2. Oncological Emergencies
May be presenting feature of cancer
Can occur in patients with curable disease or
those suitable for long term palliation
Most emergencies are similar in presentation
and management to “standard” medical
emergencies
However they may be complicated by side
effects of chemotherapy (e.g. renal/liver/bone
marrow impairment)
4. 51 year old women
6 month history of stage III ovarian cancer
Day 10 cycle 2 of carboplatin / taxol chemotherapy
2 days previously commenced on salbutamol inhaler
by GP for wheeze
Now has:
• Pleuritic right chest pain
• Dry cough
• Shortness of breath when walking
5. On Examination
Centrally cyanosed
Distressed by pain on deep breathing
Temperature : 37.5 oC
Pulse rate : 120 bpm
Respiratory rate : 25 per min.
Blood Pressure : 110/65 mmHg
No leg swelling
6. On Examination
JVP : Elevated 3cms
Heart sounds : Gallop rhythm
“Creaking noise” at right lung base
Mild wheeze bilaterally
No crepitations
Breath sounds vesicular
14. Management
Oxygen: 100%
Commence Low Molecular Weight Heparin (e.g.
Enoxaparin)
Consider either:
• Commencing warfarin after 24 hours
Or
• Long term LMWH
If haemodynamically unstable then thrombolysis via
pulmonary arterial catheter
15. Summary – Pulmonary Embolism
• Cancer patients are more prone to PE as they can be in a
HYPERCOAGULABLE state. This can be due to cancer related blood
constituent changes or pressure on vessel walls causing stasis/altered
blood flow
• Active cancer is on the WELLS score criteria for DVT
• Symptoms:
– SOB
– Pleuritic chest pain
– Dry cough
– May have calf pain/swelling
• Signs
– Raised JVP
– Tachycardia and tachypnoea, S1Q3T3
– “gallop rhythm” – high output states
– Peripheral/central cyanosis
– Vesicular breath sounds in most areas
16. Summary – Pulmonary Embolism
• Investigations
– ABG: decreased PaO2, decreased PaCO2 (due to reduced ventilation), can cause
respiratory alkalosis
– ECG: right heart strain S1Q3T3. rule out MI
– D-dimer: raised (non-specific)
– CTPA/VQA scan: identify non-perfused part of lung
– CXR: wedge infarct
• Treatment:
– Oxygen therapy
– Enoxaparin 1.5mg/kg/day
– Consider starting warfarin for 6m
– Analgesia: NSAIDs
– ENOXAPARIN works best for cancer patients
21. Case: 62 Year old man
Locally advanced prostatic carcinoma 4 years
previously – treated with radiotherapy and hormones
Relapsed disease 1 year ago now receiving combined
anti-androgen (Bicalutamide) and LHRH agonist
(Goserelin) treatment for elevated PSA
Over past 4 days:
• Increasing back pain and falls at home
• Constipation and urinary retention for 3 days
• Commenced on MST 30mg b.d by GP
22. On Examination
Orientated but distressed by pain
Tone in legs: ↓
Power in legs: 4/5 bilaterally
Sensation: ↓ in saddle area
Anal tone: ↓
Reflexes : ↓ bilaterally
Plantars: equivocal
25. Management
Bed rest
Catheterise
Dexamethasone 8 mg
b.d. intravenously/orally
Consider urgent surgical
decompression or
radiotherapy
Analgesia : NSAID +/-
opioid
Consider Ranitidine or a
proton pump inhibitor
(omeprazole) for gastro-
protection, especially if
NSAID used
26. Subsequent results
Patient had Emergency Radiotherapy – 20Gy in 5
fractions over 5 days
Prostatic specific antigen (PSA): 100u/ml
Isotope bone scan: multiple hot spots throughout
skeleton
Later received I.V. Samarium for analgesic
purposes
29. MSCC: Refer for surgery if…
Survival likely to be over 3
months
Unknown primary requiring
tissue diagnosis
Previous radiotherapy to
spine
Bone fragment compressing
spinal cord
Single site of compression
and no systemic disease
30.
31.
