Oncologic challenges in the ED

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Oncologic challenges in the ED

• (besides not getting the old chart from TBCC)
• Grand Rounds
• Gord McNeil

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• 6 Cases
• Approach
• Management
• Calgary perspective

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Case 1

• 52 year old female with breast cancer presents to
  the ED with mid back discomfort, progressive
  weakness of left leg X 1 week and today urinary
  incontinence
• Recent radiation at TBCC (no old chart available)

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Approach

• Physical
• T37.3 Hr92, RR14, BP172/89
• Decreased sensation left abdominal wall and right
  lower leg
• Decreased power at right knee and ankle
• Labs
• Hg109, Plts 302, WBC 6.8, normal lytes and INR.

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Differential diagnosis

• Epidural abscess
• Epidural hematoma
• Metastatic spinal cord compression
• Routine causes of back pain

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Treatment

• Dexamethasone IV 10mg prior to MRI, then 4-8 mg
  q6-8hours
• Emergent MRI of entire spine (because pt can have
  synchronous, multifocal, asymptomatic MSCC.

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Treatment

• Call Spine service
• Decompression of spinal cord is the key to
  salvage of function
• Patchell et al2 in 2005 - radiation for 10 days
  and decompressive surgery within 24 hours
  improved outcomes of ambulation, continence and
  functional abilities from 84 compared to
  radiation alone for 57

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Metastatic spinal cord compression

• Causes
• breast(30),
• lung (15)
• prostate (15)
• Other
• Sites
• thoracic, then lumbar then cervical

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MSCC - causes

• Expansion of vertebral bone metastasis into
  epidural space causing cord compression
  radiation helps
• Neural foramina extension by a paraspinal mass.
  radiation helps
• Destruction of vertebral cortical bone -requires
  surgical intervention.

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Prognosis

• Start of onset of symptoms
• Onset 1-7 days 8-14days gt14 days
• Ambulate 35 55 86 (1)
• Faster onset worse prognosis
• Start of therapy
• dexamethasone and time to surgery
• Favorable histology - radiosensitive tumors

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Treatment

• Radiation only arrests the progression of
  nonradiosensitive tumors and does not stabilize
  the spine
• Surgery allows immediate cord decompression
  whereas radiotherapy typically takes several days
  to weeks.

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Calgary perspective

• Radiation oncology Dr. Elizabeth Yan
• Radiation did have an important initial role
  prior to 2005. Now acute surgical decompression
  and post op radiation is the standard of care.

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Calgary perspective

• Case scenarios
• Highly suspicious for occult CA and back pain
  then plain films and MRI no steroids
• Known CA and back pain without neuro deficit then
  MRI, steroids and radiation oncology
• Known CA with neuro deficit, then steroids, MRI
  and spine service

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Case 2

• 48 yr old male presents to ED with large
  hemoptysis X 2
• Recently treated at TBCC for lung CA (old
  chart not available)
• HR 129, RR32, sat90 5L, BP167/96

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Approach

• Mobilize team early
• Pulmonary
• DI/ IR
• ICU
• Thoracics

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Approach

• Stabilize
• Unstable airway
• ETT large size to faciliate bronchoscope
• Not the panacea
• Pulmonary toilet very important
• Selective placement of ETT

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Approach

• Stabilize
• CXR localizes bleeding
• Patient position bleeding side down
• Blood products/ fluids prn

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Approach

• Imaging
• CT scan can be done if pt not intubated and has
  stable airway prior to interventional radiology
  for bronchial artery emobilization
• If ETT then often bronch before IR to localize
  bleeding

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Approach

• Hemoglobin not important
• patients die of hypoxia not anemia
• not like GI bleed

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Causes

• Friable endobronchial tumors
• tumor eroding into a small intrapleural vessel
• tumour eroding in to one of the major vessels of
  the thorax.
• Large vessels bleeds death

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Calgary perspective

• Dr. Alain Tremblay
• One of the few indications for stat call for
  pulmonary in the middle if the night involve
  pulmonary early
• Mobilize CT and Interventional radiology early
• Supportive management essential

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Case 3

• 73 yr old male with thyroid cancer c/o increased
  secretions, stridor and SOB.
• HR 112, RR36, BP178/102, sat91on NRB

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Approach

• Stabilize
• O2, suctioning of secretions and allowing patient
  to sit up
• Labs, CXR

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Why is it happening?

