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Oncologic Emergencies

Francis L. Counselman, M.D., CPE, FACEP

Department of Emergency Medicine

Eastern Virginia Medical School

Norfolk, Virginia

Superior Vena Cava Syndrome

Compression of SVC by mediastinal or pulmonary mass or intraluminal occlusion by thrombosis

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Epidemiology

• Male:Female ratio 2.5:1

• Average age 56yo

• Approx 60% of patients without history of cancer

Incidence

• 5-15% of all Lung CA

• 5% of all Lymphomas

• 1% of all Pulmonary Mets

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Etiology

• Malignancy: Most common

• Mediastinal fibrosis

• Aortic aneurysm

• Granulomatous infection

• Goiter

• Iatrogenic: 20-40%

• Radiation fibrosis

Malignancies and SVC

• Lung 75%

• Lymphoma 10-15%

• Metastatic 10%

• Breast

• Thymus

• Testicular

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Symptoms

• Gradual onset

• Malignancy: more rapid progression

• Benign: slower progression

• 75% have signs/symptoms more than one week

• Symptoms worse upon awakening

Symptoms

• Headache 80%

• Dyspnea 65%

• Cough 55%

• Nausea/vomiting

• Dysphagia

• Tightness of shirt collar

• Visual changes

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Symptoms

• Altered mental status

• Syncope

• Swollen arms

• Hoarseness

• Orthopnea

• Stridor

• Seizure

• Weight loss

Physical Exam

• Dilated neck veins 80%

• Thoracic vein distention 74%

• Face/upper torso edema 70%

• Cyanosis of upper body 44%

• Plethora 14%

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Physical Exam

• Worsening of symptoms with arms above head (Pemberton’s sign)

• Paralyzed true vocal cords

• Tachypnea

• Horners syndrome

• Abdominal vein distention

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Imaging

• CXR

• Venogram

• Radionuclide scan

• Contrast chest CT scan

• Ultrasound

• Echocardiography

• MRI

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CXR

• Mediastinal widening 64%

• Pleural effusion 25%

• Right hilar mass

• Bilateral diffuse infiltrates

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CXR

• Cardiomegaly

• Anterior mediastinal mass

• Upper lobe collapse

• Calcified paratracheal

nodes

Normal CXR in 16% of SVC Syndrome

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Venogram

• Gold standard (old)

• Advantages

• Disadvantages

Contrast Chest CT Scan

• 92% sensitivity; 96% specificity

• Location/extent of tumor or thrombus

• Info for needle biopsy

• Plan radiation portals

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Ultrasound of Subclavian Veins

• Quick, noninvasive, inexpensive and no radiation

• Indirect evaluation of SVC patency

Echocardiography

• Transesophageal

• Bedside procedure

• No contrast material

• Differentiates between intravascular obstruction and extravascular compression

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Magnetic Resonance Imaging

• Contrast

• 94% sensitivity

• 100% specificity

• Limited use

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Management

• Initiate diagnostic workup

• Can better plan appropriate treatment with histologic diagnosis

Management

• Elevate head of bed

• Oxygen

• Steroids?

• Diuretics

• IV access

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Management

• Upper airway obstruction

• Cerebral edema

Rare but life-threatening

Require endovenous stent placement

and radiation therapy

Management

• Radiation therapy

• Subjective response within 72h

• Objective response within 7 to 14 days

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Management

• Thrombolytic therapy/Anticoagulation

• Common with indwelling catheters

• Contraindicated if brain mets

Management

• Chemotherapy

• Surgery

• Endovascular stents

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Hypercalcemia of Malignancy

• Most common metabolic complication

• Occurs in 10-30% of all CA patients

• In ED: malignancy (44%) followed by hyperparathyroidism (20%)

Differential Diagnosis

PAM P SCHMIDT

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Primary Diagnosis

• PrimaryHyperparathroidism

• Addisons Disease

• Multiple Myeloma

• Pagets Disease

Differential Diagnosis

• Sarcoidosis

• Cancer

• Hyperthyroidism

• Mild-Alkali Syndrome

• Immobilization

• D Vitamin Toxicity

• Thiazide Diuretics

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Pathophysiology

• Tumor secretion of PTH-related protein

• Responsible 80% of time• Stimulates osteoclast mediated bone resorption

• Stimulates renal tubular reabsorption of calcium

Pathophysiology

• Local bone destruction from mets with osteoclast activating factors

• Tumor production of Vitamin D analogues

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Solid Tumors with Bone Mets

• Breast 42%

• Lung 15%

• Prostate

Clinical Presentation

• Consider in all patients with malignant disease who feel sick

• Bones, stones, moans and groans

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Clinical Presentation

• Weakness

• Lethargy

• Fatigue

• Dehydration

Gastrointestinal

• Anorexia

• Nausea/vomiting

• Constipation

• Abdominal pain

• Obstipation

• Ileus

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Renal

• Polyuria

• Polydypsia

• Dehydration

• Nocturia

• Nephrolithiasis

• Nephrocalcinosis

Neurologic

• Anxiety

• Agitation

• Depression

• Impaired concentration

• Fatigue

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Neurologic

• Increased sleep requirements

• Altered level of consciousness*

• Decreased DTRs

• Ataxia

Cardiovascular

• Hypertension

• Arrhythmias

• Vascular calcifications

• EKG abnormalities

• Digitalis sensitivity

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Musculoskeletal

Bone pain

Diagnosis

• Serum calcium

• EKG

• Urinalysis

• Serum chloride

• Parathyroid hormone (PTH)

