59 year old lady



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tarix25.12.2016
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#2829





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





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