Transcript Emergencias Oncologicas

Oncologic Emergencies
Mauricio Burotto MD
National Cancer Institute
National Institutes of Health
Oncologic Emergencies
Concepts
• Can be at presentation or during the evolution of
the malignancy
• Usually caused by the tumor itself (primary or
metastasis) or secondary to humoral factors
• Also an oncologic emergency can be related to
the cancer treatment
Oncologic Emergencies
Concepts
– Primary : SVC syndrome related to a NSCLC
– Metastasis : Cord compression
– Humoral : Hypercalcemia, Hyponatremia
Oncologic Emergencies
Classification
Structural or mechanical
Metabolic or humoral
Oncologic Emergencies
Concepts
• Emergency related to the cancer treatment
– Chemotherapy
• TLS
– Targeted Agents
• Hemorrhage
• Bowel perforation
• “Allergic reaction” → Infusion reaction
Brain metastasis
• Metastasis to the brain is the most common
neurologic complication of cancer (40%)
• Suspicion at the presentation of any neurological
deficit or
– Nausea and vomiting
– Altered mental status
– Seizures
Brain metastasis
Diagnosis
• Contrast-enhanced CT
– Without contrast in patient with known lesions when
hemorrhage is suspected
• MRI with gadolinium phase
– More sensitive and better for posterior fossa
– Expensive
– Longer
Melanoma metastasis
Brain metastasis
Emergencies
• Intracranial hypertension (ICP)
– Herniation
• Hemorrhagic stroke
• Seizures
Increased ICP
Management
• Corticosteroids are routinely used to treat increased ICP
caused by brain metastasis by reducing vasogenic
cerebral edema. Dexamethasone
• Osmotic diuresis: Mannitol and hypertonic saline
• Intensive Care: ICP monitoring and Hyperventilation
Malignant cord compression
• Called epidural spine compression (ESCC)
• Defined as : Compression of the dural sac and its contents by an extradural
tumor mass. The minimal radiological evidence for SCC is indentation of the
theca at the level of the clinical symptoms
• Anatomical Causes: Epidural compression by tumor mass or pathological Fx
of the vertebrae and retropulsion of bony fragments into the canal
Malignant cord compression
Malignant cord compression
• Probability in patient with cancer 2-5%
– LUNG, BREAST, MYELOMA, PROSTATE
• Consequences: irreversible loss of neurologic function
• Clinical presentation: pain, (seven weeks before neurologic symptoms),
weakness, bladder and bowel dysfunction (later)
Malignant cord compression
Distribution
• Thoracic spine 50-70%
• Cervical 10-30%
• Lumbosacral 20-30%
Malignant cord compression
Diagnosis
• History and physical examination
• Imaging
– Spine X ray
– CT scan
– MRI
Malignant cord compression
Diagnosis
• History and physical examination
– Basic neurologic examination ALWAYS!!!
• Imaging
– Spine X ray
– CT scan
– MRI of the entire spine
Malignant cord compression
Treatment
• Symptomatic treatment:
– Pain control, anticoagulation*,avoid constipation
• Glucocorticoids
– Not clarity between initial high vs low dose (range 10
to 100 Dexamethasone ) then 16 mg in divided doses
Malignant cord compression
Treatment
• Definitive treatment: spinal stability, type of tumor
and grade of cord compression
• Surgery: resection + stabilization → Rdt
• Radiation :
– Radiosensitive : Lymphoma, SCLC, MM, Seminoma
– Radioresistance : Melanoma, RCC, CRC, Sarcoma
– Dose and schedule : Range (8Gy x1 to 40Gy x20 )
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Prognostic factors associated with shortened survival after RT include relatively radioresistant
histology, the presence of visceral metastases or other bone metastases, non-ambulatory status
at treatment, an interval from the original diagnosis to ESCC ≤15 months, and an interval <14
days from the onset of motor symptoms to the initiation of RT
Malignant cord compression
Treatment
• Stereotactic body radiotherapy (STBR)
– SBRT with a single 16-24 Gy fraction gives excellent tumor control, even in patients who
have relatively radioresistant tumors.
• Chemotherapy
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Greater than 50 percent vertebral body collapse
Subluxation/translation
Bilateral facet destruction
Movement-related pain
• Patients with a score of 7 or higher
– Spine Instability Neoplastic Score (SINS)
Superior vena cava syndrome
Any condition that leads to
obstruction of blood flow
through the SVC
Superior vena cava syndrome
• Malignancy accounts for 60% to 85% of cases
– 20% to 40% intravascular devices causing thrombosis.
– Lung cancer and non-Hodgkin lymphoma are responsible for most cases
• Symptom severity depends on the extent of the obstruction and its
rapidity of onset
– Dyspnea, facial swelling, and distended neck veins
– Collaterals develop over time and slow the progression symptoms
Superior vena cava syndrome
Diagnosis
• Chest x ray
– Abnormal in 80% of the cases : Widening and pleural effusion
• US
– First test in patients with vascular devices who present with extremity
swelling.
• CT Chest
– Test of choice : identification of the cause and collaterals
Superior vena cava syndrome
Management
• Emergent treatment is indicated in patients with airway obstruction or laryngeal
edema. However, SVC syndrome most commonly develops gradually, and
treatment can be delayed until the primary diagnosis is established.
