Oncologic EmergenciesOncologic Emergencies

Ahmed M Badheeb , MD. Ahmed M Badheeb , MD.

Professor Of Oncology & Internal medicineProfessor Of Oncology & Internal medicine

Case “1”Case “1”

A 45 years old man A 45 years old man A known case of lung CAA known case of lung CACC : dyspneaCC : dyspnea On exam : On exam :  increased JVP , hypotension,

and diminished heart sounds.

Which immediate investigation is helpful?

Try to increase venous Try to increase venous returnreturn

All the following are used All the following are used except :except :

ICU admission,bed rest with leg ICU admission,bed rest with leg elevation elevation

OxygenOxygenPlasma, dextranPlasma, dextran Isotonic sodium chloride solutionIsotonic sodium chloride solution Inotropic drugs (eg, dobutamine) Inotropic drugs (eg, dobutamine) Positive-pressure mechanical Positive-pressure mechanical

ventilation.ventilation.

The wrong answer:The wrong answer:

Positive-pressure mechanical Positive-pressure mechanical ventilation should be avoided b/c it ventilation should be avoided b/c it may decrease venous return and may decrease venous return and aggravate aggravate S & S S & S of tamponade.of tamponade.

MedicationsMedications

Limited role !Limited role ! inotropic agents that do not increase inotropic agents that do not increase

peripheral vascular resistance, ex peripheral vascular resistance, ex dobutamine, may be used to dobutamine, may be used to increase cardiac output.increase cardiac output.

Hemodynamically stable PatientsHemodynamically stable Patients

Percutaneous balloon Percutaneous balloon pericardiotomypericardiotomy

Surgical Care in Hemodynamically Surgical Care in Hemodynamically Unstable PatientsUnstable Patients

Surgical creation of a pericardial Surgical creation of a pericardial windowwindow

Posteroanterior chest x-ray showing the heart before (left) and after (right) pericardiocentesis.

Khouzam R N et al. Circulation 2007;116:e342-e344

Copyright © American Heart Association

Recurrent cardiac tamponade Recurrent cardiac tamponade or pericardial effusionor pericardial effusion

Sclerosing the pericardiumSclerosing the pericardiumPericardio-peritoneal shuntPericardio-peritoneal shuntPericardiectomyPericardiectomy

Case”2”Case”2” A 63-year-old man is evaluated A 63-year-old man is evaluated

in ER for facial swelling, cough, in ER for facial swelling, cough, and' progressive dyspnea.and' progressive dyspnea.

He reports He reports nono headache, headache, change in vision, or chest pain. change in vision, or chest pain. He has a 40-pack-year history He has a 40-pack-year history of tobacco use.of tobacco use.

On exam, temp is 37,0 °C ,BP On exam, temp is 37,0 °C ,BP is 160/95 , PR is 110/min, and is 160/95 , PR is 110/min, and RR is 24/min. O2 sat is 90% on RR is 24/min. O2 sat is 90% on room airroom air. .

On physical examinationOn physical examination

Facial plethoraFacial plethora

CyanosisCyanosis

Distended jugular veinsDistended jugular veins

The lungs are dear. The lungs are dear.

Heart is normal without extra Heart is normal without extra sounds or murmurs. sounds or murmurs.

No peripheral edemaNo peripheral edema

No cervical, supraclavicular, or No cervical, supraclavicular, or axillary lymphadenopathyaxillary lymphadenopathy

CXR : CXR : widened mediastinumwidened mediastinum

CT chest CT chest Mediastinal mass with impingement on Mediastinal mass with impingement on SVCSVC

Which of the following is the most Which of the following is the most appropriate next step appropriate next step management ?management ?

