|
Parameter
|
n
|
Percentage
|
|
Age (years)
|
|
|
|
1-5
|
29
|
66
|
|
6-12
|
15
|
34
|
|
Immobilization device
|
|
|
|
Thermoplastic mould
|
34
|
77
|
|
Vacloc
|
10
|
23
|
|
Treatment technique
|
|
|
|
Conventional
|
24
|
55
|
|
Conformal
|
11
|
25
|
|
IMRT
|
8
|
18
|
|
V-MAT
|
1
|
2
|
|
Number of fractions
|
|
|
|
Minimum
|
7
|
Not applicable
|
|
Maximum
|
33
|
Not applicable
|
Discussion
Our study shows that 88% of children can be treated safely without general anesthesia/sedative.
Children as young as 2 years can be treated without anesthesia. This is especially
important in resource challenge setting as it leads to decreased utilization of machine
time, need for anesthetist, equipments, and avoids the risk of use of anesthetic agents/sedatives
for a prolonged period. Another significant perspective is that there is no need to
follow nil per oral for treatment execution and patients need not stay in the hospital.
The need for postprocedure monitoring is also avoided. In our study, children were
more cooperative for Vac-Lok immobilization [Figure 1] devices when compared to thermoplastic head and neck mold, but with the help of
distraction aids, they cooperated for the immobilization.
Figure 1: Treatment setup of a child without anesthesia
There is paucity of data in literature on the treatment of children with radiotherapy
without the use of sedation or anesthesia. Similar to our study, Ayan et al. have reported successful treatment of eleven children without anesthesia.[1] Anghelescu et al. observed that the rate of anesthesia related complication during radiotherapy delivery
for children was 1.3%.[2]
The study has shown that with the help of proper counselling, distraction aids, spending
time with children, explaining the procedure, making them to visualize the procedures
executed on other children made them comfortable for undergoing radiotherapy without
the use of anesthesia/sedatives.
Conclusions
Radiotherapy can be safely and successfully delivered without anesthesia or sedation
in children. Our study findings will be useful for centers were facilities to give
anesthesia to children are limited or not available.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms.
In the form the patient(s) has/have given his/her/their consent for his/her/their
images and other clinical information to be reported in the journal. The patients
understand that their names and initials will not be published and due efforts will
be made to conceal their identity, but anonymity cannot be guaranteed.
