Common Common Complications of Complications of

CancerCancer

Dr. Shad Salim AkhtarDr. Shad Salim AkhtarMB, MD, FRCP(Edin)Fellow UICC .

Consultant Medical OncologistAsst. DirectorPrince Faisal Oncology CentreKFSH, Buraidah, Al-Qassim

Therapy

Advanced cancer

Common Complications Common Complications of Cancerof Cancer

Common Complications of Cancer

• Acute – Nausea, vomiting– Diarrhoea– Extravasations– Hypersensitivity reactions

Therapy related

• Immediate– Alopecia– Febrile Neutropenia– Pulmonary toxicity– Neurological

• Late– Cardiac– Reproductive

Common Complications of Cancer

Therapy related

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30

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100 100-500 500-1000 1000-1500 1500

Severe infectionAll infections

Common Complications of Cancer

%age of days spent due to infectionNeutrophil Count

% d

ays w

ith in

fect

ion

• Could be a medical emergency• Fever >380 (2 spikes) or 38.50

• Elderly patients may react differently• ANC <500 or rapidly falling• Assess general condition of the patient • Infection screen• Broad spectrum antibiotics

Common Complications of Cancer

Febrile neutropenia

Common Complications Common Complications of Cancerof Cancer

• Neurological• Skeletal• Haematological• Gastrointestinal• Endocrine• Respiratory• Effusions

– Increase with disease progression

Advanced cancer

• A middle aged man– Lassitude, backache, generalized weakness– Constipation, vomiting, somnolence

• Pale, dehydrated, kyphosis with tenderness

• Anaemia, raised ESR, BUN, Cr, TP• X-ray

Common Complications Common Complications of Cancerof Cancer

• Serum Calcium 3.2 mmol/l

Common Common Complications of Complications of

CancerCancer• 15-20% patients affected• Epidural cord compression• Raised intracranial pressure• Status epilepticus• Intracerebral haemorrhage• Delirium

Neurological

Neurological Complications

• May be the first sign of malignant disease

•Often present as a true emergency

•In patients known to have cancer•Diagnosis may be easy

•Rapid diagnosis therapy can preserve function

• A young lady with a breast mass• Responded to repeated hormonal therapies• Relapse managed with chemotherapy• Responded well• Progressive disease in spite of different

modalities of therapy• Admitted with backache

Neurological Complications

Case History

Epidural Cord Epidural Cord CompressionCompression

• Compression of thecal sac by tumour– Spinal cord– Cauda equina

• One of the most common neurological emergencies in oncology

• App 5% of all cancer pts affected• Incidence increasing with improved survival

Epidural Cord Epidural Cord CompressionCompression

– Prostate– Lung– Breast– Lymphoreticular malignancies– Sarcoma– Renal cell carcinoma– Gastrointestinal cancers– Melanoma

Causes

• Cervical (10)%

• Thoracic (70%)

• Lumbosacral (20%)• 10-38% multiple non-contiguous sites

LungBreast

ColonPelvic

Location

Epidural Cord Epidural Cord CompressionCompression

• Direct extension from vertb body (90%)– 71% lytic– 21% mixed– 8% blastic

• Paravertebral gutter• Direct to epidural space

HematogenousBatson’s plexus

RetroperitonealLymphomas

Routes of spread

Epidural Cord Epidural Cord CompressionCompression

Clinical features

Epidural Cord Compression

• Pain– First symptom in 96% pts– Median duration ~7 wks (hrs to months)– Localized initially to back– Midline

Pain• May mimic disc disease except:

– Exacerbated by recumbence – Improves by upright position

• Radicular– Less frequent– Localizing

• Referred

Epidural Cord Compression

Neurological dysfunction– Three quarters-weakness– 50% --sensory loss+autonomic

• Weakness– 2nd most common symptom– Typically lower limbs

• Irrespective of site– Proximally more marked– Paraplegia may be abrupt

Epidural Cord Compression

Sensory symptoms

• Concurrent with weakness-usually• Begin in the toes and ascend• Cauda equina—dermatomal loss

• Bilateral• Perianal area• Posterior thigh• Lateral aspect of leg

Epidural Cord Compression

Epidural Cord Compression

• Late• Impotence• Horner’s• Absence of sweating• Usually not the sole presenting symptom• Ataxia-with pain

Autonomic dysfunction

Diagnosis

• MRI the best diagnostic tool

• Myelography under special circumstances• Image the entire spine• High index of suspicion

Epidural Cord Compression

Epidural cord compression

– Tumour– Abscess– Haematoma– Disc herniation– Vertebral haemangioma

Differential diagnosis

Spinal Cord Dysfunction

Intramedullary processes

• Metastasis• Abscess• Hematoma• Syrinx

Differential diagnosis

Spinal Cord Dysfunction

Myelopathy– Radiation– Intrathecal chemotherapy– Paraneoplastic

Leptomeningeal metastasisSpinal arachnoiditis

Spinal Cord Dysfunction

• PalliativeCorticosteroids• Radiation• Surgery

CytotoxicHormonal

Adjunctive

Treatment

Epidural Cord Compression

• Pain relieving • Oncolytic• Anti-inflammatory• Anti-oedema• Dose, duration, timing?

Corticosteroids

Epidural Cord Compression

Dexamethasone• Dose

– 10mg bolus then 16mg/d– 100mg bolus then 96mg/d

Randomised trials lacking

Epidural Cord Compression

• Undefined role• Laminectomy

– Destabilises the spine– Poor access to ant. tumors

• Anterior resection may be better• Mortality-6-10% (comp 48%)

Surgery

Epidural Cord Compression

Epidural Cord Compression

• No history or remote h/o cancer• Spinal instability• Bony compression• Compression in irradiated area• Ideal candidate

Good performance statusTreatable malignancySingle level disease

Surgery- Indications