• Usually a subacute process unless an already
  marginal airway is suddenly compromised by an
  acute infection, bleeding or the patients
  inability to handle secretions.
• Thyroid and esophageal carcinomas may compress
  the trachea by invading the surrounding soft
  tissue
• Can occur from scarring from prolonged intubation
  or from radiation therapy

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Treatment

• Consultant
• Pulmonary Rigid scope for endobronchial
  stenting or laser abalation
• Steroids not helpful (only if known
  lymphoma)

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Calgary perspective

• Needs rigid scope
• Drs Tremblay and Michaud only 2 pulmonologist in
  Calgary who do rigid scope (Some thoracic
  surgeons do as well)
• Can call pulmonary at any site and then can help
  management patient and arrange for rigid scope

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Case 4

• 86 yr old female with metastatic lung CA with
  progressive SOBOE over last 2 weeks, now SOB at
  rest.
• Nonproductive cough, no fever.
• HR 92, RR24, BP 164/92 Sat94 on 2L

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Effusion CXR
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Approach

• Stabilize
• Labs
• CXR
• Pleurocentesis

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Why is it happening ?

• Most common from lung, breast, ovary and lymphoma
• Pleural seeding by neoplastic cells increases
  capillary permeability and produces an exudative
  effusion
• Direct erosion into a blood vessel can cause an
  abrupt hemorrhagic effusion

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Calgary perspective

• Dyspnea clinic
• Run by Dr. Trembaly and Dr. Michaud
• Refer if known CA with symptomatic effusion or if
  highly suspicious for cancer
• Dont necessarily need tissue diagnosis

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Dyspnea Clinic

• Tap in ED, send referral. Appt usually in 2 weeks
• Clinic places pleurodex catheter and have home
  care drain it off as necessary
• If tapped in ED and return prior to appt, may
  need admission to pulmonary
• Clinic number -521 3511 Pat Barkley

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Case 5

• 64 yr old female with metastatic breast CA to
  liver flu like symptoms, N/V, lethargy,
  weakness X 2 weeks
• HR 110, RR16, BP100/56, Sat 84 RA
• GCS 13, no focal deficit, clinically dry

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Approach

• Labs
• Hg 112, WBC 9.4 Plts 186
• Glc 7.5, Na 132, K 3.5
• Creatinine 364 (new)
• Calcium 3.64 albumin 29
• Management

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Treatment

• Measure ionized calcium
• ABG
• Corrected calcium measured calcium (0.02 X(40
  measured albumin)
• Lower the albumin and the corrected calcium goes
  up

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Treatment

• Replace volume first
• Sodium inhibits reabsorption of calcium
• Need urine output 100cc/hr
• After euvolemic, then lasix with volume
  maintenance
• Follow K and Mg closely

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Causes of hypercalcemia in malignancy

• One of the most common complications of cancer -
  10-20
• MC caused by breast, lung, renal and
  cholangiocarcioma and multiple myeloma and
  lymphoma
• Mobilization of bone calcium more rapidly than it
  can be cleared by the kidneys
• Secretion of parathyroid hormone
• Presence of bone mets that cause local destruction

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Case 6

• 62 yr old male with CML with a recent
  exacerbation of COPD put on prednisone and
  levaquin
• Acute onset of flank pain then new tonic clonic
  seizure x 3 minutes
• Hr 48, RR 28, BP 88/52, sat 94NRB, T37.6,
  C/S6.8

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Approach

• Stabilize
• Labs
• Hg 109, WBC 38, plts201
• K 6.8, Na 132, glc 6.9
• Cr 342, urea 32
• Calcium 1.87, Phosphate 2.78, albumin 38
• Diagnosis ?

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Tumor Lysis Syndrome

• Hyperkalemia
• Hyperphosphatemia
• Hypocalcemia
• Renal failure
• Renal colic

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Tumour lysis syndrome - causes

• Large burden of tumor is rapidly and acutely
  destroyed causes outpouring of potassium, nucleic
  acids and phosphates.
• Sudden build up of electrolytes
• MC seen with lymphoma and leukemia, but can also
  occur with solid organ tumors
• Usually within 6 hours to 6 days after the
  initiation of therapy
• Can occur with the administration of
  corticosteroids to a susceptible patient

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• Symptoms of hyperkalemia
• - weakness and altered MS and arrthymias
• Hyperphosphotemia
• Causes acute precipitation of calcium in the
  kidneys and tissues leading to.
• Symptoms of hypocalcemia
• carpopedal spasm and seizures
• Renal failure
• secondary to increased uric acid levels producing
  renal tubular necrosis
• Symptoms of renal colic
• secondary to increased uric acid levels producing
  renal tubular necrosis

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Treatment -Tumor lysis syndrome

• Aggressive hydration if urine output exists
• Alkalinization of urine to pH 7 (can worsen
  hypocalcemia)
• Correct electrolytes and follow closely
• Lasix
• Allopurinol 600- 900mg loading dose
• Hemodialysis

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Rad onc, Med onc, no oncwho goes where?

• Radiation therapy
• Patient with active radiation usually gets s/e
  2 weeks after starting radiation until 2 weeks
  after completing radiation eg diarrhea
• Medical oncology
• Patient with chemo within the last month
• Usually febrile neutropenia at 5 days
• No oncology
• No tissue diagnosis?? hospitalist

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• Questions