oncological emergencies

ONCOLOGY

EMERGENCIES

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)

1. Pulmonary embolism

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

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

On Examination

JVP : Elevated 3cms

Heart sounds : Gallop rhythm

“Creaking noise” at right lung base

Mild wheeze bilaterally

No crepitations

Breath sounds vesicular

Investigations

FBP: White cell count elevated –

Neutrophils: 16 x109/l (n: 2.0-7.5)

U+E: Normal

Arterial Blood Gas:

• PO2 : 7 kPa (n: 10-14)

• PCO2 : 3 kPa (n: 4-6)

• pH : 7.5 (n: 7.25-7.35)

COAG Screen

D-Dimer: 4.0 (n: < 0.5)

Other coagulation factors normal

Chest X-Ray

ECG Findings

Important to rule out this!

CT Chest

Pulmonary

Angiogram

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

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

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

2. Spinal cord compression

Spinal Cord Compression

• Mechanism

– Lymphoma – mediastinal or retroperitoneal nodes or mets from vertebral bodies

• Symptoms

– Back Pain – syndrome insidious

– Paraplegia – bowel and bladder dysfunction

– 12 – 24 hr progression

– Permanent when completed

Spinal Cord Compression

• Diagnosis

– Myleogram or MRI

• Treatment

– Steroids

– Decompression Laminectomy

– Chemotherapy

– X- ray therapy

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

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

Lab tests

FBP :

Hb : 9.8g/dl

(12-18)

WCC : 2.0x109/l

(4.0-10.0)

Plts : 90x109/l

(150-450)

U+E :

Na+ : 145 mmol/l

(135-145)

K+ : 4.5 mmol/l

(3.5-5.0)

Ca2+: 2.4 mmol/l

(2.2-2.65)

Alb : 20 g/dl

(35-45)

MRI of SPINE

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

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

Radiotherapy Treatment Field

Positive bone scan:

Prostate Cancer

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

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

• 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

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

3. Neutropenic sepsis

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

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

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

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

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

Result

Recovered fully from infection

Further 2 cycles of BEP uneventful

Now disease free for 3 years and well

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

4. Hypercalcaemia

Hypercalcaemia

• Mechanism – Mets to bone, breast, lung, renal

– Myeloma

– Ectopic parathyroid hormone production

• Symptoms – Nausea

– Vomiting

– Constipation

– Urinary frequency

– Lethargy

– Confusion

– Coma

– Death

Hypercalcaemia

• Diagnosis

– Serum Calcium level - correct for albumin

• Therapy

– Hydration - saline

– Diuresis - Lasix

– Mithramycin

– Steroids

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

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

On Examination

Uncooperative

Dehydrated

Temp: 37.0oC

Blood pressure : 90/60mmhg pulse 120bpm

No obvious neurological deficit

Abdominal exam: Indentable mass left iliac fossa

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.

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

Further Investigations

CXR : mass right hilum

Isotope bone scan: no bone mets

CT scan : mass right hilum, new liver

metastases

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

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

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

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.

Differential Diagnosis of thirst, polyuria, constipation

• Diabetes mellitus

• Diabetes insipidus

• Hypercalcaemia

• Hypernatraemia

• Psychogenic polydipsia

5. Raised ICP/

Brain metastases

Increased Intracranial Pressure

• Mechanism – Primary Brain Tumor – Metasitic Tumor – Meninges

• Diagnosis – Headaches – Personality Changes – Lethargy – Coma – Papilledema – Stiff neck – Fixed pupil – tentorial herniation – CT/MRI of Brain – LP - cells

• Treatment

– Steroids

– Crainotomy – primary

– Whole Brain Irradiation – 3000 r – 2 weeks

– Meningeal – MTX or ARA C IT

Increased Intracranial Pressure

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

Symptoms

2 week history of irritability

Persistent nausea and vomiting

2 falls at home

No weakness, no double vision, no

headaches

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

Lab Tests

FBP: Normal

U+E and calcium: Normal

CT Brain


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.)

Whole head Radiotherapy Field

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

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

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)

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)

6. Chemotherapy related

thrombocytopenia

26 year old man

Receiving CHOP chemotherapy for stage

IIIA non-Hodgkins lymphoma

Currently day 15, cycle 3 of treatment

Admitted with severe epistaxis

On Examination

Obvious nose bleed, left side

Temperature: 36oc

BP : 120/55mmHg

Multiple petechiae over trunk and limbs

Petechiae


Pressure on soft part of nose

Get IV access

Send FBP, U+E, Coag screen, D-dimer

Group and cross match 2 units

Results

FBP :

Hb: 7.9 g/dl

(12-18)

WCC: 0.1 x109/l

(4.0-10.0)

Plts : 3 x109/l

(150-450)

ANC: < 0.1 x109/l

(2.0-7.5)

U+E:

Normal

Coagulation screen:

Normal

D-Dimer: 1.0

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

Outcome

Bleeding stopped with platelet transfusion

Received 6 cycles of CHOP in total

Now 5 years from treatment. Well, no

evidence of recurrent disease

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.

