Oncologic emergency

Oncologic emergency

1) Space occupying lesion

2) , (paraneoplastic syndrome)

3)
Oncologic emergency
SVC syndrome
Spinal cord compression
Pericardial effusion
Intracranial metastasis
Intestinal obstruction
Urinary obstruction
Hypercalcemia
Tumor lysis syndrome
HUS
Oncologic emergency

1) Space occupying lesion

2) , (paraneoplastic syndrome)

3)
SVC anatomy
SVC syndrome
SVC syndrome
SVC obstruction with severe reduction in
venous return from head, neck, upper
extremities

Etiology
Malignant -90%
Lung ca (SCLC, squ.cell ca) ; 85%
Lymphoma
Metastatic tumor (testicular, breast ca)
Benign
Aortic aneurysm
Thyroid enlargement
Thrombosis
Longterm venous catheters, shunt, pacemaker
SVC syndrome
Clinical manifestation
Dilated neck vein, collat. vein ,
facial edema, cough, headache
Hoarseness, hemoptysis, syncope, lethargy, glossal,
laryngeal edema, dyspnea
The severity of symptom is determined

by the rate of obstruction and the development of collateral

circulation
Diagnosis: a clinical one
X-ray ; Widening of sup. Mediastinum, pleural effusion,
CT ; most accurate
SVC syndrome
SVC syndrome
SVC syndrome
cancer CT cancer

Treatment

Upper airway obstruction ; emergency

Diuretics, low salt diet, O2

RTx ; NSCLC, other metastatic tumor

CTx ; lymphoma, SCLC, germ cell tumor

Self expanding stents

Surgery ; benign process

Mortality caval obstruction underlying cause

collateral
SVC syndrome
Spinal cord compression
Cancer pts 5-10%
Lung, breast, prostate, MM, melanoma, RCC
; Thoracic spine (70%)> LS spine(20%)
> cervical spine(10%)
Clinical manifestation
Localized back pain, tenderness
,
Radicular pain, Lhermites sign, loss of bowel or
bladder control( )

Erosion of pedicle, increased intrapedicular distance,
vertebral destruction, lytic lesion
Spinal cord compression


ambulation

Ambulation 75%
paraplegia 10%

Radiation therapy + glucocorticoid

Surgical intervention
Unknown etiology
Failure of RT
Radio-resistant tumor type(melanoma, RCC)
Vetebral instability Pathologic fracture dislocation
Rapidly evolving neurologic symptom

Rapid onset and quick progression
Pretreatment ambulatory function is the main determinent
of post-teatment gait function
Increased Intracranial Pressure
Cancer pts 25% ; die with intracranial
metastasis
Lung, breast, melanoma
Sx & Sg
Headache, nausea, vomiting, behavioral change,
seizure, visual disturbance, neck stiffness,
neurologic change

Melanoma, germ cell tumor, RCC

high incidence of ICH (intracranial hemorrhage)
Intracranial metastasis
Intracranial metastasis

Treatment
Brain herniation Sx & Sg
Hyperventilation ;
PCO2 30 mmHg
head elevation, fluid restriction, and hypertonic saline
with diuretics
Mannitol, dexamethasone
brain RTx

Radioresistant tumor
Surgical resection if possible

Gamma knife
Neoplastic meningitis
3-8% of pts with cancer
Melanoma, breast, lung ca, lymphoma, acute leukemia

Dx
CSF analysis
Malignant cell , protein
3
MRI ; nodular enhance of meninges

Tx

Intrathecal MTX, ara-C

Acute leukemia, lymphoma ; systemic CTx

Px ; median survival (10-12 weeks)

Seizure
Cause
Metastatic disease (TMC)
Metabolic disturbance
Radiation injury
Cerebral infarction
Chemotherapy

High risk
Frontal lesion
Hemispheric Sx
Metastasis from melanoma
Malignant pleural effusion
Not strictly an emergency
Usually exudate
Management
Tailored to patients symtom
Chemical pleurodesis
VATS with pleurectomy
Pleuroperitoneal shunt
Chronic indwelling catheter
Pericardial effusion

Associated cancer
Lung, breast, leukemia, lymphoma
Cancer pt PE ; 50% (-)
Irradiation, drug, hypothyroidism, infection,
autoimmune disease
Symptoms
Dyspnea, cough, chest pain, orthopnea,
Jugular venous distension, hepatomegaly,
Paradoxical pulse,
Pericardial effusion
Pericardial effusion
Pericardial effusion
Treatment
Pericardiocentesis
pericardial window
cardiac RTx, systemic CTx
Intestinal obstruction
Etiology
colorectal,ovarian,lung,breast,melanoma
25% ; benign cause

