1. Oncological Emergencies
Dr Lauren Bradbury
Medical Oncologist
21st December 2016

2. 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

3. Spinal Cord Compression

4. 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

5. Investigation & Management
Start DEX!!!
Analgesia
Imaging options
Radiotherapy vs. surgery
Systemic cancer treatment

6. Hypercalcaemia of Malignancy

7. Hypercalcaemia Common problem – occurs in 20-30% of patients
Breast, lung (SCC) & haematological malignancies most common cancers associated
Associated with poor prognosis

8. 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

9. Lab Findings
Elevated serum PTHrp – levels may predict response to treatment
Low/suprssed serum intact PTH
Normal to low serum 1,25 dihydroxyvitamin D

10. Symptoms Neurological Gastrointestinal Renal Cardiovascular
Lethargy, confusion, coma, muscle weakness
Gastrointestinal
Constipation, anorexia, nausea
Renal
Acute kidney injury
Cardiovascular
Shortened QT interval, arrhythmias

11. 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

12. 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

13. Superior Vena Cava Obstruction

14. 26/07/2016

15. 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%

16. Management Depends on the underlying malignancy Supportive management
Head raised to decrease hydrostatic pressure
Consider anticoagulation
Steroids in haematological causes
Radiotherapy
Chemotherapy

17. 15/08/2016

18. Fluoropyrimidine-Associated Cardiac Toxicity

19. 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

20. 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

21. 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

22. DPD Deficiency

23. 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

24. 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

25. 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

26. Immunotherapy Side Effects

27. 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

30. 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