(A) Chemotherapy(A) Chemotherapy (B) Combination chemo radiotherapy(B) Combination chemo radiotherapy (C) Corticosteroids(C) Corticosteroids (D) Mediastinoscopy and biopsy(D) Mediastinoscopy and biopsy (E) Radiation therapy(E) Radiation therapy

The correct answer is :The correct answer is :

(D) Mediastinoscopy and biopsy(D) Mediastinoscopy and biopsy

Tissue diagnosis Tissue diagnosis

SVC SyndromeSVC Syndrome

Mechanism (mMechanism (masse(s) in asse(s) in chest/mediastinum compress SVC)chest/mediastinum compress SVC) Lung (commonest)Lung (commonest) LymphomaLymphoma Mediastinal GCTMediastinal GCT

SymptomsSymptoms Facial EdemaFacial Edema Periorbital EdemaPeriorbital Edema Cyanosis – speed determines Cyanosis – speed determines

collateral pattern on chest wallcollateral pattern on chest wall

Management of SVC Management of SVC SyndromeSyndrome

Radiotherapy . Chemo Radiotherapy . Chemo SteroidsSteroids DiureticsDiuretics Endovascular stentingEndovascular stenting

Case “3”Case “3” A 46-year-old woman is evaluated for the recent A 46-year-old woman is evaluated for the recent

onset of headaches that are most intense on onset of headaches that are most intense on waking in the morning and are not relieved by waking in the morning and are not relieved by analgesics. She has no nausea or vomiting but analgesics. She has no nausea or vomiting but notes some difficulty with fine motor skills when notes some difficulty with fine motor skills when using her right hand. The patient has a 2-year using her right hand. The patient has a 2-year history of stage II breast cancer last treated with history of stage II breast cancer last treated with chemotherapy 2 years ago.chemotherapy 2 years ago.

On physical examinationOn physical examination

Temp 37.0 oc, BP 140/95 mm Hg, PR: Temp 37.0 oc, BP 140/95 mm Hg, PR: 90/min, & RR 12/min. 90/min, & RR 12/min.

She has reduced strength ( 4/5+) in her She has reduced strength ( 4/5+) in her right hand. right hand.

The reminder of the exam is The reminder of the exam is unremarkable.unremarkable.

What is missed clinical test in this What is missed clinical test in this case??case??

Brain CT scanBrain CT scan

Multiple masses Multiple masses Brain edemaBrain edema

Which of the following is the Which of the following is the most appropriate most appropriate

management?management?(A) Chemotherapy(A) Chemotherapy(B) Intravenous dexamethasone and (B) Intravenous dexamethasone and

radiation therapyradiation therapy(C) Lumbar puncture(C) Lumbar puncture(D) Resection of the masses(D) Resection of the masses

Increased Intracranial Increased Intracranial PressurePressure

The commonest cancer as causes :The commonest cancer as causes : Metastatic Tumor (breast , lung & melanoma)Metastatic Tumor (breast , lung & melanoma)

DiagnosisDiagnosis HeadachesHeadaches Personality ChangesPersonality Changes LethargyLethargy ComaComa PapilledemaPapilledema Stiff neckStiff neck Fixed pupil – tentorial herniationFixed pupil – tentorial herniation CT/MRI of BrainCT/MRI of Brain LP - cellsLP - cells

Increased Intracranial Increased Intracranial Pressure Pressure

TreatmentTreatmentSteroidsSteroidsCrainotomy – primaryCrainotomy – primaryWhole Brain Irradiation Whole Brain Irradiation Meningeal mets : intrathecal CTxMeningeal mets : intrathecal CTx

Case : 4Case : 4

64-year-old man is evaluated for 64-year-old man is evaluated for

A.A.3-month history of progressive mid back 3-month history of progressive mid back pain pain

B.B.a2-week history of lower extremity a2-week history of lower extremity weakness.weakness.

No history of trauma or cardiopulmonary No history of trauma or cardiopulmonary disease.disease.

On physical examinationOn physical examination

Temp 37.0 °C , BP 110/60, PR Temp 37.0 °C , BP 110/60, PR ~110/min, and RR is 18/min. ~110/min, and RR is 18/min.

