onc emergencies

Oncologic EmergenciesOncologic EmergenciesNoel Rowan, MD, FACPNoel Rowan, MD, FACP

Comprehensive Cancer CenterComprehensive Cancer CenterLas Vegas, NevadaLas Vegas, Nevada

cccnevada.comcccnevada.com

Oncologic EmergenciesOncologic Emergencies CardiovascularCardiovascular

Pericardial TamponadePericardial Tamponade Superior Vena Cava SyndromeSuperior Vena Cava Syndrome

Central Nervous System EmergenciesCentral Nervous System Emergencies Increased Intracranial PressureIncreased Intracranial Pressure Spinal Cord CompressionSpinal Cord Compression

GastrointestinalGastrointestinal Bowel ObstructionBowel Obstruction Bowel PerforationBowel Perforation AscitesAscites Esophageal Obstruction and PerforationEsophageal Obstruction and Perforation

Oncologic EmergenciesOncologic Emergencies

Hematologic EmergenciesHematologic EmergenciesDICDICLeukostasisLeukostasisThrombocytopeniaThrombocytopenia

Infectious EmergenciesInfectious EmergenciesSepsis in the leukopenic patientSepsis in the leukopenic patientDisseminated Viral InfectionsDisseminated Viral InfectionsFungal and Parasitic DiseasesFungal and Parasitic Diseases


Metabolic EmergenciesMetabolic EmergenciesHyperuricemiaHyperuricemiaHypercalcaemiaHypercalcaemiaHypoglycemiaHypoglycemiaLactic AcidosisLactic AcidosisTumor Lysis SyndromeTumor Lysis Syndrome

Orthopedic EmergenciesOrthopedic EmergenciesPathologic FracturePathologic Fracture

Oncologic EmergenciesOncologic Emergencies WaldenstromsWaldenstroms

Hyperviscosity SyndromeHyperviscosity Syndrome PlasmaphoresisPlasmaphoresis


Renal EmergenciesRenal Emergencies Ureteral Obstruction – Pelvic TumorsUreteral Obstruction – Pelvic Tumors

Respiratory EmergenciesRespiratory Emergencies Airway ObstructionAirway Obstruction PneumothoraxPneumothorax EffusionEffusion

Symptomatic EmergenciesSymptomatic Emergencies PainPain VomitingVomiting MucositisMucositis DyspneaDyspnea

Pericardial TamponadePericardial Tamponade MechanismMechanism

Fluid in pericardial sac due to metastaic tumorFluid in pericardial sac due to metastaic tumor Post X-ray treatment – 4000 rPost X-ray treatment – 4000 r Decreased CO because of decreased venous returnDecreased CO because of decreased venous return

SymptomsSymptoms DyspneaDyspnea ConfusionConfusion ComaComa Distended neck veinsDistended neck veins Pulses ParadoxesPulses Paradoxes CHFCHF

Pericardial TamponadePericardial TamponadeDiagnosisDiagnosis

Enlarged heartEnlarged heartCXR – sac-like heartCXR – sac-like heartEchoEcho

Treatment Treatment PercardiocentesisPercardiocentesisCatheter SFUCatheter SFUX-Ray TherapyX-Ray TherapySurgery – window vs. pericardiectomySurgery – window vs. pericardiectomy

SVC SyndromeSVC Syndrome MechanismMechanism

Masse(s) in chest/mediastinum compress SVCMasse(s) in chest/mediastinum compress SVC LymphomaLymphoma Hodgkin'sHodgkin's LungLung BreastBreast

SymptomsSymptoms Facial EdemaFacial Edema Periorbital EdemaPeriorbital Edema Cyanosis – speed determines collateral pattern on Cyanosis – speed determines collateral pattern on

chest wallchest wall

SVC SyndromeSVC Syndrome

DiagnosisDiagnosisChest X-ray – right sided mediastinal massChest X-ray – right sided mediastinal massRadionucleotide SVC gramRadionucleotide SVC gramTissue Diagnosis – may have to waitTissue Diagnosis – may have to wait

TherapyTherapyX-ray therapy – high doseX-ray therapy – high doseSteroidsSteroidsChemotherapyChemotherapy

Increased Intracranial Increased Intracranial PressurePressure

MechanismMechanism Primary Brain TumorPrimary Brain Tumor Metasitic TumorMetasitic Tumor MeningesMeninges

DiagnosisDiagnosis HeadachesHeadaches Personality ChangesPersonality Changes LethargyLethargy ComaComa PapilledemaPapilledema Stiff neckStiff neck Fixed pupil – tentorial herniationFixed pupil – tentorial herniation CT/MRI of BrainCT/MRI of Brain LP - cellsLP - cells

Increased Intracranial Increased Intracranial Pressure Pressure

TreatmentTreatmentSteroidsSteroidsCrainotomy – primaryCrainotomy – primaryWhole Brain Irradiation – 3000 r – 2 weeksWhole Brain Irradiation – 3000 r – 2 weeksMeningeal – MTX or ARA C ITMeningeal – MTX or ARA C IT

Spinal Cord CompressionSpinal Cord Compression

MechanismMechanismLymphoma – mediastinal or retroperitoneal Lymphoma – mediastinal or retroperitoneal

nodes or mets from vertebral bodiesnodes or mets from vertebral bodiesSymptomsSymptoms

