Common complications of cancer
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Transcript of Common complications of cancer
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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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