Acute Oncology Presentations Caused by Disease Dr Omar Din Consultant Clinical Oncologist Weston Park Hospital Acute Oncology Study Day 9th October 2013

Obstructive/structural Types of Emergency Treatment Related Febrile neutropenia Tumour Lysis Syndrome Extravasation Diarrhoea Nausea/vomiting Biochemical Hypercalcaemia Hyponatraemia (SIADH) Obstructive/structural SVCO Raised ICP Pathological fracture Spinal Cord Compression Airway Obstruction Pericardial Effusion Pleural effusion Ascites

Case 1 59 year old lady 6 month history of lumbar back pain Referred to rheumatology Bone scan

Case 1 Admitted Drowsy Dehydrated Abdominal pain Worsening back pain BP 90/60 P 110

Case 1 Bloods Hb 9.8 Na 135 K 4.0 Urea 9.4 Creat 135 Ca 5.3 Alk Phos 347

Malignant Hypercalcaemia Ca >2.6 mmol/l Causes: Bone metastases PTH-RP: – breast, renal, lung, head and neck, myeloma, lymphoma (Primary Hyperparathyroidism)

Hypercalcaemia - Symptoms Constipation Fatigue Nausea/vomiting Confusion Polyuria Polydipsia Abdominal pain Dehydration

Hypercalcaemia - Treatment IV Fluids - 3L normal saline over 24 hrs IV Bisphosphonates Zolendronic Acid (most potent) Palmidronate Stop frusemide whilst dehydrated, Ca/Vit D Calcitonin for resistant cases Treat underlying cause

Bloods Hb 10.1 Na 118 K 4.2 Urea 4.0 Creat 60

9am Cortisol 500 TSH 2.1 Glucose 4.5 Lipids normal Serum osmolality 260 Urine osmolality 368 Urine Na 98

SIADH Syndrome of inappropriate ADH secretion Excess ADH leading to water retention and low serum sodium due to dilutional effect. Low serum sodium and reduced plasma osmolality cf. urine osmolality Urine Na >20mmol

SIADH Cancer; SCLC, NHL, HD, thymoma, sarcoma CNS disease (infection, trauma) Chest disease (infection) Drugs (thiazide, anti-epileptics, PPI, cytotoxics) Symptoms: nil, fatigue, nausea/vomiting, confusion, coma

SIADH - treatment Ensure Addison’s and Thyroid disease excluded (cortisol, TSH) Fluid restriction 1l in 24 hours, daily U&E Demeclocycline 600-1200mg/day divided Discussion with endocrinology Newer agents eg Tolvaptan (vasopressin receptor antagonists) In EMERGENCY ONLY i.e. coma/fitting D/W Critical care. May need transfer to HDU for slow IV NaCl 1.8% - caution with osmotic demyelination Treat underlying cause eg chemo for SCLC

Case 3 78 year old lady Breast cancer 2008, node +, Her2 + Admitted via A & E Headache Facial and arm swelling SOBOE Fixed raised JVP Conjunctival oedema

Superior Vena Cava Obstruction Definition; compression, invasion or occasionally intraluminal obstruction of the superior vena Causes; SCLC, NSCLC, lymphoma account for 90% cases. Others include thymoma and germ cell. Often insidious onset Compensatory collaterals over chest wall Neck/face swelling Headache Dizziness Syncope Conjunctival oedema

Diagnosis Timely identification of the cause is essential CT Chest Up to 60% of patients with SVC syndrome related to neoplasia do not have a known diagnosis of cancer Need a tissue biopsy to guide subsequent management

Histological Diagnosis Sputum cytology, pleural fluid cytology, biopsy of enlarged peripheral nodes Bone marrow biopsy for NHL Bronchoscopy, mediastinoscopy, or thoracotomy are more invasive but sometimes necessary

Treatment O2 Dexamethasone/PPI SVC Stent Anticoagulation if thrombus Does not require urgent radiotherapy – GET DIAGNOSIS Stridor – may require ICU admission Histopathology Treatment depends on cause RT vs chemotherapy (SCLC, lymphoma, germ cell)

Case 4 64 year old man Haematuria PS 0 No PMH

Case 4 CT right renal mass, nodes, small volume lung metastases Developed loin pain Palliative nephrectomy Obstructive LFTs Biliary stricture - stented Developed pain in left shoulder

Pathological Fracture broken bone caused by disease leading to weakness of the bone metastatic tumours: breast, lung, thyroid, kidney, prostate primary malignant tumours: chondrosarcoma, osteosarcoma, Ewing's tumour Bloods: FBC, PSA, myeloma screen. CXR. Mammogram

Pathological Fracture Orthopaedic opinion – stabilisation/reamings/biopsy Post operative radiotherapy – 20Gy in 5 fractions Mirel’s Risk 1 2 3 Site Upper limb Lower limb Peritrochanter Pain Mild Moderate Severe Lesion Blastic Mixed Lytic Size <1/3 1/3-2/3 >2/3 8=15% risk 9=33% risk >9=High risk

Case 4 Treated with sunitinib Shortly afterwards developed reduced visual acuity Seen by opthalmology Urgent phone call

Choroidal Metastases Choroid: vascular layer in and around eye Breast, lung, prostate, kidney, thyroid, GI, lymphoma, leukaemia Symptoms: flashing lights, visual disturbance Urgent treatment: Radiotherapy to save vision 20Gy in 5 fractions

Brain Metastases Lung, breast, melanoma Headache, nausea, vomiting, seizures, change in behaviour, focal neurological deficit CT/MRI Dexamethasone up to 16mg/day Risk of hydrocephalus – neurosurgeons ?shunt Multiple mets – whole brain RT Solitary met – excision or stereotactic radiosurgery

Case 6

Pericardial effusion Obstruction of lymphatic drainage or fluid from tumour on pericardium Tamponade – tachycardia, hypotension, JVP, oedema Echocardiogram Urgent discussion with cardiothoracics Percardiocentesis – fluid for cytology Pericardial window Complete pericardial stripping Treat underlying cause

Case 7

Lymphangitis Carcinomatosa Breathlessness, dry cough, haemoptysis diffuse infiltration and obstruction of pulmonary parenchymal lymphatic channels by tumour Breast, lung, colon, stomach 80% adeno CXR – diffuse reticulonodular shadowing CT or High Resolution CT

Lymphangitis Carcinomatosa Treatment of underlying condition Dexamethasone Chemotherapy Endocrine Therapy Prognosis poor – 50% die within 3 months of first symptom

The End