ONCOLOGICAL EMERGENCIES (except neutropenic sepsis!)

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ONCOLOGICAL EMERGENCIES (except neutropenic
sepsis!)
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Spinal cord compression
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MRI features

• Compressed cord

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Spinal cord compression

• An emergency.
• Under-recognised.
• May patients unnecessarily left paraplegic as
  early symptoms signs not recognised by doctors.

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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.

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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
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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.

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Confirmation of diagnosis

• URGENT MRI of SPINE
• Accuracy of establishing level of compression
• Plain X-rays 21.
• Bone scan 19.

Levack 2002
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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.

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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
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Radiotherapy

• Single posterior field.
• Patient usually supine.
• Abnormal area plus 1-2 vertebra.

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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.

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Surgery for cord compression

• Improvements in pain in 75-100.
• Improvements in neurology in 50-75.after
  surgery.

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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.

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Conclusions

• Common, often unrecognised with serious impact on
  patients quality of dying.
• RADICULAR PAIN
• CORD COMPRESSION!
• Needs steroids and URGENT MRI!

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Superior vena cava obstruction
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Superior Vena Cava Obstruction

• Obstruction of blood flow through the SVC

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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
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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.

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Superior Vena Cava Obstruction
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Superior Vena Cava Obstruction

• SIGNS
• Early stage puffy neck, neck veins dont
  collapse.
• Later
• Distended neck chest wall
• veins.
• Swollen face, neck and arms.
• In advanced cases
• Injected conjunctiva.
• Sedation.

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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.

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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.

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Superior Vena Cava Obstruction

• Examination
• Extent of problem.
• Any evidence of malignancy elsewhere
• Lymphadenopathy.
• Hepatomegaly.
• collapse/consolidation of lung.

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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.

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Superior Vena Cava Obstruction
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Superior Vena Cava Obstruction
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Treatment options Clot

• Local thrombolysis with streptokinase.
• Anti-coagulation heparin (IV or LMWH) for at
  5/7 whilst starting warfarin.

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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 gt70.
• Radiotherapy
• used for other malignant causes
• response rate 60.
• Stent
• 95 response rate. Rapid relief of symptoms
• but doesnt treat the cause.

Rowell 2002
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Superior Vena Cava Syndrome- stented
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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.

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Metabolic Malignant Hypercalcaemia
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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.

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Hypercalcaemia

• Symptoms in the cancer patient
• Nauseated, anorexic.
• Thirsty.
• Pass lots urine (polydypsia and polyuria).
• Constipated.
• Confused.
• Poor concentration, drowsy.

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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

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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.

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

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Malignant Pericardial Tamponade

• SYMPTOMS
• Primarily shortness of breath.
• Fatigue.
• Palpitations.
• Symptoms of pericarditis (chest pain improved by
  sitting forward).
• Symptoms of advanced cancer.

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Malignant Pericardial Tamponade

• SIGNS Becks 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.

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Malignant Pericardial Tamponade

• INVESTIGATIONS
• CXR - enlargement of cardiac silhouette.
• ECG - reduced complex size.
• Echocardiogram rim of pericardial fluid.
• Cytology of pericardial fluid.

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Malignant Pericardial Tamponade
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Malignant Pericardial Tamponade

• TREATMENT
• Pericardiocentesis drain into pericardium.
• Pericardial window operation to allow
  pericardial fluid to drain into pleural cavity.
• Systemic management of malignancy.

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So Oncology emergencies

• SCC (spinal cord compression)
• SVCO (superior vena cava obstruction)
• Hypercalcaemia
• Tamponade

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Conclusions

• There are a variety of conditions related to
  cancer that can be life-threatening.
• Swift treatment can reduce impact on a patients
  quality of life.
• If in doubt about what to do speak to an
  oncologist!!