ONCOLOGICAL EMERGENCIES (except neutropenic sepsis!)

ONCOLOGICAL EMERGENCIES

(except neutropenic sepsis!)

Spinal cord compression

MRI features

Compressed cord

Spinal cord compression

An emergency.

Under-recognised.

May patients unnecessarily left paraplegic as early symptoms & signs not recognised by doctors.

Presenting symptoms in Scottish audit

95% pain. 85% weakness (median duration 20

days). only 18% walking at time diagnosis. 68% altered sensation. 56% urinary problems. 74% bowel problems (6% on strong

opioids). 5% faecal incontinence.

Symptoms – description of pain Pain in spine (80%).

Worse on coughing and straining.

Frequently associated with radicular pain -band like burning pain sometimes with hypersensitivity – precedes weakness.

Levack 2002

Symptoms -others Weakness – bi-lateral or unilateral. Sensory changes can be loss of one

or all of: Proprioception. Light touch. Pin-prick.

Change in bladder – retention. Change in bowels – constipation.

Confirmation of diagnosis

Levack 2002

URGENT MRI of SPINE

Accuracy of establishing level of compression:

Plain X-rays 21%.

Bone scan 19%.

Treatment Steroids –

Immediate dexamethasone as ‘holding measure.’

Cancer Centre recommendation 16mg IV stat then 4mg qds PO with PPI cover.

Aim to reduce vasogenic oedema.

Radiotherapy Mainstay of treatment. UK usual dose 20Gy/5#, in US

30Gy/10#*.

Hanover series: ~33% improved and 20%

deteriorated. Those patients whose motor function.

declined the slowest, had the best outcome.*Plasmacytoma / solitary lymphoma deposit should receive 40Gy/20# CT

planned

Radiotherapy

Single posterior field.

Patient usually supine.

Abnormal area plus 1-2 vertebra.

Surgery Should be considered in any patient

with: Single vertebral region of involvement. No evidence of widespread

metastases. Radio-resistant primary e.g. renal,

sarcoma. Previous RT to site. Unknown primary- get tissue.

Surgery for cord compression

Improvements in pain in 75-100%.

Improvements in neurology in 50-75%.after surgery.

Chemotherapy

In theory can be used for the very sensitive tumours: Lymphoma. Teratoma. SCLC (maybe).

However, in view of devastating effects of neurological deterioration practice is often to treat small RT field (reduce bone marrow suppression) then move to chemotherapy.

Conclusions Common, often unrecognised with

serious impact on patients’ quality of dying.

RADICULAR PAIN = CORD COMPRESSION!

Needs steroids and URGENT MRI!

Superior vena cava obstruction

Superior Vena Cava Obstruction

Obstruction of blood flow through the SVC

Superior Vena Cava Obstruction

CAUSES:

Lung Cancer* 80%

Lymphoma 10%

Other Malignancy 5%

Benign causes 5%(e.g. aneurysm, goitre, fibrosis, infection etc.)

Occurs in 10% SCLC cases and 1.7% of NSCLC cases Rowell 2002Rowell 2002

Superior Vena Cava Obstruction

SYMPTOMS:

Swelling of face, neck one or both arms. (one arm suggests more distal)

Distended veins.

Shortness of breath.

Headache.

Lethargy.

Superior Vena Cava Obstruction

Superior Vena Cava Obstruction

SIGNS:

Early stage: puffy neck, neck veins don’t collapse.

Later: Distended neck & chest wall

veins. Swollen face, neck and arms.

In advanced cases: Injected conjunctiva. Sedation.

Superior Vena Cava Obstruction

Main aim is to distinguish whether obstruction is blockage from within: Clot (DVT) – often fast onset. Foreign body (e.g.line). Tumour in vessel (e.g. renal cancer).

Or without: Extrinsic compression from mass.

History How long?

Speed of onset?

How advanced? If patient is becoming drowsy this is an emergency.

Any risk factors e.g. recent central line.

Any symptoms of cancer esp. lung cancer or lymphoma.

Any other local symptoms e.g. pain, stridor.

Superior Vena Cava Obstruction

Examination: Extent of problem.

Any evidence of malignancy elsewhere Lymphadenopathy. Hepatomegaly. collapse/consolidation of lung.

