ONCOLOGICAL EMERGENCIES (except neutropenic sepsis!)

Spinal cord compression

MRI features Compressed cord

Spinal cord compression An emergency. Under-recognised. May patients unnecessarily left paraplegic as early symptoms & signs not recognised by doctors.

Presenting symptoms in Scottish audit 95% pain. 85% weakness (median duration 20 days). only 18% walking at time diagnosis. 68% altered sensation. 56% urinary problems. 74% bowel problems (6% on strong opioids). 5% faecal incontinence.

Symptoms – description of pain Pain in spine (80%). Worse on coughing and straining. Frequently associated with radicular pain -band like burning pain sometimes with hypersensitivity – precedes weakness. Levack 2002

Symptoms -others Weakness – bi-lateral or unilateral. Sensory changes can be loss of one or all of: Proprioception. Light touch. Pin-prick. Change in bladder – retention. Change in bowels – constipation.

Confirmation of diagnosis Levack 2002 URGENT MRI of SPINE  Accuracy of establishing level of compression:  Plain X-rays 21%.  Bone scan 19%.

Treatment Steroids – Immediate dexamethasone as ‘holding measure.’ Cancer Centre recommendation 16mg IV stat then 4mg qds PO with PPI cover. Aim to reduce vasogenic oedema.

Radiotherapy Mainstay of treatment. UK usual dose 20Gy/5#, in US 30Gy/10#*. Hanover series: ~33% improved and 20% deteriorated. Those patients whose motor function. declined the slowest, had the best outcome. * Plasmacytoma / solitary lymphoma deposit should receive 40Gy/20# CT planned

Radiotherapy  Single posterior field.  Patient usually supine.  Abnormal area plus 1-2 vertebra.

Surgery Should be considered in any patient with:  Single vertebral region of involvement.  No evidence of widespread metastases.  Radio-resistant primary e.g. renal, sarcoma.  Previous RT to site.  Unknown primary- get tissue.

Surgery for cord compression Improvements in pain in %. Improvements in neurology in %. after surgery.

Chemotherapy  In theory can be used for the very sensitive tumours:  Lymphoma.  Teratoma.  SCLC (maybe).  However, in view of devastating effects of neurological deterioration practice is often to treat small RT field (reduce bone marrow suppression) then move to chemotherapy.

Conclusions Common, often unrecognised with serious impact on patients’ quality of dying. RADICULAR PAIN = CORD COMPRESSION! Needs steroids and URGENT MRI!

Superior vena cava obstruction

Superior Vena Cava Obstruction Obstruction of blood flow through the SVC

Superior Vena Cava Obstruction CAUSES: Lung Cancer*80% Lymphoma10% Other Malignancy5% Benign causes5% (e.g. aneurysm, goitre, fibrosis, infection etc.) Occurs in 10% SCLC cases and 1.7% of NSCLC cases Rowell 2002

Superior Vena Cava Obstruction SYMPTOMS: Swelling of face, neck one or both arms. (one arm suggests more distal) Distended veins. Shortness of breath. Headache. Lethargy.

Superior Vena Cava Obstruction

SIGNS: Early stage: puffy neck, neck veins don’t collapse. Later: Distended neck & chest wall veins. Swollen face, neck and arms. In advanced cases: Injected conjunctiva. Sedation.

Superior Vena Cava Obstruction Main aim is to distinguish whether obstruction is blockage from within: Clot (DVT) – often fast onset. Foreign body (e.g.line). Tumour in vessel (e.g. renal cancer). Or without: Extrinsic compression from mass.

History How long? Speed of onset? How advanced? If patient is becoming drowsy this is an emergency. Any risk factors e.g. recent central line. Any symptoms of cancer esp. lung cancer or lymphoma. Any other local symptoms e.g. pain, stridor.

Superior Vena Cava Obstruction Examination: Extent of problem. Any evidence of malignancy elsewhere Lymphadenopathy. Hepatomegaly. collapse/consolidation of lung.