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

Lines

• Hickman:

– under clavicle

– Tunnel catheter

– Into subclavian vein, down to superior vena cava

• PICC:

– Peripherally inserted central catheter

7. Superior Vena Cava

Syndrome

SVC Syndrome

• Mechanism – Masse(s) in chest/mediastinum compress SVC

– Lymphoma

– Hodgkin's

– Lung

– Breast

• Symptoms – Facial Edema

– Periorbital Edema

– Cyanosis – speed determines collateral pattern on chest wall

• 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

• CNS complaints - headache, drowsy, visual disturbances

• Dyspnoea

• Cough

• Cyanosis

• Chest pain

• Aggravated by changes in position - stooping / bending forward

• Dysphagia

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

• T Cell Leukaemia / Lymphoma

• Kaposi Sarcoma

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”

On Examination

Plethoric face

Dilated veins over chest wall and upper

limbs

Arms and neck swollen

CXR: widening of the upper mediastinum

SVC Venogram: Catheter in

external Jugular vein

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)

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

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

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.

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

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

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

Obstruction • Intestinal

– Pelvic cancers: ovarian 6-42%, cervical 5%, colonic 10-30%

– May be complete, subacute or functional

– Signs & symptoms: N&V, colicky pain, constipation, disyension, dehydration, projectile vomiting

– Inv: erect and supine abdominal x-ray, barium studies, MRI

– Treatment: IV fluid, NG tube, surgery/radiotherapy

• Urinary Tract – Causes: bladder, prostate, cervis, pelvic cancers

– Symptoms: asymptomayic, pain

– Inv: abdominal US, cystoscopy

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


• Mechanism

– Rapid necrosis of tumour cells

– Release of massive intracellular material into the circulation - metabolic load

– Ascites

– Renal impairment

– Arrhythmias

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


• Diagnosis

– Potassium increased

– Phosphate increased

– Calcium decreased

– Uric Acid increased

– Acidosis

– Azotemia


• Treatment

– Correct acidosis, potassium, uric acid

– Diuresis

– Dialysis if needed

• Prompt treatment can prevent death

Mucositis/Oesophagitis

• Mechanism

– Radiation therapy

– Chemotherapy

– Antitumor antibiotics

– Antimetabolics

• Symptoms

– Pain

– Vomiting


• Treatment

– Hydration

– Mycostatin/Magic Mouthwash

– Kepivance (palifermin) 60 mcg/kg/d for 3 days before and after chemo

– Gelclair (coating agent)

– Recombinant Keratiocyte Growth Factor

• Antibiotics

• Antivirals

• Other

– Morphine Patch

– TPN/nutritional support


• Avastin (Bevacizumab)

• Erbitux (Cetuximab)

• Tarceva (Erlotinib)

• Iressa (Gefitinib)

• Gleevec (Imatinib)

• Rituxan (Retuximab)

• Others…..

New Drugs New Complications

• Avastin – Abdominal Perforation

– Wound dehiscence after surgery

– Stroke risk

• Erbitux – Acneform Rash 90%! (10% severe)

• Rituxan (Anti CD-20 antibody) – Anaphylactic reaction

• Tarceva – Acneform Rash, pulmonary toxicity

• Iressa – Rash, pulmonary toxicity


• Acniform Rash


Emergencies

• Cardiovascular – Pericardial Tamponade – Superior Vena Cava Syndrome

• Central Nervous System Emergencies – Increased Intracranial Pressure – Spinal Cord Compression

• Gastrointestinal – Bowel Obstruction – Bowel Perforation – Ascites – Esophageal Obstruction and Perforation

Emergencies

• Hematologic Emergencies

– DIC

– Leukostasis

– Thrombocytopenia

• Infectious Emergencies

– Sepsis in the leukopenic patient

– Disseminated Viral Infections

– Fungal and Parasitic Diseases

Emergencies

• Metabolic Emergencies

– Hyperuricemia

– Hypercalcaemia

– Hypoglycemia

– Lactic Acidosis

– Tumor Lysis Syndrome

• Orthopedic Emergencies

– Pathologic Fracture

Emergencies

• Waldenstroms

– Hyperviscosity Syndrome

– Plasmaphoresis

Emergencies

• Renal Emergencies – Ureteral Obstruction – Pelvic Tumors

• Respiratory Emergencies – Airway Obstruction

– Pneumothorax

– Effusion

• Symptomatic Emergencies – Pain

– Vomiting

– Mucositis

– Dyspnea

Pericardial Tamponade

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

• Symptoms – Dyspnea – Confusion – Coma – Distended neck veins – Pulses Paradoxes – CHF

Pericardial Tamponade

• Diagnosis – Enlarged heart

– CXR – sac-like heart

– Echo

• Treatment – Percardiocentesis

– Catheter SFU

– X-Ray Therapy

– Surgery – window vs. pericardiectomy

oncological emergencies

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