He has point tenderness over the Tl0 He has point tenderness over the Tl0 and T11 vertebral bodies, decreased and T11 vertebral bodies, decreased lower extremity muscle strength lower extremity muscle strength (3/5+), increased reflexes isolated to (3/5+), increased reflexes isolated to both lower extremities, and bilateral both lower extremities, and bilateral extensor plantar reflexes. extensor plantar reflexes.

physical examinationphysical examinationThe remainder of exam is unremarkable. The remainder of exam is unremarkable. .,.,Laboratory studies:Laboratory studies:Hemoglobin 6.5 g/dL (65 g/L)Hemoglobin 6.5 g/dL (65 g/L)Leukocyte count 8500/pL (8.5 x 109 /L)Leukocyte count 8500/pL (8.5 x 109 /L)Calcium 12 mg/ dL ( 3 mmol/L)Calcium 12 mg/ dL ( 3 mmol/L)Total protein 13 g/dL (130 g/L)Total protein 13 g/dL (130 g/L)CXR is unremarkable. CXR is unremarkable.

Spine MRI (TL)Spine MRI (TL)

a vertebral body mass with extension a vertebral body mass with extension into the epidural space (T12) and into the epidural space (T12) and compression of the spinal cord. compression of the spinal cord.

Bone marrow biopsy Bone marrow biopsy

sheets of atypical sheets of atypical plasma cells plasma cells with with eccentric immature nuclei eccentric immature nuclei representingrepresenting

80% of the cellular elements.80% of the cellular elements.

Which of the following is the most Which of the following is the most appropriate next step in appropriate next step in management?management?

(A) Biopsy of the epidural mass(A) Biopsy of the epidural mass(B) Corticosteroids followed by (B) Corticosteroids followed by

radiotherapyradiotherapy(C) Lenalidomide(C) Lenalidomide(D) Radiation therapy(D) Radiation therapy

Spinal Cord CompressionSpinal Cord Compression

DiagnosisDiagnosisMRIMRI

TreatmentTreatmentSteroidsSteroidsDecompression LaminectomyDecompression LaminectomyChemotherapyChemotherapyRadiotherapyRadiotherapy

Tumor Lysis SyndromeTumor Lysis Syndrome

TreatmentTreatmentCorrect acidosis, potassium, uric acidCorrect acidosis, potassium, uric acidDiuresisDiuresisDialysis if neededDialysis if needed

Prompt treatment can prevent deathPrompt treatment can prevent death

Oncologic EmergenciesOncologic Emergencies

CardiovascularCardiovascular Pericardial TamponadePericardial Tamponade Superior Vena Cava SyndromeSuperior Vena Cava Syndrome

CNS CNS Increased Intracranial PressureIncreased Intracranial Pressure Spinal Cord CompressionSpinal Cord Compression

GastrointestinalGastrointestinal Bowel ObstructionBowel Obstruction Bowel PerforationBowel Perforation AscitesAscites Esophageal Obstruction and PerforationEsophageal Obstruction and Perforation

Oncologic EmergenciesOncologic EmergenciesHematologic EmergenciesHematologic Emergencies

DICDICLeukostasisLeukostasisThrombocytopeniaThrombocytopeniaHyperviscosity SyndromeHyperviscosity Syndrome

Infectious EmergenciesInfectious EmergenciesSepsis & neutropenic feverSepsis & neutropenic feverDisseminated Viral InfectionsDisseminated Viral InfectionsFungal and Parasitic DiseasesFungal and Parasitic Diseases

Oncologic EmergenciesOncologic EmergenciesMetabolic & renalMetabolic & renal

HyperuricemiaHyperuricemiaHypercalcaemiaHypercalcaemiaHypoglycemiaHypoglycemiaLactic AcidosisLactic AcidosisTumor Lysis SyndromeTumor Lysis SyndromeUreteral Obstruction – Pelvic TumorsUreteral Obstruction – Pelvic Tumors

Orthopedic EmergenciesOrthopedic EmergenciesPathologic FracturePathologic Fracture

Oncologic EmergenciesOncologic EmergenciesRespiratory EmergenciesRespiratory Emergencies

Airway ObstructionAirway Obstruction PneumothoraxPneumothorax EffusionEffusion

Symptomatic EmergenciesSymptomatic Emergencies PainPain VomitingVomiting MucositisMucositis DyspneaDyspnea

Thank youThank you