1. Oncologic Emergencies Department of Emergency Medicine Minhong Choa

2. Contents 1. Metabolic Emergencies2. Neurologic Emergencies3. Cardiovascular Emergencies4. Hematologic Emergencies

3. Metabolic Emergencies

4. Hypercalcemia Introduction Hypercalcemia is common problem in advanced cancer. 10%~30% of patients with cancer during disease. Most common malignancies Breast cancer Lung cancer Multiple myeloma Poor prognosis with elevated PTHrP

5. Hypercalcemia Pathophysiology Three type of Hypercalcemia Humoral hypercalcemia of malignancy Local bone destruction Tumor production of Vitamin D

6. Hypercalcemia Clinical Presentation Symptoms of Hypercalcemia percalcemia are Multiple and Nonspecpic. Lethargy, confusion, anorexia, nausea, constipaton Polyuria, polydipsia P/Ex is seldom helpful in making the diagnosis of hypercalcemia. The patient is often severely hypovolemic due to excessive fluid loss and impaired fluid intake.

7. Hypercalcemia Diagnosis Measuring ionized serum calcium. Total serum calcium (correct for albumin level) Corrected calcium=measured total calcium + [0.8 ⅹ (4.0-albumin)] Creatinine, other electolyte, alkaline phosphate should be checked. A low serum chloride level (<100mEq/L) is suggestive of hypercalcemia of malignancy.

8. Hypercalcemia Treatment (1) Untreated, symptomatic hypercalcemia is a life-threatening entity. Lethargy, confusion, anorexia, nausea, constipaton Polyuria, polydipsia Severe hypercalcemia is usually associated with pronounced hypovolemia. First step in treatment is IV hydration with normal saline. 500 to 1000mL N/S can be given during the first hour

9. Hypercalcemia Treatment (2) Loop diuretics should be avoided until euvolemia. Discontinuing the use of medication Thiazide diuretics, Vitamin D Bisphosphonate block osteoclatic bone resorption. Pamidronate, Zoledronic acid SQ or IM calcitonin can quickly lower calcium level Mithramycin and gallium nitrate.

10. Hypercalcemia

11. Tumor lysis Syndrome Introduction Several metabolic derangement that may be life-threatening. Most commonly seen after therapy for hematologic malignancies. High-grade lymphomas, acute leukemias TLS may be seen after the treatment of active solid tumors.

12. Tumor lysis Syndrome Pathophysiology Massive release of intracellular contents after tumor cell death. Neucleic acid : hyperuricemia Intracellular potassium : hyperkalemia, arrhythmia Increasing level of phosphorus : hypocalcemia, tetany, seizure

13. Tumor lysis Syndrome Clinical Presentation and Diagnosis Symptoms and signs of TLS are usually nonspecific. Recently started chemotherapy Urine output may decrease, symptoms of uremia or volume overload Seizure and arrhythmias can occur. A high index of suspicion is nesassary.

14. Tumor lysis Syndrome Clinical Presentation and Diagnosis

15. Tumor lysis Syndrome Treatment Patients at high risk Tumors of high proliferative rate Large tumor burden Chemosensitive disease The risk of TLS can be reduced by administering allopurinol and maintaing good hydration status. TLS need hospital admission and cardiac monitoring.

16. Tumor lysis Syndrome Treatment

17. Neurologic Emergencies

18. Malignant Spinal Cord Compression Introduction MSCC is a relatively common problem and true oncologic emergencies. All cancers can cause MSCC. Breast Ca, Lung Ca, Prostate Ca Overall survival depends on the tumor type. Patients with lung cancer have an especially poor prognosis. Neurologic status at diagnosis and the time to development of symptoms are important prognostic factors.

19. Malignant Spinal Cord Compression Pathophysiology Develop from tumors metastatic to the vertebral bodies. Thoracic spine is the most common location. Mechanism of injury is due to direct compression Neural elements Vascular mechanism Venous plexus obstruction can cause marked cord edema.

20. Malignant Spinal Cord Compression Clinical Presentation 90% of patients with MSCC have back pain. 80% of all cases of MSCC occur in patients with a preceding diagnosis of malignancies. Other symptoms Radicular pain, motor weakness, gait disturbance, dysfunction of bladder and bowel function

21. Malignant Spinal Cord Compression Diagnosis MRI is the imaging study of choice. CT myelography can be used. Plain radiographs are easy to obtain Abnormal finding in 80% of patients with symptomatic spinal metastasis.

