Oncological emergencies (except neutropenic sepsis!) Spinal cord compression


Stent: 95% response rate. Rapid relief of symptoms but doesn’t treat the cause. Superior Vena Cava Syndrome- stented



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Stent:



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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