oncological emergencies comep oct 2010
TRANSCRIPT
MALIGNANT SPINAL CORD
COMPRESSION
MANAGEMENT
The Facts
Incidence is variable More common in breast, lung cancer
and multiple myeloma May occur in patient with known
diagnosis of malignancy May be first presenting feature of
malignancy Initial management very important
The Facts
May occur in Hodgkins, NHL, Plasmacytoma, Spinal Cord Glioma
May represent curable, localised disease in the above
Case 1
45 years female Previous right breast cancer 8 years ago 3 month history of mid lumbar back pain
Key Symptoms
Pain – localised, severe, unremitting, escalating, positional, worsened by coughing/sneezing
Power loss Paraesthesiae Sphincter disturbance
Key Symptoms
Pain may be the only symptom
Case 1
What signs would you look for?
Key Signs
THERE MAY BE NONE APART FROM PAIN ON MOVEMENT
Power loss Sensory level Saddle anaesthesia Reduced anal tone Distended abdomen Urinary retention
Management
Diagnosis Treatment Rehabilitation Ongoing Care
Case 1
What are the key features in the history?
Diagnosis - History
PAIN on background of known previous or current malignancy
Pain with no previous history of malignancy but with other suspicious symptoms/signs
Power loss Sensory disturbance Sphincter disturbance
Diagnosis - Examination
Pain on movement Motor dysfunction Sensory abnormalities/sensory level Reflexes Sphincter tone Distended abdomen Urinary retention
Diagnosis - Examination
General clinical examination Breast examination Chest signs Palpable adenopathy
Case 1
How would you investigate further ?
Diagnosis - Investigations Plain radiology – CXR and spinal X rays MRI spine CT Bone scan (Histology) FBC, ESR Biochem – bone, Ca, Igs/PPE
Diagnosis - Histology
Crucial in all new cases Some patients with SCC are curable
Case 1
What do you look for in the MRI report or better still, what do you ask when you discuss with the radiologist?
Diagnosis - Radiology
Beware of reports stating “ no SCC ” when clinical suspicion is to the contrary
Loss of vertebral height Soft tissue mass Angulation Subluxation Cord/nerve root impingement Meningeal disease
Case 1
SCC at L3 No other spinal metastases Slight angulation of spine and degree of
anterior subluxation No other disease on CT How do you proceed?
Treatment
Discuss with Oncologist and/or Neurosurgeon at earliest possible opportunity
Commence Dexamethasone 16mg daily with gastric protection
Lie “ flat “ Laxatives/catheter ANALGESIA Bone scan
Treatment
Role of neurosurgery – isolated lesion, unstable spine with low volume disease
Always discuss if in doubt
Treatment - Radiotherapy Generally palliative May be curative Provides pain relief also Fractionated from 1 to 5 weeks May cause nausea, diarrhoea, sore
throat depending on level being treated
Treatment - Chemotherapy NHL, Hodgins disease, Multiple
Myeloma, SCLC May be used in other solid tumours
where site already irradiated
Case 1
Describe the roles of rehab and ongoing care in this case
Rehabilitation
Crucial role to play Should begin early, pain permitting Physio prevents muscle wasting and
assists improving power Physio improves morale OT important particularly for those
patients returning home
Ongoing Care
Rehab care Gradual tailing off of steroids Specific anti cancer therapies Bisphosphonates Analgesia Bowel and bladder care
Neutropenia
NEUTROPENIC SEPSIS
Neutropenia
Neutropenic Sepsis
FactsIncidence is variable in patients receiving
chemotherapyAffects adjuvant and palliative patientsPotentially life threatening medical
emergencyOccurs within 1 to 3 weeks of
chemotherapy*
Case 153 years femaleGP requests assessment in A and EReceiving adjuvant chemo for breast
cancer10 days post chemoNon specific malaise for 5 daysAfebrileNot acutely unwell
PresentationFebrile neutropeniaAfebrile malaise with stomatitis and non
specific symptomsPlease listen to patient and GP
DefinitionNeutrophils <0.5 or <1 and fallingPyrexia greater/same as 38 C on 2
occasions or 38.5 C on one occasion or hypothermia < 36 C
Clinically unwell
Case 1Define cardinal features of neutropenic
sepsis
Clinical FeaturesTemp as describedMay be afebrileHypothermia is a serious signMalaiseFever, sweats, chillsTachypnoea > 20/minTachycardia >90bpmHypotensiveMay appear well perfused even if
hypotensive
Be awareSepsis may occur with normal neutrophils
in immunocompromised patientsSteroids may mask symptoms of sepsisHypotension may be due to
antihypertensives
Case 1Patient has temp of 37.8NormotensivePulse 100Neutrophils 0.1How do you manage her?
