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

2. 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

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

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

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

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

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

9. 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

10. Bloods
Hb 10.1
Na 118
K 4.2
Urea 4.0
Creat 60

11. 9am Cortisol 500
TSH 2.1
Glucose 4.5
Lipids normal
Serum osmolality 260
Urine osmolality 368
Urine Na 98

12. 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

13. 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

15. SIADH - treatment
Ensure Addison’s and Thyroid disease excluded (cortisol, TSH)
Fluid restriction 1l in 24 hours, daily U&E
Demeclocycline mg/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

17. 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

20. 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

21. 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

22. 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

23. 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)

24. Case 4
64 year old man
Haematuria
PS 0
No PMH

25. 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

27. 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

28. 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

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

30. 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

31. 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

33. Case 6

34. 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

35. Case 7

36. 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

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

38. The End