• Radiation (NSCLC)
• Steroids (NHL and Thymoma)
• Chemotherapy (SCLC, testicular, NHL)
Superior vena cava syndrome
Management
• Angioplasty and stenting
• Surgery
• Thrombolytic therapy
• The American College of Chest Physicians recommends
establishment of a histologic diagnosis before instituting
treatment in stable patients
Superior vena cava syndrome
Management
Always try to obtain and histologic
diagnosis
Exceptions
Central airway obstruction
Coma because of cerebral edema
Pericardial tamponade
Pericardial effusion
• Thoracic radiation
– During radiation of early after finished
– Recall reaction
• Infectious
• Paraneoplastic autoimmune
– Immunotherapies for cancer
Pericardial effusion
• The most common primary malignancy involving the pericardium is lung
(2nd breast)
• Pericardial tamponade is an increase in intrapericardial pressure that
impairs intracardiac filling and cardiac output. Very rare***
• Don’t forget primary tumor from the pericardium
– Mesothelioma
Pericardial tamponade
Diagnosis and Treatment
• Echocardiography
– Right atrial collapse is a more sensitive marker of
pericardial tamponade, whereas right ventricular
collapse is more specific.
• Emergent pericardiocentesis
– Indwelling catheter
– Window
Intestinal emergencies
• Acute bowel obstruction
– CRC 10-30%
– Ovarian Cancer 20-50%*
– Treatment options: surgery, endoscopic intervention, and pharmacologic palliation; selfexpanding metallic stents
• Perforation
– CRC and lymphomas
– Targeted agents: Anti-angiogenic agents Bevacizumab
Tumor lysis syndrome
• The tumor lysis syndrome is the most common
disease-related emergency in hematological
malignancies
• Potential consequences
– Renal failure
– Cardiac arrhythmias
– Seizures
– Death
Tumor lysis syndrome
• Usually after treatment (most effective most probable)
– Can be spontaneous
• Most common hematological malignancies compared with solid
tumors but…
– LMA and NHL
– Combination chemotherapy
– Targeted agents : started to be reported
Tumor lysis syndrome
• Syndrome that may include :
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hyperkalemia
hyperphosphatemia
hypocalcemia
hyperuricemia
massive tumor cell death
Cairo and Bishop definition
Management
• Hydration
• Allopurinol*
• Rasburicase: most widely accepted dosing is based
on the 2008 International Expert Panel on TLS, which
suggests a dose of 0.1 mg/kg daily for TLS prevention
and 0.2 mg/kg daily for TLS treatment
• Alkalinization: not longer recommended
Hypercalcemia
• Hypercalcemia is the most common oncologic metabolic emergency
(10% to 30% at some point during disease course)
• It is defined as a total serum calcium concentration greater than 10
mg/dL or an ionized calcium concentration greater than 5.6 mg/dL.
Mechanisms
• Humoral hypercalcemia of malignancy
– 80% of cases PTHrP
• Local osteoclastic hypercalcemia
• 1,25(OH)2D-secreting lymphomas
• Ectopic hyperparathyroidism
Hypercalcemia
Presentation
• Neurologic symptoms
– Lethargy, confusion (coma)
• Gastrointestinal
– Constipation, Nausea, Anorexia
– Pancreatitis
• Renal
– Nephrogenic diabetes insipidus (Poliuria, polidipsea)
Diagnosis
• Measurement
– Always check with albumin and correct
– Ideally check ionized calcium
• Levels
– Mild <12 mg/dL [3 mmol/L]
– Moderate 2 to 14 mg/dL [3 to 3.5 mmol/L]
– High >14 mg/dL [3.5 mmol/L]
Hypercalcemia
Treatment
• Hydration (volume expansion)
– NaCL 0,9% 150-200 ml urine output 80-100 ml
– Loop Diuretics ???
• Bisphosphonates
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Always in high Ca+ almost always in moderate
Check renal function
Maximum effect in two to four days
Zolendronic Acid (4mg over 15-20 min)
Pamidronate ( 60-90-mg over 2 hours)
Hypercalcemia
Treatment
• RANKL inhibitors
– Denusumab **recommended patients with zoledronic acid
(ZA)-refractory hypercalcemia 6-120 sc
– Can be used in the setting of renal dysfunction
– Can cause hypocalcemia (Check vit D levels before )
• Steroids: Lymphomas (granulomatous component)
• Calcitonin (only in symptomatic patients with high Ca+)
• Hemodialysis
Hypophosphatemia Associated with
Cancer
• Tumor-induced osteomalacia (TIO) tumor production of phosphaturic factors → FGF23 results in phosphate wasting
– Chondrosarcoma and hemangiopericitoma
• Hypophosphatemia in hypercalcemia context
– Hyperparathyroidism
• Hypophosphatemia in hypocalcemia context
– Vit D deficiency
Hyponatremia in Cancer
• Hyponatremia is the most common electrolyte disorder encountered
in patients with malignancies ( 20-30%)
• Marker for inpatient mortality in cancer patients
• Can be an oncological emergency
Mechanical complications
Brain Mets
ESCC
SVC
Cardiac
Tamponade
PE
Intestinal
obstruction
Central airway
obstruction
Esophagobronquial fistula
TLS
↑K
↑P
Hyponatremia
↑Uric
Acid
Tumor
DIC
Hypercalcemia
Leukostasis
Message
• A cancer patient can have any medical
complication
• Many oncological emergencies can be anticipated
but not necessarily prevented
• Be aware of the new cancer therapies being used
in your hospital (discuss with your oncologists)
• Read the following section
– NEJM Reviews (all)
– Lancet Seminars (all)
NCI-NIH
Clinical Research Center