Case 2Patient has temp 37.6ClammyHypotensive BP 80/65Tachycardia 130O2 sats 94%Neutrophils 0.01How do you manage her?
ManagementGeneral clinical examCheck mouthChest examCheck Hickman line site if presentSkin lesions eg. herpetic, unhealed woundsPerianal area eg. fissures, haemarrhoidsArrange CXR
ManagementIV access and fluidsCommence O2FBCU and E, LFT, Ca, CRP, glucoseCoag screenBlood culturesMSSU, sputum if possible, swab Hickman lineCommence IV Tazocin 4.5g 6 hourly and IV
Gentamicin as per nomogramIf Penicillin allergy, commence IV Vancomycin as per
nomogram plus Gentamicin and CiprofloxacinDiscuss with microbiology if in doubt or for advice
ManagementContinue to monitor vital signsFluid balance chartCatheter for urinary outputConsider repeat FBC, coag, renal function in
sick patientMonitor Gentamicin / Vancomycin levelsMonitor haematology and biochemistry
dailyCommence GCSF in sick or unstable
patients
ManagementIf neutropenic sepsis in spite of
Ciprofloxacin prophylaxis, give Vancomycin and Gentamicin
Vancomycin in suspected line sepsis and remove line
Clarithromycin if suspected atypical pneumonia
Fluconazole in suspected fungaemia
Case 2Patient has dry coughFine bi basal cracklesO2 94% on air ( non smoker )CXR shows ground glass appearance and
reticular shadowingHow would you proceed?What are your thoughts?Receiving palliative chemotherapy for
metastatic breast cancer
Case 2HRCTRespiratory opinionBALCommence Septin and Prednisolone whilst
awaiting results of BALConsider adding in Fluconazole alsoTazocin and GentamicinClarithromycinConsider HDU transfer for assisted
ventilation if necessary
GCSFMay not prevent sepsisHave a low threshold for using in patients
admitted with sepsis particulary if profoundly neutropenic or unwell
PreventionGrowth factors given prophylactically
reduce but do not eliminate the riskDrug dose modificationOral hygieneEducation
SVCO
MechanismSVC compression by right upper lobe
tumour
SVC compression by mediastinal adenopathy ( usually right paratracheal or pre carinal )
Case 163 years male, ex smoker of 5 years3 month history of cough and weight loss2 weeks of neck swellingWhat other clinical features might you look
for?What other symptoms might he describe?
Clinical SignsDistended neck veinsDistended chest wall veinsVenous collateralsFacial swelling/Plethoric/conjunctival
injectionArm swelling (uni and bilateral)Cyanosis in more advanced casesHypoxic in more advanced cases
SymptomsDyspnoeaHeadacheSensation of facial fullness worse on
coughing and stooping
Causes of SVCOWhat malignant causes might you
consider?Any other causes?
Malignant causesLung cancer ( both SCLC and NSCLC )NHLHodgkins diseaseMetastatic disease ( eg. breast )MesotheliomaThymoma
Non malignant causesSVC thrombosis secondary to central line or
as a consequence of extrinsic compression
Assessment of the patientWhat does this involve ?
Assessment of the patientFull history including oncology history if
existsAssessment of severity of SVCOGeneral clinical exam ( palpable
adenopathy )CXRDiscuss with on call oncology teamDiscuss with respiratory physicians if first
presentation and CXR suspicious of primary lung lesion
Meanwhile organise CT CAP
ImagingWhat do you look for on CT?
ImagingMediastinal massRight upper lobe mass/diseaseAssociated thrombusCollateralsAssociated tracheal/main airway
compression
Assessment of patientIf no previous oncology history and imaging
suggestive of lung primary, arrange bronchoscopy+/- mediastinoscopy
If no previous oncology history and imaging suggestive of malignancy, ?origin, discuss with oncology and cardiothoracics, re mediastinoscopy.
If imaging, age and history suggestive of lymphoma/Hodgkins, discuss with Haem
Biopsy /FNA of palpable nodes
Management of patientHow do you manage?
Management of patientManage as you investigateOxygenSteroids – Dexamethasone 16 mg daily
with gastric protectionConsider SVC stent insertion +/-
thrombolysis to buy time whilst awaiting tissue diagnosis
Specific treatmentWhat tumours are chemosensitive?
Chemosensitive tumoursSCLCNHLHodgkins diseaseThymomaBreast, colon and others some extent
Potentially curable tumoursWhat are they?
Potentally curable tumoursNHLHodgkins Disease??? SCLCThymoma
RadiotherapyGenerally palliative but may effect good
relief of signs and symptoms
Cannot be repeated
Recurrent SVCOConsider chemotherapy depending on
tumour typeConsider SVC stentConsider anticoagulation