Transcript Acute Oncology Presentations Caused by Disease
Acute Oncology Presentations Caused by Disease
Dr Omar Din Consultant Clinical Oncologist Weston Park Hospital Acute Oncology Study Day 9 th October 2013
Types of Emergency
Biochemical
Hypercalcaemia Hyponatraemia (SIADH)
Treatment Related
Febrile neutropenia Tumour Lysis Syndrome Extravasation Diarrhoea Nausea/vomiting
Obstructive/structural
SVCO Raised ICP Pathological fracture Spinal Cord Compression Airway Obstruction Pericardial Effusion Pleural effusion Ascites
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
• • • • • • • • Bloods Hb 9.8
Na 135 K 4.0
Urea 9.4
Creat 135 Ca 5.3
Alk Phos 347
Case 1
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)
• • • • 64 year old man Haematuria PS 0 No PMH
Case 4
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 Risk
1 2 3
Site Pain Lesion Size Upper limb Mild Blastic <1/3 Lower limb Moderate Mixed 1/3-2/3 Peritrochanter Severe Lytic >2/3 8=15% risk 9=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