Oncologic Emergencies

Douglas Eyolfson, MD, FRCP(C)

Department of Emergency Medicine

University of Manitoba

Objectives

Categories of complications due to cancer

Review selected oncologic emergencies in detail

Diagnostic considerations of oncologic emergencies

Treatment of selected oncologic emergencies

Cancer: Challenges

Patients uncertain of diagnosis/treatments

(Incorrect) assumption of futility

Increasing number of treatable cancers

Increasing survival times

Increasing treatment options

Complications as initial presentation of malignancy

Complications: Categories

Local tumour compression

Biochemical/metabolic derangement

Myelosuppression

Thromboembolic disease

Local Tumour Compression

Acute spinal cord compression

Superior vena cava syndrome

Malignant pericardial effusion

Upper airway obstruction

Biochemical/Metabolic Derangement

Hypercalcemia

Tumour lysis syndrome

Hyperviscosity syndrome

SIADH

Adrenocortical insufficiency

Myelosuppression

Granulocytopenia & sepsis

Immunosuppresssion & opportunistic infections

Thrombocytopenia & hemorrhage

Thromboembolic Disease

Deep venous thrombosis

Pulmonary embolus

SVC syndrome

Acute Spinal Cord Compression

Neoplastic epidural spinal cord compression (ESCC)

Includes cauda equina syndrome

Defn: Any radiologic evidence of thecal sac compression

Severe back pain permanent loss of neurologic function

Diagnosis often delayed

ESCC

Typically metastases to vertebrae (85-90%)Any 10 cancer site

» Lung» Breast» Lymphoma

Varying locations» Thoracic: 60%» Lumbosacral: 30%» Cervical: 10%

20% are initial presentation of malignancy

ESCC: Clinical Features

Pain» 83-95% first symptom» Often precedes neurologic findings by 7 weeks

Motor findings» Present in 60-85% at time of diagnosis» Typically (not 100%) symmetrical

Sensory findings» Sensory typically 1-5 levels below compression

Bladder & bowel dysfunction» Late finding

ESCC: Diagnosis

Any patient with cancer » Back pain

» Neurologic findings

» Bowel/bladder symptoms

Any patient with unexplained back pain or neurologic findings

Any patient with unexplained bowel/bladder symptoms

ESCC: Diagnosis

MRI» Gold standard» Spinal cord, bone soft tissues» Contraindicated with indwelling metal» Requires lying still (sometimes patient unable)

Myelography» Previous prefered modality» Equivalent sensitivity to MRI» Consider if contraindications to MRI

ESCC: Diagnosis

CT» More availability» Low sensitivity, high specificity

X-ray» Limited utility» High predictive value if vertebral collapse or pedicle

erosion corresponding to radiculopathy» Insufficient sensitivity

Bone scan» No information about thecal sac

ESCC: Treatment

Start when diagnosis suspectedGlucocorticoids (Dexamethasone)High dose

» Paraparesis or paraplegia» 96mg bolus, ½ dose q every 3 days

Low dose» Minimal or no neurologic findings» 10 mg bolus, 16 mg daily in divided doses» Taper when definitive treatment underway

ESCC: Treatment

Spine unstable» Changes in pain/findings with position,

subluxation/translation, bilateral facet destruction

» Surgical stabilization + resection

Spine stable» Radiotherapy

Superior Vena Cava Syndrome

Invasion or compression of SVC» Right lung (lung CA 60-85%)

» Lymph nodes (NHL 10%)

» Other mediastinal structures

Thrombus within SVC

SVC Syndrome: Clinical Features

Typically slow progression

Edema to head and neck» Striking, little clinical consequence

Laryngeal compression» Dyspnea, stridor

Increase ICP» Headache, N&V, coma

SVC Syndrome: Diagnosis

CT» Most useful

» Collateral vessels found: Sens. 96%, Spec. 92%

Venography» Most useful if clot is sole etiology

MRI venography» Contrast dye allergy

Early tissue diagnosis essential

SVC Syndrome: Treatment

Rarely immediately life-threatening» Slow progression

Supportive careSteroids

» Lymphoma/thymoma (glucocorticoid-responsive)

