Oncological emergencies (except neutropenic sepsis!) Spinal cord compression



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ONCOLOGICAL EMERGENCIES (except neutropenic sepsis!)


Spinal cord compression



MRI features

  • Compressed cord



Spinal cord compression

  • An emergency.

  • Under-recognised.

  • May patients unnecessarily left paraplegic as early symptoms & signs not recognised by doctors.



Presenting symptoms in Scottish audit

  • 95% pain.

  • 85% weakness (median duration 20 days).

  • only 18% walking at time diagnosis.

  • 68% altered sensation.

  • 56% urinary problems.

  • 74% bowel problems (6% on strong opioids).

  • 5% faecal incontinence.



Symptoms – description of pain

  • Pain in spine (80%).

  • Worse on coughing and straining.

  • Frequently associated with radicular pain -band like burning pain sometimes with hypersensitivity – precedes weakness.



Symptoms -others

  • Weakness – bi-lateral or unilateral.

  • Sensory changes can be loss of one or all of:

      • Proprioception.
      • Light touch.
      • Pin-prick.
  • Change in bladder – retention.

  • Change in bowels – constipation.



Confirmation of diagnosis



Treatment

  • Steroids –

    • Immediate dexamethasone as ‘holding measure.’
    • Cancer Centre recommendation
        • 16mg IV stat then 4mg qds PO with PPI cover.
    • Aim to reduce vasogenic oedema.


Radiotherapy

  • Mainstay of treatment.

  • UK usual dose 20Gy/5#, in US 30Gy/10#*.

  • Hanover series:

    • ~33% improved and 20% deteriorated.
    • Those patients whose motor function.
    • declined the slowest, had the best outcome.


Radiotherapy



Surgery

  • Should be considered in any patient with:

    • Single vertebral region of involvement.
    • No evidence of widespread metastases.
    • Radio-resistant primary e.g. renal, sarcoma.
    • Previous RT to site.
    • Unknown primary- get tissue.


Surgery for cord compression

  • Improvements in pain in 75-100%.

  • Improvements in neurology in 50-75%.after surgery.



Chemotherapy

  • In theory can be used for the very sensitive tumours:

    • Lymphoma.
    • Teratoma.
    • SCLC (maybe).
  • However, in view of devastating effects of neurological deterioration practice is often to treat small RT field (reduce bone marrow suppression) then move to chemotherapy.



Conclusions

  • Common, often unrecognised with serious impact on patients’ quality of dying.

  • RADICULAR PAIN =

  • CORD COMPRESSION!

  • Needs steroids and URGENT MRI!



Superior vena cava obstruction



Superior Vena Cava Obstruction

  • Obstruction of blood flow through the SVC



Superior Vena Cava Obstruction

  • CAUSES:

  • Lung Cancer* 80%

  • Lymphoma 10%

  • Other Malignancy 5%

  • Benign causes 5%

    • (e.g. aneurysm, goitre, fibrosis, infection etc.)
  • Occurs in 10% SCLC cases and 1.7% of NSCLC cases



Superior Vena Cava Obstruction

  • SYMPTOMS:

  • Swelling of face, neck one or both arms.

    • (one arm suggests more distal)
  • Distended veins.

  • Shortness of breath.

  • Headache.

  • Lethargy.



Superior Vena Cava Obstruction



Superior Vena Cava Obstruction

  • SIGNS:

  • Early stage: puffy neck, neck veins don’t collapse.

  • Later:

    • Distended neck & chest wall
    • veins.
    • Swollen face, neck and arms.
  • In advanced cases:

    • Injected conjunctiva.
    • Sedation.


Superior Vena Cava Obstruction

  • Main aim is to distinguish whether obstruction is blockage from within:

    • Clot (DVT) – often fast onset.
    • Foreign body (e.g.line).
    • Tumour in vessel (e.g. renal cancer).
  • Or without:

    • Extrinsic compression from mass.


History

  • How long?

  • Speed of onset?

  • How advanced? If patient is becoming drowsy this is an emergency.

  • Any risk factors e.g. recent central line.

  • Any symptoms of cancer esp. lung cancer or lymphoma.

  • Any other local symptoms e.g. pain, stridor.



Superior Vena Cava Obstruction

  • Examination:

    • Extent of problem.
    • Any evidence of malignancy elsewhere
      • Lymphadenopathy.
      • Hepatomegaly.
      • collapse/consolidation of lung.