32. Summary – Spinal cord compression
• Bone involvement from cancer LBTKP
– Commonly: lung, breast, lung, myeloma, lymphoma
– Less common: thyroid, kidney, bladder, bowel, melanoma
• Can be initial presentation of malignancy: prostate, breast,
myeloma
• Crush fracture or tumour extension common
• Occasional intramedullary METS
• 66% cases: thoracic cord
• Symptoms:
– Back pain: within a nerve root, worse on coughing/straining
– Saddle anaesthesia
– Urinary retention/dribbling/incontinence – late
– Constipation/dribbling/incontinence of faeces – late
– Loss of power and sensation distal to area of obstruction
– Limb weakness/unsteadiness when walking
– Brisk reflexes early, absent reflexes late
33. • Signs:
– Reduced tone in legs
– Reduced reflexes late. Brisk early.
– Decreased power and sensation
– Reduced anal tone
– Upgoing plantars (late)
• Investigations
– MRI whole spine
– Bone scan (radioisotope)
– If no Hx of malignancy, investigate for malignancy – CT chest/abd/pelvis
• Management
– Bed rest and catheter
– DEXAMETHASONE 8MG BD IV/PO
– Analgesia
– Surgery or radiotherapy to METS (20Gy in 5fractions over 5days)
• Indications for surgery: survival likely >3m, single site compression, no systemic
disease, previous radiotherapy to spine, unknown 1o requiring Dx, bone
fragment compressing cord, no response to steroids, no cancer
Summary – Spinal cord compression
34. Cauda Equina Syndrome
• Tumours below L1/L2 level
• Symptoms:
– Bilateral sciatic pain
– Bladder dysfunction (retention/incontinence)
– Impotence
– Saddle anaesthesia
– Loss of anal sphincter tone – MUST DO PR EXAM!!!
– Weakness and wasting of gluteal muscles
• Diagnosis by MRI spine
• Rx: dexamethasone 8mg IV BD, RT, Sx
36. 25 year old man
History of testicular teratoma
Currently day 14 cycle 2 of BEP chemotherapy
2 day history of sore throat
Admitted with history of collapse at home; found by
parents unrousable
37. On examination
Drowsy, incoherent
Cold peripheries
Temperature: 36 oC
Pulse: 134 bpm low volume
Blood pressure: 75/35 mmHg
Hickman line in situ
Chest: clear
Abdominal examination: normal
38. Immediate management
Oxygen by mask
Get peripheral intravenous access: take blood for :
FBP/U+E/Bacterial culture/GP and hold
Commence intravenous fluids eg colloid/crystalloid
Cultures from : Hickman line, urine, throat, diarrhoea if
present
Monitor urinary output by catheter (keep >30mls/hr)
Commence broad spectrum antibiotics
39. Continued management
FBP :
Hb : 10.1g/dl
(12-18)
WCC : 0.4 x109/l
(4.0-10.0)
Plts : 113x109/l
(150-450)
ANC: 0.1 X 109/l
(2.0-7.5)
U+E :
Na : 134mmol/l
(135-145)
K : 3.5mmol/l
(3.5-5.0)
Urea: 13.7mmol/l
(3.3-8.8)
Creat: 167mmol/l
(40-110)
Blood cultures: E Coli
Urine Culture: E Coli
40. Continued management
Continue with broad spectrum antibiotics, with an
aminoglycoside included
• (BCH policy TAZOCIN and Gentamicin)
Commence Granulocyte Colony Stimulating Factor
(GCSF) to raise neutrophil count over 1.5x109/l
• E.g. Filgrastim (Neulasta®) 30 million units s.c. daily
Prophylactic GCSF next cycle of treatment
41. Result
Recovered fully from infection
Further 2 cycles of BEP uneventful
Now disease free for 3 years and well
42. Summary – Neutropenic Sepsis
• Chemotherapy can cause bone marrow suppression, leading to pancytopenia.
The reduction in WCC (neutropenia) leaves the patient at risk of developing
infections. This can quickly lead to sepsis and septic shock
• Cannot judge sepsis by temperature!!!
