59 year old lady

59 year old lady

• 59 year old lady

• 6 month history of lumbar back pain

• Referred to rheumatology

• Bone scan

Admitted

• Admitted

• Drowsy

• Dehydrated

• Abdominal pain

• Worsening back pain

• BP 90/60

• P 110

Bloods

• Bloods

• Hb 9.8

• Na 135

• K 4.0

• Urea 9.4

• Creat 135

• Ca 5.3

• Alk Phos 347

Ca >2.6 mmol/l

• Ca >2.6 mmol/l

• Causes:

• Bone metastases
• PTH-RP: – breast, renal, lung, head and neck, myeloma, lymphoma
• (Primary Hyperparathyroidism)

• Constipation

• Fatigue

• Nausea/vomiting

• Confusion

• Polyuria

• Polydipsia

• Abdominal pain

• Dehydration

IV Fluids - 3L normal saline over 24 hrs

• IV Fluids - 3L normal saline over 24 hrs

• IV Bisphosphonates

• Zolendronic Acid (most potent)
• Palmidronate

• Stop frusemide whilst dehydrated, Ca/Vit D

• Calcitonin for resistant cases

• Treat underlying cause

Bloods

• Bloods

• Hb 10.1
• Na 118
• K 4.2
• Urea 4.0
• Creat 60

9am Cortisol 500

• 9am Cortisol 500

• TSH 2.1

• Glucose 4.5

• Lipids normal

• Serum osmolality 260

• Urine osmolality 368

• Urine Na 98

Syndrome of inappropriate ADH secretion

• Syndrome of inappropriate ADH secretion

• Excess ADH leading to water retention and low serum sodium due to dilutional effect.

• Low serum sodium and reduced plasma osmolality cf. urine osmolality

• Urine Na >20mmol

Cancer; SCLC, NHL, HD, thymoma, sarcoma

• Cancer; SCLC, NHL, HD, thymoma, sarcoma

• CNS disease (infection, trauma)

• Chest disease (infection)

• Drugs (thiazide, anti-epileptics, PPI, cytotoxics)

• Symptoms: nil, fatigue, nausea/vomiting, confusion, coma

Ensure Addison’s and Thyroid disease excluded (cortisol, TSH)

• Ensure Addison’s and Thyroid disease excluded (cortisol, TSH)

• Fluid restriction 1l in 24 hours, daily U&E

• Demeclocycline 600-1200mg/day divided

• Discussion with endocrinology

• Newer agents eg Tolvaptan (vasopressin receptor antagonists)

• In EMERGENCY ONLY i.e. coma/fitting D/W Critical care. May need transfer to HDU for slow IV NaCl 1.8% - caution with osmotic demyelination

• Treat underlying cause eg chemo for SCLC

78 year old lady

• 78 year old lady

• Breast cancer 2008, node +, Her2 +

• Admitted via A & E

• Headache

• Facial and arm swelling

• SOBOE

• Fixed raised JVP

• Conjunctival oedema

Definition; compression, invasion or occasionally intraluminal obstruction of the superior vena

• Definition; compression, invasion or occasionally intraluminal obstruction of the superior vena

• Causes; SCLC, NSCLC, lymphoma account for 90% cases. Others include thymoma and germ cell.

• Often insidious onset

• Compensatory collaterals over chest wall

• Neck/face swelling

• Headache

• Dizziness

• Syncope

• Conjunctival oedema

Timely identification of the cause is essential

• Timely identification of the cause is essential

• CT Chest

• Up to 60% of patients with SVC syndrome related to neoplasia do not have a known diagnosis of cancer

• Need a tissue biopsy to guide subsequent management

Sputum cytology, pleural fluid cytology, biopsy of enlarged peripheral nodes

• Sputum cytology, pleural fluid cytology, biopsy of enlarged peripheral nodes

• Bone marrow biopsy for NHL

• Bronchoscopy, mediastinoscopy, or thoracotomy are more invasive but sometimes necessary

O2

• O2

• Dexamethasone/PPI

• SVC Stent

• Anticoagulation if thrombus

• Does not require urgent radiotherapy – GET DIAGNOSIS

• Stridor – may require ICU admission

• Histopathology

• Treatment depends on cause

• RT vs chemotherapy (SCLC, lymphoma, germ cell)

64 year old man

• 64 year old man

• Haematuria

• PS 0

• No PMH

CT right renal mass, nodes, small volume lung metastases

• CT right renal mass, nodes, small volume lung metastases

• Developed loin pain

• Palliative nephrectomy

• Obstructive LFTs

• Biliary stricture - stented

• Developed pain in left shoulder

broken bone caused by disease leading to weakness of the bone

• broken bone caused by disease leading to weakness of the bone

• metastatic tumours: breast, lung, thyroid, kidney, prostate

• primary malignant tumours: chondrosarcoma, osteosarcoma, Ewing's tumour

• Bloods: FBC, PSA, myeloma screen.

• CXR.

• Mammogram

Orthopaedic opinion – stabilisation/reamings/biopsy

• Orthopaedic opinion – stabilisation/reamings/biopsy

• Post operative radiotherapy – 20Gy in 5 fractions

• Mirel’s Risk

Treated with sunitinib

• Treated with sunitinib

• Shortly afterwards developed reduced visual acuity

• Seen by opthalmology

• Urgent phone call

Choroid: vascular layer in and around eye

• Choroid: vascular layer in and around eye

• Breast, lung, prostate, kidney, thyroid, GI, lymphoma, leukaemia

• Symptoms: flashing lights, visual disturbance

• Urgent treatment: Radiotherapy to save vision

• 20Gy in 5 fractions

Lung, breast, melanoma

• Lung, breast, melanoma

• Headache, nausea, vomiting, seizures, change in behaviour, focal neurological deficit

• CT/MRI

• Dexamethasone up to 16mg/day

• Risk of hydrocephalus – neurosurgeons ?shunt

• Multiple mets – whole brain RT

• Solitary met – excision or stereotactic radiosurgery

Obstruction of lymphatic drainage or fluid from tumour on pericardium

• Obstruction of lymphatic drainage or fluid from tumour on pericardium

• Tamponade – tachycardia, hypotension, JVP, oedema

• Echocardiogram

• Urgent discussion with cardiothoracics

• Percardiocentesis – fluid for cytology

• Pericardial window

• Complete pericardial stripping

• Treat underlying cause

Breathlessness, dry cough, haemoptysis

• Breathlessness, dry cough, haemoptysis

• diffuse infiltration and obstruction of pulmonary parenchymal lymphatic channels by tumour

• Breast, lung, colon, stomach

• 80% adeno

• CXR – diffuse reticulonodular shadowing

• CT or High Resolution CT

Treatment of underlying condition

• Treatment of underlying condition

• Dexamethasone

• Chemotherapy

• Endocrine Therapy

• Prognosis poor – 50% die within 3 months of first symptom