Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Neurological, airway or haemorrhagic compromise before radiotherapy
New weakness or sphincter dysfunction, impending brain herniation, stridor, major haemorrhage, unstable fracture or obstructed viscus requires immediate physiological and anatomical rescue; radiotherapy may contribute but is not a substitute for stabilisation.
Action: Use ABCDE care, control bleeding and protect an unstable spine or limb. Give dexamethasone 16 mg for neurological metastatic cord compression, obtain whole-spine MRI within 24 hours and seek urgent surgical and radiation review; use airway, neurosurgical, endoscopic, embolisation or operative intervention first when delay for radiation would risk irreversible harm.
Synopsis
Select palliative radiotherapy for a defined pain, bleeding, compression or neurological target, stabilise emergencies before planning, choose the shortest evidence-based fractionation that meets the goal and anticipate response, flare, field toxicity, retreatment and supportive care.
Palliative radiotherapy is local treatment for a defined symptom or threatened structure; it does not treat every site of metastatic disease simultaneously.
Common indications include uncomplicated painful bone metastasis, selected MSCC, brain metastasis, tumour bleeding, painful soft-tissue mass, airway or venous compression and skin ulceration.
Back pain with weakness, gait change, sensory loss or bladder or bowel dysfunction requires the MSCC emergency pathway before a routine radiotherapy referral.
Neurological emergency
Weakness, sensory or sphincter change, falling consciousness or posterior-fossa pressure needs urgent imaging, steroid when indicated and decompression assessment.
Investigation priorities
01
First-line symptom, function and goal assessmentFirst stepFirst line
Define the target, mechanism, severity, emergency, performance, prognosis, previous local treatment and outcome the patient values.
Management branches
Urgent referralStabilise first and select the fastest effective sequence
Tumour causes neurological loss, airway compromise, unstable bone, major bleeding or obstructed organ.
Use ABCDE care and activate MSCC, intracranial, airway, haemorrhage or fracture pathway with corticosteroid, transfusion, immobilisation or decompression as indicated.
Obtain the time-critical imaging and joint surgical, interventional and radiation review, deciding whether an operation, embolisation, stent or drain must precede radiation.
Key medicines
Dexamethasone for neurological MSCCGive dexamethasone 16 mg orally immediately, or equivalent parenterally, when neurological symptoms or signs suggest MSCC, then 16 mg daily while surgery or radiotherapy is awaited and taper after definitive treatment starts.
Analgesic cover for radiation response and flareContinue the established regular non-opioid and opioid schedule with immediate-release rescue matched to current 24-hour exposure; some services use a short dexamethasone course for high bone-pain-flare risk.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.