Oncologic

EmergenciesDR JANABEL SAID

2018

Oncologic Emergencies

� Oncologic emergencies can occur at any time during the course of a malignancy, from the presenting symptom to end-stage disease.

� Prompt identification and intervention can prolong survival and improve quality of life, even in the setting of terminal illness:

� Neutropenic sepsis

� Spinal cord compression

� Superior vena cava syndrome

� Cardiac tamponade

� Hypercalcaemia

� Hyponatraemia

� Increased intracranial pressure

� Seizures

� Airway obstruction

� Tumour Lysis Syndrome

� Pulmonary Embolism

� Chemotherapy Extravasation

Metabolic Emergency – Hypercalcaemia

(HCa)

Most prevalent in:

� Breast (bone destruction, but prostate cancer diesn’t cause Hca

� Lung

� Renal Cell

� Cervical

� Endometrial

� Ovarian

Pathophysiology:

� 30 day mortality rate in close to 50%

� Systemic release of PTHrP by the tumor (80%) mimicking action of PTH on bones and kidneys but not on intestines

� Systemic secretion of vilamin D analogues by the tumor

� Local paracrain stimulation of osteoclasts leading to osteolytic effects

Metabolic Emergency – Hypercalcaemia

(HCa)

Presentation

� Bone pain

� Nephrolithasis(kidney stones)

� Abdominal Pain

� Altered consciousness

Treatment

Metabolic Emergency – Hypercalcaemia

(HCa)

Denosumab

� Monoclonal antibody

� Inhibitor of the receptor acitivator of muclear factor-KB (RANK)/RANKL signalling pathway

� Inhibits RANKL to bind to RANK on osteoclasts thus decreasing bone resorption (used in breast)

Zolendronic Acid

� 3rd gen bisphosphoate that directly inhibits osteoclast activiy at the site of increased bone turnover (fracture site)

Metabolic Emergency – Hyponatraemia

(HNa)

� HNa is low level of Sodium in the blood either due to :

� Excess water relative to sodium due to water retention

� Sodium loss

� May cause:

� Lethargy

� Delirium

� Seizures

� Coma

� Plasma (circulatory volume) Ξ interstitial space (outside vasculature) Ξ cells

Metabolic Emergency – Hyponatraemia

(HNa)

� Iatrogenic HNa:

� Cisplatin (salt wasting nephroathy)

� Cyclophosphamide

� Vinca alkaloids

� Imatinib

� SIADH most commonly in:

� Lung (SCLC 1-=45%)

� Pleura

� Thymus

� Brain

Metabolic Emergency – Tumor Lysis Syndrome

(TLS)

� TLS occurs when cancer cells release their contents into the bloodstream either spontaneously or following antineoplastic therapy leading to an influx of electrolytes and nucleic acids into the circulation

� Most common in germ cell tumours, but also in SCLC, IBC, Melanoma and liver mets

� Laboratory TLS:

� Uric Acid, K, PO4 25% increase from baseline

� Ca 25% decrease from baseline

� Clinical TLS

� Cr more than 1.5 times limit of normal

� Arrhythmia

� Seizures

� Sudden death

Metabolic Emergency – Tumor Lysis Syndrome

(TLS)

Cardiovascular emergencies – Cardiac

Tamponade

� Poor Prognosis

� Most common in breast, lung, mesothelioma, melanoma

� May be caused by thoracis XRT

� Diastolic pressures throughout the chambers begin to equalize and adversely affect cardiac output by compromising filling

� Beck triad:

� hypotension

� elevated jugular venous pressure

� muffled pre-cordium

� Treatment:

� Pericardiocentesis

� Chemotherapy

Cardiovascular emergencies – Superior Vena

Cava Obstruction and Airway Obstruction

� SVC returns all blood from the cranial, neck, and upper limbs

� Obstruction is caused by

� Extrinsic compression

� (germ cell, thymoma, lymphoma)

� Thrombosis

� underlying hypercoagulable state eg: RCC

� endothelial damage from an indwelling line

� Increased risk of Cavernous Sinus Thrombosis

� Signs and Symptoms:

� Swelling of face, neck one or both arms (one arm suggests more distal)

� Distended veins

� Shortness of breath/orthopnoea

� Hoarseness

� Headache

� Lethargy

Cardiovascular emergencies – SVCO and

Airway Obstruction

� Treatment

� STEROIDS (NB try to avoid if no diagnosis)