22. Malignant Spinal Cord Compression Treatment Therapy should be initiated as soon as possible. Glucocorticoids should be given immediately if there is a delay in performing the imaging studies. Dexamethasone is the most commonly used corticosteroid 10~16 mg followed by 4 mg every 4 hours

23. Malignant Spinal Cord Compression Treatment Radiation therapy has been the mainstay of the treatment. Indications for surgical treatment continued to be debated. Consider surgery highly selected cases Maintain good performance status Gross instability of the spine Tissue for diagnosis is needed

24. Brain Metastasis and Increased ICP Introduction MSCC is a relatively common problem and true oncologic emergencies. All cancers can cause MSCC. Breast Ca, Lung Ca, Prostate Ca Overall survival depends on the tumor type. Patients with lung cancer have an especially poor prognosis. Neurologic status at diagnosis and the time to development of symptoms are important prognostic factors.

25. Brain Metastasis and Increased ICP Introduction Intracranial mets occur in up to 25% of patients dying of cancer. Any cancer can metastasize to the brain. Most common cancer Lung Ca Breast Ca Melanoma

26. Brain Metastasis and Increased ICP Pathophysiology Brain mets arises from hematogenous spread of tumor. 90% of brain mets are found in the supratentorial region. Lacated at watershed areas Brain edma and tumor expansion commonly resulted in IICP.

27. Brain Metastasis and Increased ICP Clinical Presentation and Diagnosis Less commonly, brain mets are the initial presentation of malignancy. In rare case, the brain mets are the only known site of disease. Brain metastases of unknown primary tumor Symptoms depends on the location of the lesion. MRI is the most sensitive and specific diagnostic modality

28. Brain Metastasis and Increased ICP Treatment Brain mets portended a poor prognosis for most patients. Treat only to alleviate symptoms

29. Cardiovascular Emergencies

30. Malignant Pericardial Effusion Introduction and pathophysiology Commonly seen in patients with advanced cancer. Frequently asymptomatic Pathophysiology Metastases to pericardium Direct invasion of the cancer Therapy

31. Malignant Pericardial Effusion Clinical Presentation and Diagnosis Symptoms of pericardial effusions Dyspnea, cough, chest pain, dysphagia, hiccups, and hoarseness Physical finding of pericardial effusions Tachycardia, distant heart sounds, fixed jugular venous distention, upper and lower extremity edema, pulsus pardoxus Preferred diagnostic method is echocardiography.

32. Malignant Pericardial Effusion Treatment Asymptomatic effusions do not need to be treated. Echocardiographically guided pericardiocentesis is a safe and effective. Dyspnea, cough, chest pain, dysphagia, hiccups, and hoarseness Surgery for palliation of symptoms Systemic and intrapericardial chemotherapy Radiation therapy

33. Superior Vena Cava Syndrome Introduction SVC becomes occluded or compressed, restricting blood return to heart. Most common malignancies Lung cancer Lymphoma CVP catheters are increasingly found as a cause of SVC syndrme. Intraluminal thrombus can also cause of SVC syndrome.

34. Superior Vena Cava Syndrome Pathophysiology The thin-walled SVC is easily compressed by tumors. Resulting in impaired venous drainage from head, neck, upper extremities. If the occlusion occurs gradually, collaterals may form and mitigate the symptoms.

35. Superior Vena Cava Syndrome Clinical Presentation and Diagnosis The onset of SVC syndrome is usually insidious. Most common symptoms dyspnea, facial swelling, cough Aggravated by bending forward or stooping Most common signs. Distended neck vein, facial edema, edema of upper extremities CT with venography or MRI.

36. Superior Vena Cava Syndrome Treatment SVC syndrome is not true medical emergency. Biopsies should be performed before instituting therapy. Mediastinoscopy, bronchoscopy, biopsy Stenting of the SVC Radiotherapy is a standard treatment modality. Chemotherapy and corticosteroids can also be used.

37. Hematologic Emergencies

38. Hyperleukocytosis and Hyperviscosity Introduction Increased viscosity secondary to leukocytosis is a well recognized complication associated with acute leukemia. Hyperleukocytosis is seen up to 13% of AML Leukostasis is much less common in ALL, CML, CLL

39. Hyperleukocytosis and Hyperviscosity Clinical presentation and diagnosis

40. Hyperleukocytosis and Hyperviscosity Treatment Prompt leukoreduction is the mainstay of therapy Leukapheresis Chemotherapy needs to be initiated as soon as possible. Hydroxyurea

41. Thank you Photo= Korea Tourism Organization