Superior Vena Cava Obstruction

Initial Investigations: CXR – is there a mass? Venogram – is there a clot?

If extrinsic compression from mass try and obtain tissue (SCLC, lymphoma treated with chemo) FNA node. Mediastinoscopy.

Superior Vena Cava Obstruction

Superior Vena Cava Obstruction

Treatment options: Clot

Local thrombolysis with streptokinase.

Anti-coagulation – heparin (IV or LMWH) for at 5/7 whilst starting warfarin.

Treatment Options: Extrinsic compression

Steroids: frequently prescribed but no evidence to support their use

(Cochrane review)

Chemotherapy: used for SCLC, lymphoma and teratoma

response rate >70%.

Radiotherapy: used for other malignant causes response rate ~60%.

Stent: 95% response rate. Rapid relief of symptoms

but doesn’t treat the cause.Rowell 2002

Superior Vena Cava Syndrome- stented

Management Approach Is there time to obtain tissue?

If yes – obtain tissue by safest route.

If no – consider inserting stent to allow time to obtain tissue to ensure curable tumour not missed.

Lymphoma cured with chemo +/- RT.

Limited stage SCLC can be cured by chemo-radiation.

Metabolic: Malignant Hypercalcaemia

Hypercalcaemia Affects 10-30% of cancer patients.

CAUSES: Humoural.

Often mediated by PTHrP. Local bone destruction.

Especially lung, breast and myeloma. Tumour production of vitamin D

analogues. Especially lymphomas.

Hypercalcaemia Symptoms in the cancer patient:

Nauseated, anorexic.

Thirsty.

Pass lots urine (polydypsia and polyuria).

Constipated.

Confused.

Poor concentration, drowsy.

Investigations: Calcium (normal range 2.1-2.6).

Albumin to correct calcium: (corrected calcium = Ca2+ + 0.02x (40-albumin)

Urea and electrolytes – looking for dehydration.

Phosphate (low in hyperparathyroidism).

If no known malignancy – myeloma screen

Treatment Rehydration first:

Need several litres of normal saline. If risk of cardiac failure consider CVP

measurements.

Bisphosphonates: e.g. 60-90mg pamidronate IV over 2 hours. Can cause renal failure so must make sure

properly rehydrated first. Takes up to a week to work.

Systemic management of malignancy.

Malignant Pericardial Tamponade

Pericardial Tamponade

Pericardial effusion develops and compresses ventricle reducing cardiac output and collapsing the right atrium increasing venous back pressure.

Pericardial Effusion

CAUSES: Malignant.

Trauma – injury, post-op, iatrogenic e.g. pacing line.

Infection – TB, viral.

Post MI.

Connective tissue disease e.g. SLE, Rheumatoid.

Drugs e.g. hydralazine, isoniazid.

Uraemia.

Malignant Pericardial Tamponade

SYMPTOMS: Primarily shortness of breath.

Fatigue.

Palpitations.

Symptoms of pericarditis (chest pain improved by sitting forward).

Symptoms of advanced cancer.

Malignant Pericardial Tamponade

SIGNS: Beck’s triad

Jugular venous distension.

Pulsus paradoxus –venous return drops when intra-thoracic pressure raised.

Soft heart sounds or pericardial rub.

Poor cardiac output – tachycardia with low BP and poor peripheral perfusion.

Malignant Pericardial TamponadeINVESTIGATIONS:

CXR - enlargement of cardiac silhouette.

ECG - reduced complex size.

Echocardiogram – rim of pericardial fluid.

Cytology of pericardial fluid.

Malignant Pericardial Tamponade

Malignant Pericardial TamponadeTREATMENT:

Pericardiocentesis – drain into pericardium.

Pericardial window – operation to allow pericardial fluid to drain into pleural cavity.

Systemic management of malignancy.

So – Oncology emergencies SCC

(spinal cord compression)

SVCO (superior vena cava obstruction)

Hypercalcaemia

Tamponade……

Conclusions: There are a variety of conditions

related to cancer that can be life-threatening.

Swift treatment can reduce impact on a patient’s quality of life.

If in doubt about what to do– speak to an oncologist!!