• Symptoms and Signs:
– Drowsy, decreased level of consciousness, confusion
– Cold peripheries
– Tachycardia
– Hypotension
– May be signs of infection e.g. cough in chest infection
• Investigations:
– Cultures: blood, urine, throat, current lines (hickmans, catheter)
– Venous access, IV fluids: colloids
– Catheter to monitor urinary output
– Oxygen
– IV Abx in accordance with hospital guidelines
– Granulocyte Colony Stimulating Factor (CGSF) if haemodynamically unstable/slow
response
– Give GCSF prophylactically with next dose of chemo
48. Case: 54 year old female
1 year ago treated for non-small cell lung
cancer right side
Pneumonectomy and Radiotherapy to
right lung field
Well until 7 days ago
49. Symptoms
7 day history of general aches :
commenced on MST 20mg bd by GP
5 day history of thirst, polyuria and
constipation
4 day history of confusion
51. Lab tests and investigations
U+E
Na 154mmol/l
(135-145)
K+: 6.0 mmol/l
(3.5-5.0)
Ca 3.0mmol/l
(2.10-2.60)
Alb 18g/dl
(40)
FBP
normal
Glucose: 3.3mmol/l
Urine specific gravity:
1.050
ECG: Decreased QT
interval.
52. Management
Immediate rehydration 4-6 litres N.saline
over 24 hours
Ensure urinary output>30ml/hr
After 24 hours give intravenous
bisphosphonate:
• eg Zolendronic Acid (ZOMETA®) 4mg
53. Further Investigations
CXR : mass right hilum
Isotope bone scan: no bone mets
CT scan : mass right hilum, new liver
metastases
54. Outcome
Not fit enough for chemotherapy
Cared for at home by hospice homecare
Managed with regular oral bisphosphonates,
non steroidal anti-inflammatories and MST
20mg b.d
Died at home 2 months later
55. Hypercalcaemia of Malignancy
Particular Association with:
• Breast cancer
• lung cancer (especially non-small cell)
• multiple myeloma
• prostatic cancer
Affects 20-40% of all patients with advanced cancer
3 Mechanisms:
1. Parathyroid hormone-related protein
2. Local osteolysis due to bone metastases.
3. Tumour production of Vitamin D metabolites.
Barri Y et al. Hematol Oncol Clin North Am, 10(4):775-90
56.
57.
58.
59.
60. Summary – Hypercalcaemia
• Common malignancy related causes:
– Parathyroid hormone related protein
– Local osteolysis due to bony metastasis
– Tumour producing Vitamin D metabolites
• Commonly seen with BREAST, LUNG (nonsmallcell), multiple myeloma and prostate
• Affects 20-40% pts with advanced cancer
• Signs and Symptoms:
– Bones: bone pain, pathological fractures
– Stones: polyuria, polydipsia, kidney stones
– Moans: confusion, depression, decreased level of consciousness/coma
– Groans: constipation, pancreatitis, epigastric pain
• Investigations:
– U&E: Na and K raised due to dehydration, calcium RAISED >2.6
– Cause unknown: CTCAP, CXR,
– ECG: decreased QT interval
• Management
– 4-6l saline over 24hrs
– IV bisphosphonates e.g. zolendrenic acid
– Catheter to monitor urine output
61. Corrected Calcium
• Corrected calcium is calculated from the
measured calcium. Calcium is bound to albumin
so the amount of measured calcium depends on
the level of albumin. Corrected calcium estimates
the calcium level if the albumin was within the
normal range.
• Corrected calcium = measured calcium + (40-Alb)
x 0.02
• E.g. Ca 3.46, Albumin 28
– Corrected calcium = 3.46 + (40-28) x 0.02 = 3.46 + 0.24
= 3.7 mmol/l.
65. • Treatment
– Steroids
– Crainotomy – primary
– Whole Brain Irradiation – 3000 r – 2 weeks
– Meningeal – MTX or ARA C IT
Increased Intracranial Pressure
66. Case: 45 year old women
History of T2 N1 M0 grade 3 ER+ve breast
cancer 4 years ago
Post-surgically had 6 cycles of FEC “100”
chemotherapy followed by oral tamoxifen
20mg daily
Still taking tamoxifen
Unwell for past 2 weeks
67. Symptoms
2 week history of irritability
Persistent nausea and vomiting
2 falls at home
No weakness, no double vision, no
headaches
68. On Examination
Bad tempered (not in keeping with previous
character)
Apyrexic
No obvious central neurological abnormalities
Peripherally : ? Upgoing left plantar
BP : 160/110mmhg, pulse 45bpm
71. Immediate management
Dexamethasone 8mg bd intravenously/orally
Arrange cranial radiotherapy
Anti-epileptic drugs if required to control
seizures: eg carbamazepine
Advise not to drive, patient required to
inform DVLA(N.I.)
