Transcript Oncological Emergencies

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
URGENT MRI of SPINE
Accuracy of establishing level of
compression:
Plain X-rays 21%.
Bone scan 19%.
Levack 2002
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 5075%.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 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:


Chemotherapy:


used for SCLC, lymphoma and teratoma
response rate >70%.
Radiotherapy:


frequently prescribed but no evidence to support their use
(Cochrane review)
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.


Local bone destruction.


Often mediated by PTHrP.
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:



Bisphosphonates:




Need several litres of normal saline.
If risk of cardiac failure consider CVP
measurements.
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

Symptoms of advanced cancer.
improved by sitting forward).
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 Tamponade
INVESTIGATIONS:

CXR - enlargement of cardiac silhouette.

ECG - reduced complex size.

Echocardiogram – rim of pericardial fluid.

Cytology of pericardial fluid.
Malignant Pericardial Tamponade
Malignant Pericardial Tamponade
TREATMENT:



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!!