Back Pain – syndrome insidiousBack Pain – syndrome insidiousParaplegia – bowel and bladder dysfunctionParaplegia – bowel and bladder dysfunction12 – 24 hr progression12 – 24 hr progressionPermanent when completedPermanent when completed

Spinal Cord CompressionSpinal Cord Compression

DiagnosisDiagnosisMyleogram or MRIMyleogram or MRI

TreatmentTreatmentSteroidsSteroidsDecompression LaminectomyDecompression LaminectomyChemotherapyChemotherapyX- ray therapyX- ray therapy

HyperuricemiaHyperuricemia

MechanismMechanismFollowing initial therapy of sensitive tumors – Following initial therapy of sensitive tumors –

gout – renal tubular damage and acute renal gout – renal tubular damage and acute renal failurefailure

DiagnosisDiagnosisMonitor serum uric acid levelsMonitor serum uric acid levelsUric acid precipitate stones radiolucentUric acid precipitate stones radiolucent

HyperuricemiaHyperuricemia

TherapyTherapyDiuresisDiuresisAlkalizationAlkalizationDialysisDialysisProphylaxis -- Allopurinol 600 mg daily 2 days Prophylaxis -- Allopurinol 600 mg daily 2 days

before treatment and continue for 2 weeks before treatment and continue for 2 weeks after treatmentafter treatment

HypercalcaemiaHypercalcaemia MechanismMechanism

Mets to bone, breast, lung, renalMets to bone, breast, lung, renal MyelomaMyeloma Ectopic parathyroid hormone productionEctopic parathyroid hormone production

SymptomsSymptoms NauseaNausea VomitingVomiting ConstipationConstipation Urinary frequencyUrinary frequency LethargyLethargy ConfusionConfusion ComaComa DeathDeath

HypercalcaemiaHypercalcaemia

DiagnosisDiagnosisSerum Calcium level - correct for albuminSerum Calcium level - correct for albumin

TherapyTherapyHydration - salineHydration - salineDiuresis - LasixDiuresis - LasixMithramycinMithramycinSteroidsSteroids

Tumor Lysis SyndromeTumor Lysis Syndrome

MechanismMechanismRapid necrosis of tumor cellsRapid necrosis of tumor cellsRelease of massive intracellular material into Release of massive intracellular material into

the circulation -- metabolic loadthe circulation -- metabolic loadAscitiesAscitiesRenal impairmentRenal impairmentArrhythmiasArrhythmias


DiagnosisDiagnosisPotassium increasedPotassium increasedPhosphate increasedPhosphate increasedCalcium decreasedCalcium decreasedUric Acid increasedUric Acid increasedAcidosisAcidosisAzotemiaAzotemia


TreatmentTreatmentCorrect acidosis, potassium, uric acidCorrect acidosis, potassium, uric acidDiuresisDiuresisDialysis if neededDialysis if needed

Prompt treatment can prevent deathPrompt treatment can prevent death

Mucositis/EsophagitisMucositis/Esophagitis

MechanismMechanismRadiation therapyRadiation therapyChemotherapyChemotherapyAntitumor antibioticsAntitumor antibioticsAntimetabolicsAntimetabolics

SymptomsSymptomsPainPainVomitingVomiting


TreatmentTreatmentHydrationHydrationMycostatin/Magic MouthwashMycostatin/Magic MouthwashKepivance (palifermin) 60 mcg/kg/d for 3 days Kepivance (palifermin) 60 mcg/kg/d for 3 days

before and after chemobefore and after chemoGelclair (coating agent)Gelclair (coating agent)Recombinant Keratiocyte Growth FactorRecombinant Keratiocyte Growth Factor

AntibioticsAntibioticsAntiviralsAntiviralsOtherOther

Morphine Patch Morphine Patch TPN/nutritional supportTPN/nutritional support


Avastin (Bevacizumab)Avastin (Bevacizumab)Erbitux (Cetuximab)Erbitux (Cetuximab)Tarceva (Erlotinib)Tarceva (Erlotinib) Iressa (Gefitinib)Iressa (Gefitinib)Gleevec (Imatinib)Gleevec (Imatinib)Rituxan (Retuximab)Rituxan (Retuximab)Others…..Others…..

New DrugsNew DrugsNew ComplicationsNew Complications

AvastinAvastin Abdominal PerforationAbdominal Perforation Wound dehiscence after surgeryWound dehiscence after surgery Stroke riskStroke risk

ErbituxErbitux Acneform Rash 90%! (10% severe)Acneform Rash 90%! (10% severe)

Rituxan (Anti CD-20 antibody)Rituxan (Anti CD-20 antibody) Anaphylactic reactionAnaphylactic reaction

TarcevaTarceva Acneform Rash, pulmonary toxicityAcneform Rash, pulmonary toxicity

IressaIressa Rash, pulmonary toxicityRash, pulmonary toxicity


Acniform RashAcniform Rash


onc emergencies

Art & Photos

pericardial sac

collateral pattern

bladder dysfunction12

retroperitoneal nodes

weeksmeningeal mtx

hr progressionpermanent