� STENT

� XRT

� Chemotherapy

� Anticoagulation

Cardiovascular emergencies – Pulmonary

Embolism

� VERY COMMON

� Risk Factors

� Disseminated Malignancy

� Recent surgery

� Immobility

� Chemotherapy

� OCP/HRT

� Thrombophilia/ anti-phospholipid syndrome

Cardiovascular emergencies – Pulmonary

Embolism

� Signs:

� Tachypnoea

� Cyanosis

� Tachycardia

� Hypotension

� Raised JVP

� Pleural rub

� Pleural effusion

� Pyrexia

� Symptoms:

� Asymptomatic

� Acute breathlessness

� Pleuritic chest pain

� Haemoptysis

� Dizziness

� Collapse

Cardiovascular emergencies – Pulmonary

Embolism

� Investigations

� D-Dimer (NB raised in malignancy)

� CTPA

� Treatment:

� Resuscitation

� Thrombolysis (cancer is a relative contra-indication)

� Anticoagulation

� IVC filter

Neurologic emergencies – Increased

intracranial pressure

� Intracranial neoplasms are mostly metastatic:

� lung cancer 20%

� breast cancer 5%

� melanoma 7%

� Renal cancer 10%

� colorectal cancer 1%

� Patients have a median survival of approximately 4 weeks if left untreated

� Increased ICP is due to:

� mass effect of the tumor

� cerebral edema caused by neoplastic disruption of the blood-brain barrier

Neurologic emergencies – ICP

� Signs and Symptoms:

� Tension headache worse with bending

� Nausea or vomiting

� Seizures

� Strokes

� Focal neurologic deficits

� Papilloedema

� Investigations:

� Contrast-enhanced MRI

� Noncontrast CT scan in an acute situation when hemorrhage or hydrocephalus is suspected

� Treatment:

� Dexamethasone

� Pros:

� relative lack of mineralocorticoid activity

� associated with a lower risk of infection and cognitive impairment

� Surgery

� Stereotactic radiosurgery

� Chemotherapy

� Immunotherapy

� Whole brain XRT ‘controversial’

� Levetiracetam (Keppra) only if seizures present

� NB PATIENT MUST STOP DRIVING

Chemotherapeutic emergencies - Extravasation of Chemotherapy

� Unintended leakage of the chemotherapy drug into the extravascular space

� Symptoms may occur immediately after the incident or develop in subsequent days or weeks

� Pain, erythema, swelling, blistering, induration, discoloration, ulceration

� Necrosis leading to infection, scarring, functional deficits, amputation

Changes

occurred over 3

months

Chemotherapeutic emergencies - Extravasation of Chemotherapy

� Treatment

� Immediately stop chemotherapy

� Elevate the arm

� Ask nursing team for protocol

� Try and aspirate from the cannula

� Apply cold or hot compress

� Inject hyaluronidase subcutaneously

� INFORM THE PLASTICS TEAM

Infectious emergencies – Neutropenic Sepsis

� Fever of >38º and a neutrophil count <0.5

� Usually occurs 7 to 10 days post chemotherapy

� Minimal symptoms due to absence of an inflammatory response at the infection site

� FULL HISTORY AND EXAMINATION

� FULL SEPTIC SCREEN

� Treatment

� Treat in a side room

� Broad spectrum antibiotics:

� IV tazobactam/piperacillin +/-

� Gentamycin if gram-negative infection

� Teichoplanin if IV catheter and/or MRSA

� IV meropenem if still febrile after 48hrs

� Antibiotics tailored according to identified infection

� IVI Fluids

� Avoid urinary catheterization if possible

And Finally – Spinal Cord Compression

� PEOPLE STILL DIAGNOSED TOO LATE

� Signs and Symptoms:

� Localized pain, frequently radicular

� Pain worse on straining or coughing

� Nocturnal spinal pain

� Weakness, unilateral/bilateral

� Altered sensation

� Urinary problems

� Bowel problems

� Investigations:

� MRI WHOLE SPINE

� Treatment:

� Dexamethasone

� Surgery (may be

curative eg: plasmacytoma)

� Radiotherapy

� Chemotherapy

� Bisphosphonates

FINAL POINTS

� My personal tips:

� If symptoms persist for more than 3 weeks – investigate

� By treating above conditions, OS may not be increased but QOL will

� If in doubt use online resources