Oncologic Emergencies

Spinal Cord Compression Immediate treatment to reduce risk of permanent neurological damage- Transverse Myelitis Treatment is required for tumors that involve spinal cord and result in spinal cord compression.

Pathology Can arise in three places Spinal vertebra- Most common Paravertebral Tissue Epidural Space

95% spinal cord compressions are due to mets Primary spinal cord malignancies are rare Tumors that arise from metastasis usually originate in lung, breast, or lymphomas, myeloma, sarcoma, prostate, and kidney 20% present with multiple sites of mets

Symptoms Pain- Radiating back pain often weeks or months prior to onset of neuro symptoms Weakness- Leg weakness in 75% of patients Sensory deficits- Paraplegia and paralysis- (late symptom) Autonomic disorders- Loss of bowel and bladder sphincter- (Early symptom)

Diagnostic Work Up History and Physical- Neurological assessment High suspicion in cancer patients with back pain for early diagnosis Radiographs- Reveal bony abnormalities MRI- Study of Choice CT

Treatment Multidisciplinary Corticosteroids- Dexamethasone- use high dose with rapid tapering Surgery Radiation Therapy

Surgery Indications for Surgery: Unknown primary Progression during course of radiation Recurrence in irradiated field in which spinal cord had previously reached tolerance Not for paraplegic patient or one with diffuse mets

Surgical Decompression Removal of the vertebral body when there is an anterior compression Laminectomy- when there is posterior compression

Radiation Therapy Treatment of choice Radiation should follow surgery unless cord tolerance has been met Done alone or post-op Treatment should begin immediately

Technical Aspects Patient prone Determine upper and lower extent of tumor volume from images Single posterior treatment port used with 3-4cm margin above and below lesion Tumor dose calculated at depth of 5-6cm Lateral simulation film taken to determine depth of treatment

Field Borders Superior- 3 cm above cord compression Inferior- 3-4 cm below cord compression Lateral – 7-8 cm wide depending on lateral extent of tumor

Dose Rapid onset- Use large initial dose 3-4 Gy x 3 Cord tolerance 2-2.5 Gy/fx preferable when possible Total dose varies with histology Lymphoma- 23-30 Gy Carcinoma – 30-40 Gy

Severity of Pretreatment Outcome Less than 20% of patients with paraplegia at time of diagnosis become ambulatory Sever dysfunction prior to treatment, little chance of improvement Early diagnosis is best hope!

Rapidity of Onset Slowly progressive neurological symptoms Better prognosis Optimal treatment is within 48 hours The more rapidly the compression develops the less time to relieve compression before it becomes irreversible

Histological Lymphomas and myelomas are associated with a better prognosis than carcinomas

Other Factors Upper vs. lower T Spine Presence of bony abnormalities Lower better prognosis Presence of bony abnormalities Worse prognosis Duration of pretreatment dysfunction Worse prognosis with increased duration

Side Effects of Radiation Acute Transient Radiation Myelopathy (Any disease of the spinal cord) usually mild Late Delayed or irreversible myelopathy with symptoms of: Ascending Parethesias Motor Paralysis Disturbances of bowel and bladder function

Superior Vena Cava Obstruction Tumors that infiltrate mediastinum and compress SVC Can cause life threatening complication

Anatomy SVC is major venous channel for return of blood to heart from upper thorax, head and neck, and upper extremities Surrounded by anterior mediastinal structures and encircled by numerous lymph nodes

Pathology Causes of SVC: Lung Cancer- Small Cell most common followed by Oat Cell and Squamous Cell Lymphomas- Non Hodgkin’s Metastasis- Most frequent from breast cancer Benign causes- Thyroid goiter

Obstruction of SVC May occur: Secondary to extensive compression by tumor or lymph nodes Direct invasion of tumor into vessel wall with or without associated thrombosis

Clinical Features Obstruction of venous drainage in upper thorax Dyspnea Facial Swelling Cough Chest pain Dysphagia Venous distention of neck and thorax causing: Cyanosis, Tachypnea, Upper extremity edema

Diagnosis Chest X-ray CT of chest Verification of Histology Sputum cytology Bronchoscopy with biopsy Supraclavicular nodal biopsy

Radiation Therapy Treat immediately for symptomatic patients Patient treated supine, may require a slant board or treatment chair due to respiratory distress

Treatment Portals Include primary tumor with 2-3 cm margin Mediastinal Hilar Supraclavicular Measure separation daily to decrease in edema

Dose Initially high 3-4 Gy for 2-3 days. Conventional fractionation 1.8 –2.0 Gy /fx Total dose depends on histology Lymphoma- 30-40 Gy Carcinoma- 40-50 Gy

Chemotherapy Used with radiation therapy for chemo responsive tumors: Oat Cell Germ Cell Lymphoma Palliative Systemic control

Additional Treatment Steroids Diuretics for edema Anticoagulants for thrombosis

Palliative Results Good relief in 2-3 days 2/3 show signs of response in 1-2 weeks of initial treatment Survival poor- Most have lung cancer 80% of patients with lymphoma have complete response

Airway Compression Cancer of the lung, trachea, and esophagus may cause compression of trachea, main stem bronchi or carina

Symptoms Hemoptysis- Coughing up blood Dyspnea- Difficulty breathing Stridor- Abnormal high pitch sound caused by obstruction

Treatment Cryotherapy Laser therapy Surgical resection External beam radiotherapy Brachytherapy (HDR) Long term survival- Poor