Acute Oncology Presentations Caused by Disease Dr Omar Din Consultant Clinical Oncologist Weston Park Hospital Acute Oncology Study Day 9 th October 2013.

Acute Oncology Presentations Caused by Disease

Dr Omar DinConsultant Clinical Oncologist

Weston Park HospitalAcute Oncology Study Day

9th October 2013

Types of Emergency

Biochemical Hypercalcaemia

Hyponatraemia (SIADH)

Biochemical Hypercalcaemia

Hyponatraemia (SIADH)

Obstructive/structural SVCO

Raised ICPPathological fracture

Spinal Cord CompressionAirway ObstructionPericardial Effusion

Pleural effusionAscites

Obstructive/structural SVCO

Raised ICPPathological fracture

Spinal Cord CompressionAirway ObstructionPericardial Effusion

Pleural effusionAscites

Treatment RelatedFebrile neutropenia

Tumour Lysis SyndromeExtravasation

DiarrhoeaNausea/vomiting

Treatment RelatedFebrile neutropenia

Tumour Lysis SyndromeExtravasation

DiarrhoeaNausea/vomiting

Case 1

• 59 year old lady• 6 month history of lumbar back pain• Referred to rheumatology• Bone scan

Case 1

• Admitted • Drowsy• Dehydrated• Abdominal pain• Worsening back pain• BP 90/60• P 110

Case 1

• Bloods• Hb 9.8• Na 135• K 4.0• Urea 9.4• Creat 135• Ca 5.3• Alk Phos 347

Malignant Hypercalcaemia

• Ca >2.6 mmol/l• Causes:– Bone metastases– PTH-RP: – breast, renal, lung, head and neck,

myeloma, lymphoma– (Primary Hyperparathyroidism)

Hypercalcaemia - Symptoms

• Constipation• Fatigue• Nausea/vomiting• Confusion• Polyuria• Polydipsia• Abdominal pain• Dehydration

Hypercalcaemia - Treatment

• IV Fluids - 3L normal saline over 24 hrs

• IV Bisphosphonates– Zolendronic Acid (most potent)– Palmidronate

• Stop frusemide whilst dehydrated, Ca/Vit D• Calcitonin for resistant cases• Treat underlying cause

• Bloods– Hb 10.1– Na 118– K 4.2– Urea 4.0– Creat 60

• 9am Cortisol 500• TSH 2.1• Glucose 4.5• Lipids normal• Serum osmolality 260• Urine osmolality 368• Urine Na 98

SIADH

• Syndrome of inappropriate ADH secretion• Excess ADH leading to water retention and

low serum sodium due to dilutional effect.• Low serum sodium and reduced plasma

osmolality cf. urine osmolality• Urine Na >20mmol

SIADH

• Cancer; SCLC, NHL, HD, thymoma, sarcoma• CNS disease (infection, trauma)• Chest disease (infection)• Drugs (thiazide, anti-epileptics, PPI, cytotoxics)• Symptoms: nil, fatigue, nausea/vomiting,

confusion, coma

SIADH - treatment• Ensure Addison’s and Thyroid disease excluded

(cortisol, TSH)• Fluid restriction 1l in 24 hours, daily U&E• Demeclocycline 600-1200mg/day divided• Discussion with endocrinology• Newer agents eg Tolvaptan (vasopressin receptor

antagonists)• In EMERGENCY ONLY i.e. coma/fitting D/W

Critical care. May need transfer to HDU for slow IV NaCl 1.8% - caution with osmotic demyelination

• Treat underlying cause eg chemo for SCLC

Case 3

• 78 year old lady• Breast cancer 2008, node +, Her2 +• Admitted via A & E• Headache• Facial and arm swelling• SOBOE• Fixed raised JVP• Conjunctival oedema

Superior Vena Cava Obstruction• Definition; compression, invasion or occasionally

intraluminal obstruction of the superior vena • Causes; SCLC, NSCLC, lymphoma account for 90% cases.

Others include thymoma and germ cell.

• Often insidious onset• Compensatory collaterals over chest wall• Neck/face swelling• Headache• Dizziness• Syncope• Conjunctival oedema

Diagnosis

• Timely identification of the cause is essential• CT Chest• Up to 60% of patients with SVC syndrome

related to neoplasia do not have a known diagnosis of cancer– Need a tissue biopsy to guide subsequent

management

Histological Diagnosis• Sputum cytology, pleural fluid cytology, biopsy

of enlarged peripheral nodes

• Bone marrow biopsy for NHL

• Bronchoscopy, mediastinoscopy, or thoracotomy are more invasive but sometimes necessary

Treatment• O2• Dexamethasone/PPI• SVC Stent• Anticoagulation if thrombus• Does not require urgent radiotherapy – GET

DIAGNOSIS• Stridor – may require ICU admission

• Histopathology

• Treatment depends on cause• RT vs chemotherapy (SCLC, lymphoma, germ cell)

Case 4

• 64 year old man• Haematuria• PS 0• No PMH

Case 4

• CT right renal mass, nodes, small volume lung metastases

• Developed loin pain• Palliative nephrectomy• Obstructive LFTs• Biliary stricture - stented• Developed pain in left shoulder

Pathological Fracture

• broken bone caused by disease leading to weakness of the bone

• metastatic tumours: breast, lung, thyroid, kidney, prostate

• primary malignant tumours: chondrosarcoma, osteosarcoma, Ewing's tumour

• Bloods: FBC, PSA, myeloma screen. • CXR. • Mammogram

Pathological Fracture

• Orthopaedic opinion – stabilisation/reamings/biopsy

• Post operative radiotherapy – 20Gy in 5 fractions

• Mirel’s Risk1 2 3

Site Upper limb Lower limb Peritrochanter

Pain Mild Moderate Severe

Lesion Blastic Mixed Lytic

Size <1/3 1/3-2/3 >2/3

8=15% risk9=33% risk>9=High risk

Case 4

• Treated with sunitinib• Shortly afterwards developed reduced visual

acuity• Seen by opthalmology• Urgent phone call

Choroidal Metastases

• Choroid: vascular layer in and around eye• Breast, lung, prostate, kidney, thyroid, GI,

lymphoma, leukaemia• Symptoms: flashing lights, visual disturbance• Urgent treatment: Radiotherapy to save vision• 20Gy in 5 fractions

Brain Metastases

• Lung, breast, melanoma• Headache, nausea, vomiting, seizures, change in

behaviour, focal neurological deficit• CT/MRI• Dexamethasone up to 16mg/day• Risk of hydrocephalus – neurosurgeons ?shunt• Multiple mets – whole brain RT• Solitary met – excision or stereotactic

radiosurgery

Case 6

Pericardial effusion• Obstruction of lymphatic drainage or fluid from

tumour on pericardium• Tamponade – tachycardia, hypotension, JVP,

oedema• Echocardiogram• Urgent discussion with cardiothoracics• Percardiocentesis – fluid for cytology• Pericardial window• Complete pericardial stripping• Treat underlying cause

Case 7

Lymphangitis Carcinomatosa

• Breathlessness, dry cough, haemoptysis• diffuse infiltration and obstruction of

pulmonary parenchymal lymphatic channels by tumour

• Breast, lung, colon, stomach• 80% adeno• CXR – diffuse reticulonodular shadowing• CT or High Resolution CT

Lymphangitis Carcinomatosa

• Treatment of underlying condition• Dexamethasone• Chemotherapy• Endocrine Therapy• Prognosis poor – 50% die within 3 months of

first symptom

The End