73. Outcome
Improved overnight on dexamethasone
Given radiotherapy over one week (20 Gray in 5
fractions)
CT scan: multiple lung and liver mets
Bone scan : multiple bone mets
Managed with MST, reducing dose of steroids and
bisphosphonates until death 3 months later
74. Brain Metastases
20-40% of patients with advanced cancer
Tenfold more common than brain primary
Overall survival 6 months
Most often associated with:
• Lung cancer
• Breast Cancer
• Melanoma
But increasing with other cancers!
Patchell RA. Cancer Investigation 1996;14:169-77
75. Neurosurgical Intervention
Indications:
1. Solitary brain metastasis and controlled systemic
disease, especially renal cell cancer, teratoma or
sarcoma
2. Unknown diagnosis (Solitary Brain lesion). May
not be cancer
3. Rapidly deteriorating condition
4. Hydrocephalus (shunting)
76. Summary – Raised ICP/Brain Mets
• Raised ICP: space-occupying lesion, hydrocephalus, benign intra-cranial HTN
• Brain M increasing in prevalence since people are surviving longer with cancer
• 20-40% pts with advanced disease:
• Particularly LUNG, BREAST, MELANOMA
• Symptoms:
– Headaches- worse in the morning and on stooping
– N&V – worse in morning
– Confusion, altered behaviour
– Focal neurological signs
– Seizures
• Investigations
– CT brain
• Management
– DEXAMETHASONE 8MG BD IV/PO: shrink mass/inflammation to reduce risk of coning
– whole brain radiotherapy if 2+ METS
– Anti-epileptics for seizures: carbamazepine
– ***can’t drive ever again OSCE!!!!!!!!!!!
– Surgery: solitary met with controlled systemic disease, unknown diagnosis need sample,
rapid deterioration, hydrocephalus (shunting)
78. 26 year old man
Receiving CHOP chemotherapy for stage
IIIA non-Hodgkins lymphoma
Currently day 15, cycle 3 of treatment
Admitted with severe epistaxis
79. On Examination
Obvious nose bleed, left side
Temperature: 36oc
BP : 120/55mmHg
Multiple petechiae over trunk and limbs
83. Management
6 donor platelets immediately, aim to raise platelet
count over 10x109/l. (over 20 if uraemic or infected)
Transfuse 2 units packed red cells, aim to raise Hb
over 10g/dl
If required cauterise nose
If DIC : correct coagulation abnormality with fresh
frozen plasma and treat underlying cause
84. Outcome
Bleeding stopped with platelet transfusion
Received 6 cycles of CHOP in total
Now 5 years from treatment. Well, no
evidence of recurrent disease
85. Summary – Chemo Thrombocytopenia
• Bone marrow suppression leads to thrombocytopenia, leucopenia and anaemia
• Signs & Symptoms
– Increased tendency to bleed, difficult to stop
– Petechiae
– Large haemorrhage hypovolaemic shock
• Investigations
– FBC
– Coag screen
– D-dimer: raised may indicate DIC
• Management
– Give platelets until above 10, 20 if septic
– May need packed red cells if haemorrhage
– If DIC: fresh frozen plasma required
• DIC occurs when the coagulation and fibrinolysis systems are dysregulated. This
can commonly occur in lung, pancreas, stomach and prostate cancer, as well as
APL. Many small clots form and are subsequently broken down. This process
leads to the consumption of clotting factors and platelets leading to increased
risk of bleeding.
86. Bone Marrow Suppression
• Major dose limiting factor in chemotherapy
• RBC survive 120days, platelets 8days, neutrophils 1-2days so early
problems are neutropenia and thrombocytopenia
• Neutropenia particularly if line/catheter in/previous infection/open
wound…
• Management of neutropenic pt:
– Blood cultures (peripheral and central if line in)
– Sputum culture
– Urine analysis and culture
– CXR
– Physical exam, swabs
• Treatment:
– Wide spectrum Abx e.g. IV tazocin
• Low Hb: consider packed cells, investigate cause, rule out DIC
87. Lines
• Hickman:
– under clavicle
– Tunnel catheter
– Into subclavian vein, down to superior vena cava
• PICC:
– Peripherally inserted central catheter
90. • Acute or sub-acute
• Increased venous pressure
• Facial oedema, plethora
• Dilation of veins on chest wall and neck
• Development of collateral veins
• Moderate to severe resp distress
• Conjunctival oedema
92. SVC Syndrome
• Diagnosis
– Chest X-ray – right sided mediastinal mass
– Radionucleotide SVC gram
– Tissue Diagnosis – may have to wait
• Therapy
– X-ray therapy – high dose
– Steroids
– Chemotherapy
93.