Superior Vena Cava Obstruction

  • Initial Investigations:

    • CXR – is there a mass?
    • Venogram – is there a clot?
  • If extrinsic compression from mass try and obtain tissue (SCLC, lymphoma treated with chemo)

    • FNA node.
    • Mediastinoscopy.


Superior Vena Cava Obstruction



Superior Vena Cava Obstruction



Treatment options: Clot

    • Local thrombolysis with streptokinase.
    • Anti-coagulation – heparin (IV or LMWH) for at 5/7 whilst starting warfarin.


Treatment Options: Extrinsic compression

  • Steroids:

      • frequently prescribed but no evidence to support their use (Cochrane review)
  • Chemotherapy:

      • used for SCLC, lymphoma and teratoma
      • response rate >70%.
  • Radiotherapy:

      • used for other malignant causes
      • response rate ~60%.
  • Stent:

      • 95% response rate. Rapid relief of symptoms
      • but doesn’t treat the cause.


Superior Vena Cava Syndrome- stented



Management Approach

  • Is there time to obtain tissue?

  • If yes – obtain tissue by safest route.

  • If no – consider inserting stent to allow time to obtain tissue to ensure curable tumour not missed.

  • Lymphoma cured with chemo +/- RT.

  • Limited stage SCLC can be cured by chemo-radiation.



Metabolic: Malignant Hypercalcaemia



Hypercalcaemia

  • Affects 10-30% of cancer patients.

  • CAUSES:

  • Humoural.

    • Often mediated by PTHrP.
  • Local bone destruction.

    • Especially lung, breast and myeloma.
  • Tumour production of vitamin D analogues.

    • Especially lymphomas.


Hypercalcaemia

  • Symptoms in the cancer patient:

    • Nauseated, anorexic.
    • Thirsty.
    • Pass lots urine (polydypsia and polyuria).
    • Constipated.
    • Confused.
    • Poor concentration, drowsy.


Investigations:

  • Calcium (normal range 2.1-2.6).

  • Albumin to correct calcium:

    • (corrected calcium = Ca2+ + 0.02x (40-albumin)
  • Urea and electrolytes – looking for dehydration.

  • Phosphate (low in hyperparathyroidism).

  • If no known malignancy – myeloma screen



Treatment

  • Rehydration first:

    • Need several litres of normal saline.
    • If risk of cardiac failure consider CVP measurements.
  • Bisphosphonates:

    • e.g. 60-90mg pamidronate IV over 2 hours.
    • Can cause renal failure so must make sure properly rehydrated first.
    • Takes up to a week to work.
  • Systemic management of malignancy.



Malignant Pericardial Tamponade



Pericardial Tamponade



Pericardial Effusion

  • CAUSES:

  • Malignant.

  • Trauma – injury, post-op, iatrogenic e.g. pacing line.

  • Infection – TB, viral.

  • Post MI.

  • Connective tissue disease e.g. SLE, Rheumatoid.

  • Drugs e.g. hydralazine, isoniazid.

  • Uraemia.



Malignant Pericardial Tamponade

  • SYMPTOMS:

  • Primarily shortness of breath.

  • Fatigue.

  • Palpitations.

  • Symptoms of pericarditis (chest pain improved by sitting forward).

  • Symptoms of advanced cancer.



Malignant Pericardial Tamponade

  • SIGNS: Beck’s triad

  • Jugular venous distension.

  • Pulsus paradoxus –venous return drops when intra-thoracic pressure raised.

  • Soft heart sounds or pericardial rub.

  • Poor cardiac output – tachycardia with low BP and poor peripheral perfusion.



Malignant Pericardial Tamponade

  • INVESTIGATIONS:

  • CXR - enlargement of cardiac silhouette.

  • ECG - reduced complex size.

  • Echocardiogram – rim of pericardial fluid.

  • Cytology of pericardial fluid.



Malignant Pericardial Tamponade



Malignant Pericardial Tamponade

  • TREATMENT:

  • Pericardiocentesis – drain into pericardium.

  • Pericardial window – operation to allow pericardial fluid to drain into pleural cavity.

  • Systemic management of malignancy.



So – Oncology emergencies

  • SCC (spinal cord compression)

  • SVCO (superior vena cava obstruction)

  • Hypercalcaemia

  • Tamponade……



Conclusions:

  • There are a variety of conditions related to cancer that can be life-threatening.

  • Swift treatment can reduce impact on a patient’s quality of life.

  • If in doubt about what to do– speak to an oncologist!!







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