DiureticsAnticoagulants

» Thrombus

SVC Syndrome: Definitive Treatment

Highly-dependant on type» Early tissue diagnosis essential

Radiation

Chemotherapy

Endovascular Stent

Hypercalcemia

20-30% of cancer patients» Breast

» Lung

» Multiple myeloma

Malignancy often clinically evident when hypercalcemia found

Associated with poor prognosis

Hypercalcemia: Pathophysiology

Humoral hypercalcemia (80%)» PTHrP» Squamous cell carcinoma (lung, head, neck)» Renal» Bladder» Breast» Ovarian

Osteolysis» Bone metastases (breast)» Multiple myeloma

Hypercalcemia: Clinical Features

Lethargy, weakness» Neuromuscular dysfunction

N&V, anorexia, constipation

Confusion Coma

Dehydration

EKG changes» Shortened QT interval

Hypercalcemia: Treatment

Measure PTH and PTHrP» PTHrP may direct further treatment

Fluid resuscitation» Ensure adequate renal function» Dialysis may be indicated

Diuretics» Furosemide 80mg IV

Steroids not helpful acutely» May be part of later chemotherapy

Tumour Lysis Syndrome (TLS)

Massive Tumour cell lysis

Release large amounts of intracellular substances» K+

» PO4-

» Nucleic acids uric acid

» Hypocalcemia

Arrhythmias

Renal failure

TLS: Setting

Usually post-chemotherapy (3-7 days)

Hematologic malignancies» NHL, ALL, Burkitt’s lymphoma

Solid tumours (rare)» Breast, small cell lung, neuroblastoma,

Spontaneous TLS (rare)» NHL, acute leukemias

TLS: Clinical Presentation

Typically 3-7 days post-chemotherapy

Associated with metabolic abnormalities

N&V, diarrhea, anorexia

Hematuria, oligo/anuria

Cramps, tetany, seizures

CHF, arrhythmias, syncope

Sudden death

TLS: Prevention

Aggressive IV hydration» 200 mg/kg/day

» Monitor renal function/output

Allopurinol/Rasburicase» Prevent formation/promote breakdown of uric acid

Urinary alkalinization not useful

TLS: Treatment

3-5% develop TLS despite preventative measuresAggressive IV fluids

» Resuscitation» Hyperphosphatemia

Hyperkalemia» Ca2+, ventolin, insulin/glucose, Na-polystyrene

DiureticsTreat hypocalcemia only if symptomaticRasburicase

» Hyperuricemia» 0.2mg/kg

TLS: Dialysis

Rarely needed since rasburicase

Severe oliguira or anuria

Persistant hyperkalemia

Hyperphosphatemia-induced sypmptomatic hypocalcemia

Prognosis excellent if instituted early

Hyperviscosity Syndrome

Waldenstrom’s macroglobulinemia» Increased serum proteins

Multiple myeloma/CML» Increase cell concentrations

Increase viscosity > 3 X normal» Sludging

» Reduced microcirculatory perfusion

Hyperviscosity Syndrome: Presentation

Weakness, lethargy, fatigue

Stupour, coma

CHF

Hematology» Rouleau formation on smear

Biochemistry» Laboratory difficulties (serum stasis in analyzers)

Hyperviscosity Syndrome: Treatment

IV fluid resuscitation

Immediate hematology referral

Phlebotomy with RBC replacement» Temporizing measure

Plasmapheresis

Immunosuppression in Cancer

Cachexia & malnutritionGranulocytopeniaImpaired antibody production

» CLL, multiple myeloma

Impaired cellular immunity» Lymphoma

Steroid useChemotherapy

Sepsis in Cancer: Presentation

Often nonspecific» Impaired febrile response

» Impaired localization of infections

» Neutropenia/impaired WBC shift

Weakness, lethargy Altered LOC Hemodynamic instability

Sepsis in Cancer: Diagnosis

High index of suspicion» Cancer/chemotherapy» Fever» Hemodynamic compromise (beware tachycardia)

Early full septic workup» Blood/urine culture» Chest X-ray» + LP (don’t delay antibiotics)» VBG, lactate, etc.

Cardioresp/hemodynamic monitoring» Include foley

Sepsis in Cancer: Treatment

Early broad-spectrum antibiotics» Pip/Tazo

» Ceftazidime

Aggressive IV fluids» Pressors if required

Frequent reassessment» I & O

» Frequent labs

Conclusions

Presentations of cancer and complications increasing

Complications may be first presentation of cancer

Complications often life-threatening

Survivability increasing

Vigilance and aggressive treatments required