Oncologic EmergenciesOncologic Emergencies

Noel Rowan, MD, FACPNoel Rowan, MD, FACP

Comprehensive Cancer Comprehensive Cancer CenterCenter

Las Vegas, NevadaLas Vegas, Nevadacccnevada.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

Oncologic EmergenciesOncologic Emergencies

Metabolic EmergenciesMetabolic EmergenciesHyperuricemiaHyperuricemiaHypercalcaemiaHypercalcaemiaHypoglycemiaHypoglycemiaLactic AcidosisLactic AcidosisTumor Lysis SyndromeTumor Lysis Syndrome

Orthopedic EmergenciesOrthopedic EmergenciesPathologic FracturePathologic Fracture

Oncologic EmergenciesOncologic Emergencies

WaldenstromsWaldenstroms Hyperviscosity SyndromeHyperviscosity Syndrome PlasmaphoresisPlasmaphoresis

                                                                                                     

Oncologic EmergenciesOncologic Emergencies

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 Decreased CO because of decreased venous

returnreturn SymptomsSymptoms

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

Pericardial TamponadePericardial Tamponade

DiagnosisDiagnosisEnlarged 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 Cyanosis – speed determines collateral pattern

on chest wallon chest wall

SVC SyndromeSVC Syndrome

DiagnosisDiagnosisChest X-ray – right sided mediastinal Chest X-ray – right sided mediastinal

massmassRadionucleotide 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 Whole Brain Irradiation – 3000 r – 2

weeksweeksMeningeal – 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 Paraplegia – bowel and bladder

dysfunctiondysfunction12 – 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 Following initial therapy of sensitive

tumors – gout – renal tubular damage tumors – gout – renal tubular damage and acute renal failureand acute renal failure

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

HyperuricemiaHyperuricemia

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

days before treatment and continue for days before treatment and continue for 2 weeks after treatment2 weeks after 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 Serum Calcium level - correct for

albuminalbuminTherapyTherapy

Hydration - salineHydration - salineDiuresis - LasixDiuresis - LasixMithramycinMithramycinSteroidsSteroids

Tumor Lysis SyndromeTumor Lysis Syndrome

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

into the circulation -- metabolic loadinto the circulation -- metabolic loadAscitiesAscitiesRenal impairmentRenal impairmentArrhythmiasArrhythmias

Tumor Lysis SyndromeTumor Lysis Syndrome

DiagnosisDiagnosisPotassium increasedPotassium increasedPhosphate increasedPhosphate increasedCalcium decreasedCalcium decreasedUric Acid increasedUric Acid increasedAcidosisAcidosisAzotemiaAzotemia

Tumor Lysis SyndromeTumor Lysis Syndrome

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

Mucositis/EsophagitisMucositis/Esophagitis

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

3 days before and after chemo3 days before 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

Mucositis/EsophagitisMucositis/Esophagitis

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

New DrugsNew DrugsNew ComplicationsNew Complications

Acniform RashAcniform Rash

New DrugsNew DrugsNew ComplicationsNew Complications