Superior Vena Cava Obstruction Initial Investigations: CXR – is there a mass? Venogram – is there a clot? If extrinsic compression from mass try and obtain tissue (SCLC, lymphoma treated with chemo) FNA node. Mediastinoscopy.

Superior Vena Cava Obstruction

Treatment options: Clot Local thrombolysis with streptokinase. Anti-coagulation – heparin (IV or LMWH) for at 5/7 whilst starting warfarin.

Treatment Options: Extrinsic compression Steroids: frequently prescribed but no evidence to support their use (Cochrane review) Chemotherapy: used for SCLC, lymphoma and teratoma response rate >70%. Radiotherapy: used for other malignant causes response rate ~60%. Stent: 95% response rate. Rapid relief of symptoms but doesn’t treat the cause. Rowell 2002

Superior Vena Cava Syndrome- stented

Management Approach Is there time to obtain tissue? If yes – obtain tissue by safest route. If no – consider inserting stent to allow time to obtain tissue to ensure curable tumour not missed. Lymphoma cured with chemo +/- RT. Limited stage SCLC can be cured by chemo-radiation.

Metabolic: Malignant Hypercalcaemia

Hypercalcaemia Affects 10-30% of cancer patients. CAUSES: Humoural. Often mediated by PTHrP. Local bone destruction. Especially lung, breast and myeloma. Tumour production of vitamin D analogues. Especially lymphomas.

Hypercalcaemia Symptoms in the cancer patient: Nauseated, anorexic. Thirsty. Pass lots urine (polydypsia and polyuria). Constipated. Confused. Poor concentration, drowsy.

Investigations: Calcium (normal range ). Albumin to correct calcium: (corrected calcium = Ca x (40-albumin) Urea and electrolytes – looking for dehydration. Phosphate (low in hyperparathyroidism). If no known malignancy – myeloma screen

Treatment Rehydration first: Need several litres of normal saline. If risk of cardiac failure consider CVP measurements. Bisphosphonates: e.g mg pamidronate IV over 2 hours. Can cause renal failure so must make sure properly rehydrated first. Takes up to a week to work. Systemic management of malignancy.

Malignant Pericardial Tamponade

Pericardial Tamponade Pericardial effusion develops and compresses ventricle reducing cardiac output and collapsing the right atrium increasing venous back pressure.

Pericardial Effusion CAUSES: Malignant. Trauma – injury, post-op, iatrogenic e.g. pacing line. Infection – TB, viral. Post MI. Connective tissue disease e.g. SLE, Rheumatoid. Drugs e.g. hydralazine, isoniazid. Uraemia.

Malignant Pericardial Tamponade SYMPTOMS: Primarily shortness of breath. Fatigue. Palpitations. Symptoms of pericarditis (chest pain improved by sitting forward). Symptoms of advanced cancer.

Malignant Pericardial Tamponade SIGNS: Beck’s triad Jugular venous distension. Pulsus paradoxus –venous return drops when intra-thoracic pressure raised. Soft heart sounds or pericardial rub. Poor cardiac output – tachycardia with low BP and poor peripheral perfusion.

Malignant Pericardial Tamponade INVESTIGATIONS: CXR - enlargement of cardiac silhouette. ECG - reduced complex size. Echocardiogram – rim of pericardial fluid. Cytology of pericardial fluid.

Malignant Pericardial Tamponade

TREATMENT: Pericardiocentesis – drain into pericardium. Pericardial window – operation to allow pericardial fluid to drain into pleural cavity. Systemic management of malignancy.

So – Oncology emergencies SCC (spinal cord compression) SVCO (superior vena cava obstruction) Hypercalcaemia Tamponade……

Conclusions: There are a variety of conditions related to cancer that can be life-threatening. Swift treatment can reduce impact on a patient’s quality of life. If in doubt about what to do– speak to an oncologist!!