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Acute Oncology Presentations Caused by Disease
Dr Omar DinConsultant Clinical Oncologist
Weston Park HospitalAcute Oncology Study Day
9th October 2013
Types of Emergency
Biochemical Hypercalcaemia
Hyponatraemia (SIADH)
Biochemical Hypercalcaemia
Hyponatraemia (SIADH)
Obstructive/structural SVCO
Raised ICPPathological fracture
Spinal Cord CompressionAirway ObstructionPericardial Effusion
Pleural effusionAscites
Obstructive/structural SVCO
Raised ICPPathological fracture
Spinal Cord CompressionAirway ObstructionPericardial Effusion
Pleural effusionAscites
Treatment RelatedFebrile neutropenia
Tumour Lysis SyndromeExtravasation
DiarrhoeaNausea/vomiting
Treatment RelatedFebrile neutropenia
Tumour Lysis SyndromeExtravasation
DiarrhoeaNausea/vomiting
Malignant Hypercalcaemia
• Ca >2.6 mmol/l• Causes:– Bone metastases– PTH-RP: – breast, renal, lung, head and neck,
myeloma, lymphoma– (Primary Hyperparathyroidism)
Hypercalcaemia - Symptoms
• Constipation• Fatigue• Nausea/vomiting• Confusion• Polyuria• Polydipsia• Abdominal pain• Dehydration
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
• 9am Cortisol 500• TSH 2.1• Glucose 4.5• Lipids normal• Serum osmolality 260• Urine osmolality 368• Urine Na 98
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
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
SIADH - treatment• Ensure Addison’s and Thyroid disease excluded
(cortisol, TSH)• Fluid restriction 1l in 24 hours, daily U&E• Demeclocycline 600-1200mg/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
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
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
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
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
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)
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
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
Pathological Fracture
• Orthopaedic opinion – stabilisation/reamings/biopsy
• Post operative radiotherapy – 20Gy in 5 fractions
• Mirel’s Risk1 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% risk9=33% risk>9=High risk
Case 4
• Treated with sunitinib• Shortly afterwards developed reduced visual
acuity• Seen by opthalmology• Urgent phone call
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
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
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
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
Lymphangitis Carcinomatosa
• Treatment of underlying condition• Dexamethasone• Chemotherapy• Endocrine Therapy• Prognosis poor – 50% die within 3 months of
first symptom