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Serum Calcium

• Asymptomatic < 12mg/dl

• pH

• Albumin level

• Rate of rise

Serum Calcium

• Ionized serum calcium level

• If measure total calcium:

Corrected Ca =

measured Ca + (0.8 x [4-albumin])

• Moderate: 12 to 14 mg/dl

• Severe: >14mg/dl

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EKG

• QT interval shortening

• Prolongation of PR

• Prolongation of QRS

• AV block

• Coving of ST-T segments

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Urinalysis

• Decreased specific gravity

• Increased glucose

• Increased Na

• Increased K

• Increased Mg

• Proteinuria

Serum Chloride

• Cl <100mEQ/L indicates hypercalcemia secondary to PTHrP

• Less responsive to bisphosphonates

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Parathyroid Hormone (PTH)

- Level < 20pg/mL not consistent with primary hyperparathyroidism

- If negative, consider ordering PTH-related peptide (PTHrp)

Management

• Treat underlying cause

• Rehydration

• Diuresis

• Electrolyte balance

• Specific measures

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Treatment

• Asymptomatic or mildly symptomatic with Ca <12mg/dL does not require immediate treatment

• Level >14mg/dL requires treatment, regardless of symptoms

Rehydration

• IV NS 200 to 500 cc/hr

• 100 to 150 cc/hr urine output

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Diuresis

• Rehydrate first

• Lasix no longer routine

• Consider if edema

or CHF

Electrolyte Balance

• Potassium

• Magnesium

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Calcitonin

• Increases renal calcium excretion.

• Decreases bone resorption

• Fast acting

• 4 IU/kg IM or SQ

• If responds, repeat every 6 to 12 hours

Bisphosphonates

• First line therapy

• Inhibits osteoclast mediated bone resorption

• More potent than calcitonin

• Max effect in 2-4 days

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Bisphosphonates

• Zoledronic acid 4mg IV over 15min*

• Pamidronate 60-90mg IV over 2 to 4 hours

Management

• Concurrent administration

• IV NS

• Calcitonin IM or SQ

• Zoledronic acid (ZA) IV

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Dialysis

• Hemodialysis

• Peritoneal dialysis

• Renal failure

Spinal Cord Compression

• 5% of all CA patients

• Peak age: 55 to 65yo

• 80% have dx of CA

• Prognosis time dependent

• First described in 1925

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Sites of Metastasis

• 60% Thoracic

• 30% Lumbosacral

• 10% Cervical

Location of Metastasis

• Vertebral column 90%

• Paravertebral space 10%

• Epidural space < 5%

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Primary Cancer

• Breast 20 to 30%

• Lung 15 to 20%

• Prostate 15 to 20%

• Lymphoma

• Renal

• Multiple myeloma

Back Pain

• 95% of cases

• Gradual and progressive

• Precedes other symptoms by 2 months

• Dull, aching, constant

• DJD v Metastatic disease

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Pain

• Localized initially

• Referred or radicular

• Increased with cough, sneeze, weight bearing

• Pain at night

Clinical Presentation

• Numbness

• Parasthesias

• Coldness

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Clinical Presentation

• Autonomic dysfunction

• Indicates T10-T12 involvement

• Present 50% at time of diagnosis

• Poor prognostic sign

Clinical Presentation

• Weakness

• Initial complaint 36%

• Very poor prognostic sign

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Physical Exam

• Vertebral tenderness 33%

• Straight leg raise

• Neck flexion

• Neurologic exam• hyperresponsive DTRs

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Diagnosis

• Plain films

• Myelogram

• Bone scan

• Spinal CT scan

• MRI

Plain Films

• 80% sensitivity

• Vertebral body collapse

• Osteolytic lesion

• Osteoblastic lesion

• Paraspinal mass

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Spinal CT Scan

• Transaxial plane only

• Excellent detail

• Preferred with myelogram

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Magnetic Resonance Imaging

• Gold standard

• 95% accuracy

• No contrast material

• No ionizing radiation

• Images in multiple plains

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Imaging Guidelines for Patient with history of CA and Back Pain

• High suspicion or abnormal neuro exam – emergent

• Low suspicion and normal neuro exam – outpatient imaging within 48 to 72 hours and consult

Management

• Consultation

• Steroids

• Radiation

• Surgery

• Chemotherapy

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Steroids

• Relieves pain

• Reduces edema

• Reduces inflammation

• Short-term benefit

Dexamethasone

• 10mg IV bolus then 16 mg/day (bid to QID)

• If dense paresis, consider 96 mg IV, then 24mg IV QID

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Radiation Therapy

• Definitive treatment

• Pain relief in 70 to 80% of cases

• Better prognosis if initiated prior to paraplegia

Radiation Therapy

81% ambulatant pretreat remained ambulatory post RT

17% nonambulant pretreat became ambulatory post RT

73% had improvement in pain

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Surgery

• Decompress spinal cord and nerve roots• Radiation therapy• Indications in development

Chemotherapy

• Rarely helpful