94.
95. • T Cell Leukaemia / Lymphoma
• Kaposi Sarcoma
96.
97.
98.
99.
100. Case: 67 year old man
History of stage IV non small cell lung
cancer currently receiving Gemcitabine/
Carboplatin chemotherapy
2 day history of headache (worse when
stooping) and “puffy hands”
106. Investigation
CXR: widening of the upper mediastinum
Venogram: Extrinsic compression of SVC
CT scan with contrast: dilated collateral
veins. Mass in right upper mediastinum
(investigation of choice)
107. Management
28% Oxygen via mask
Dexamethasone 8mg i.v. b.d
Arrange urgent stenting if diagnosis is NSCLC
Consider Radiotherapy
Urgent chemotx rather than XRT if chemosensitive
tumour
108. Outcome
Had urgent stenting and good symptomatic
relief
Followed by radiotherapy to mediastum
and primary tumour site
Chemotherapy discontinued as disease
progression on treatment
Lived a further 5 months before dying of a
right lower lobar pneumonia
109. SVC Obstruction
Caused by:
1. Extrinsic compression due to tumour or
nodes (90%) – breast cancer, lung
cancer (right upper lobe), lymphoma,
thymoma
2. Thrombus (10%) – central line, pacing
wire.
110. Management options
SVC Stenting if NSCLC or previous XRT
Radiotherapy
Urgent chemotherapy if chemosensitive
tumour
Thrombolysis and anticoagulation if due to
clot
Arke YS. Seminars in Oncology 2000;27:262-74
111.
112. Summary – SVC obstruction
• Obstruction of the SVC occurs commonly with lung tumours and lymphomas
which can press on SVC (right sided tumours)
• Signs & Symptoms
– Raised JVP
– Puffy face and arms
– Dilated veins on chest wall
– Plethoric face
– Headache (worse on stooping), visual disturbance (papilloedema)
• Investigations
– CXR: widened mediastinum/lung tumour
– SVC venogram
– CT with contrast
• Management
– Oxygen
– Dexamethasone 8mg BD
– Stent/radiotherapy/chemotherapy as appropriate
• External compression: breast cancer, lung cancers, lymphoma, thymoma 90%
• Internal thrombosis: central line, pacing wire 10%
• DDx: heart failure, tamponade, external jugular vein compression
113. Stridor
• Benign or malignant causes:
– Non-malignant: foreign body, tracheal stenosis, vocal palsy
– Malignant: primary respiratory tract tumours, bronchial (carina) tumours/ thyroid,
mediastinal lymphadenopathy or MET
• Signs and Symptoms
– Goitre
– Weight loss
– Clubbing
• Investigations
– CXR: widening of mediastinum, 1o lung cancer
– Bronchoscopy: biopsy/cytology
– CT scan
– Mediastinoscopy
• Treatment:
– Dexamethasone 8mg IV BD
– Tumour debulking: radio/surgery
116. Tumor Lysis Syndrome
• An oncologic emergency caused by very
sudden and rapid tumour cell death in which
the intracellular contents are released causing
metabolic abnormalities and acute kidney
injury
• May occur spontaneously, or with the
initiation of chemotherapy
117. Tumor Lysis Syndrome
• Mechanism
– Rapid necrosis of tumour cells
– Release of massive intracellular material into the
circulation - metabolic load
– Ascites
– Renal impairment
– Arrhythmias
118. Patient’s at risk of TLS
• Tumours with rapid rate of growth / high cell
turnover - high LDH
• High bulk of malignant disease - high tumour
burden, widespread mets, bm involvement
• Advanced stage of disease
• Renal impairment at time of diagnosis
• Laboratory evidence of tumour lysis syndrome