P/Ex
Abdo. distension, ascites, high pitched bowel
sound, palpable tumor mass
Intestinal obstruction
Dx
Multiple air fluid level, dilation of small or large
bowel
Acute cecal dilation ; 12 cm-> surgical emergency

Tx
Surgery ; 20% mortality
Self expanding metal stent
Supportive care
Nasogastric decompression, octreotide

Median survival ; 3-4 mo

Urinary obstruction
Prostatic, cervical ca or metastatic ds
-> bladder outlet obstruction
-> bilat. hydronephrosis
Cancer with flank pain, persistent urinary
tract infection, proteinuria, hematuria, ;
ureteral obstruction -> U/S

Tx
Flank pain, sepsis, fistula ; immediate urinary

diversion
Urinary obstruction
Intracerebral leukocytosis
Fatal Cx of acute leukemia, esp. AML
WBC 10 /uL
-> blood viscosity , endothelial
invasion by leukemic blast
-> ICH
-> stupor, dizziness, visual
disturbance, ataxia, coma

600 cGy whole brain radiation ; protect Cx

Oncologic emergency

1) Space occupying lesion

2) , (paraneoplastic
syndrome)

3)
Hypercalcemia
10% of advanced ca
Lung, breast, head and neck, kidney, MM,
lymphoma
PTH realted peptide by tumor cell ; Central
role as mediator of hypercalcemia
Clinical manifestation
Fatigue, anorexia, constipation, polydipsia, nausea,
vomiting
Treatment
Intravenous saline, diuretics, steroid
Bisphosphonate (pamidronate)
Calcitonin
SIADH
Production of vasopressin by tumor cell
Lab. characteristics
Hyponatremia
High urine osm higher than plasma osm
High urine Na excretion
Renal, adrenal, thyroid insufficiency ; must be
excluded
Low serum uric acid

Cause
SCLC, CNS, pulmonary disease,
drug(vincristine, cyclophosphamide, cisplatin,
melphalan, ACE inhibitor)
SIADH
Clinical manifestation
Anorexia, depression, lethargy, confusion,
muscle weakness
Areflexia, pseudobulbar palsy, coma, seizure

Tx
Water restriction
Normal saline infusion and furosemide
Demeclocycline, lithium ; inhibit effect of
vasopressin
Hypoglycemia
Associated condition
Pancreatic islet cell tumor, hepatoma,
adrenocortical tumor,
Liver metastaisis and increased glucose
consumption
Tumor overproduction of insulin like growth factor

Tx
Underlying tumor treatment
Glucose infusion, glucagon, steroid
Oncologic emergency

1) Space occupying lesion

2) , (paraneoplastic syndrome)

3)
Tumor lysis
Tumor lysissyndrome
syndrome
Cause
Destruction of large number of rapidly proliferating
neoplastic cell
Burkitt lymphoma, ALL, other high grade lymphoma
1-5 , spontaneous
necrosis

Lab characteristics
Cell death leads to the release of K, P, uric acid
Overwhelming kidney capacity for clearance
Hyperuricemia -> renal tubule -> ARF
Hyperkalemia
Hyperphosphatemia ; release of intracellular phosphate pool-
> deposition of calcium phosphate -> ARF
2nd Hypocalcemia
lactic acidosis
Tumor lysis tumor burden renal
function .
Uric acid, LDH: total tumor burden Tumor
lysis syndrome

: TLS risk
1.Hydration
2.Urine
alkalization
3.Allopurinol
Hemolytic uremic syndrome
HUS, TTP
Drug ; mitomycin C (TMC), cisplatin,
bleomycin, gemcitabine
tumor ;Gastric, colorectal, breast

HUS
CTx 4-8

; MAHA, thrombocytopenia, renal failure

Cl/m
Dyspnea, fatigue, oliguria, purpura, hypertension,
pulmonary edema
Hemolytic uremic syndrome
Lab finding
Schistocyte, reticulocytosis, plasma haptoglobin
, LDH
Bilirubin ;
Coombs test ;
Normal coagulation profiles ; PT, aPTT
WBC ; , PLT ;
Serum creatinine ;
UA ; hematuria, proteinuria
MAHA

schistocyte
Hemolytic uremic syndrome
Pathogenesis
Renal endothelial damage
Depostion of fibrin in the wall of capillary and
arteriole
Mainly kidney

Tx
ARF ; Supportive care, Dialysis
Plasmapheresis and plasma exchange