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Oncological Emergencies
Dr Lauren Bradbury Medical Oncologist 21st December 2016
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Mr RB 74 year old man 2014 found to have PSA 14, declined further investigation/management Sept 2016 presents to Forbes ED on a Sunday with falls, acute urinary retention & new faecal incontinence PSA done 2 days later 9800
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Spinal Cord Compression
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Symptoms Pain – often the first symptom & present in up to 95% of patients Muscle weakness present in 60-85% Sensory disturbance – less common than motor symptoms, ascending pattern Look for a sensory level, typically 1 to 5 levels below the actual cord compression Bowel & bladder dysfunction Ataxic gait
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Investigation & Management
Start DEX!!! Analgesia Imaging options Radiotherapy vs. surgery Systemic cancer treatment
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Hypercalcaemia of Malignancy
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Hypercalcaemia Common problem – occurs in 20-30% of patients
Breast, lung (SCC) & haematological malignancies most common cancers associated Associated with poor prognosis
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Mechanisms Tumour secretion of parathyroid hormone related protein (PTHrP) – most common accounting for up to 80% - PTHrP causes increased bone resorption & distal renal tubular calcium reabsorption Osteolytic metastases with local release of cytokines (approx 20% of cases) - Increased bone resorption & release of calcium from the bones Tumour production 1,25- dihydroxyvitamin D - Combination increased intestinal calcium absorption & bone resorption
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Lab Findings Elevated serum PTHrp – levels may predict response to treatment Low/suprssed serum intact PTH Normal to low serum 1,25 dihydroxyvitamin D
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Symptoms Neurological Gastrointestinal Renal Cardiovascular
Lethargy, confusion, coma, muscle weakness Gastrointestinal Constipation, anorexia, nausea Renal Acute kidney injury Cardiovascular Shortened QT interval, arrhythmias
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Treatment Depends on severity of hypercalcaemia
Corrected Ca <3.0 can often be managed conservatively Anything over 3.5 needs treatment Levels in between depend on symptom burden Options: IVF +/- loop diuretics Bisphosphonates Denosumab if refractory to bisphosphonates
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Case – Mr AB 70 year old man Newly diagnosed cancer, presented to chemotherapy unit with rapid onset SOB Feeling pre syncopal Noted to have distension neck veins & facial swelling
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Superior Vena Cava Obstruction
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26/07/2016
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Malignant SVCO Intra thoracic malignancy is responsible for 60-85% of SVCO cases It is the presenting symptom of a previously undiagnosed tumour in up to 60% Lung & NHL account for over 95%
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Management Depends on the underlying malignancy Supportive management
Head raised to decrease hydrostatic pressure Consider anticoagulation Steroids in haematological causes Radiotherapy Chemotherapy
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15/08/2016
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Fluoropyrimidine-Associated Cardiac Toxicity
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Infusional 5-FU or oral Capecitabine (Xeloda)
Lower & upper GI, breast plus head & neck cancer Uncommon but potentially lethal Incidence less than 10% Method of administration Underlying CAD Concurrent RTx Anthracyclines DPD deficiency
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Mechanism – coronary vasospasm
Chest pain most common symptom +/- Trop/CK rise Other symptoms – palpitations, SOB, arrhythmias, hypotension & cardiac arrest Stop drug & investigate for native CAD
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What Next? Rechallenge? Alternative treatments Controversial
Treat underlying CAD Prophylaxis (Aspirin, calcium channel blocker etc) Dose reduction Change treatment schedules Alternative treatments Raltitrexed, UFT (FU prodrug) Less effective
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DPD Deficiency
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Dihydropyrimidine dehydrogenase (DPD), the first of three enzymes in the fluoropyrimidine metabolic pathway, is the rate limiting enzyme in FU catabolism Patients who are partially or totally deficient in DPD activity cannot adequately degrade fluoropyrimidines, leading to an increased risk of severe, sometimes fatal toxicity
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Presentation In patients with even partial DPD deficiency, administration of a fluoropyrimidine can lead to life-threatening complications: Severe diarrhoea Mucositis Pancytopenia Nausea & vomiting Rectal bleeding Volume depletion Skin changes Neurologic abnormalities cerebellar ataxia, cognitive dysfunction altered level of consciousness
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Management Most cases of DPD deficiency are diagnosed only after a severe reaction to FU. Management of these patients should include: aggressive hemodynamic support parenteral nutrition antibiotics hematopoietic colony stimulating factors
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Immunotherapy Side Effects
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Immunotherapy Ipilimumab, Nivolumab & Pembrolizumab (plus others!)
Similar side effect profiles Only on PBS for melanoma BUT multiple clinical trials running in lung, breast, bladder, renal, haematology
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Management Call your friendly medical oncologist Depends on grade
Early involvement of other medical specialities Steroids Oral Prednisone 1-2mg/kg daily IV Methylprednisone 2mg/kg/day Targeted monoclonal Ab
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