Acute Oncology Presentations
Caused by Disease
Dr Omar Din
Consultant Clinical Oncologist
Weston Park Hospital
Acute Oncology Study Day
9th October 2013
Types of Emergency
Treatment Related
Febrile neutropenia
Tumour Lysis Syndrome
Extravasation
Diarrhoea
Nausea/vomiting
Biochemical
Hypercalcaemia
Hyponatraemia (SIADH)
Obstructive/structural
SVCO
Raised ICP
Pathological fracture
Spinal Cord Compression
Airway Obstruction
Pericardial Effusion
Pleural effusion
Ascites
Case 1
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59 year old lady
6 month history of lumbar back pain
Referred to rheumatology
Bone scan
Case 1
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Admitted
Drowsy
Dehydrated
Abdominal pain
Worsening back pain
BP 90/60
P 110
Case 1
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Bloods
Hb 9.8
Na 135
K 4.0
Urea 9.4
Creat 135
Ca 5.3
Alk Phos 347
Malignant Hypercalcaemia
• Ca >2.6 mmol/l
• Causes:
– Bone metastases
– PTH-RP: – breast, renal, lung, head and neck,
myeloma, lymphoma
– (Primary Hyperparathyroidism)
Hypercalcaemia - Symptoms
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Constipation
Fatigue
Nausea/vomiting
Confusion
Polyuria
Polydipsia
Abdominal pain
Dehydration
Hypercalcaemia - Treatment
• 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
– Hb 10.1
– Na 118
– K 4.2
– Urea 4.0
– Creat 60
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9am Cortisol 500
TSH 2.1
Glucose 4.5
Lipids normal
Serum osmolality 260
Urine osmolality 368
Urine Na 98
SIADH
• 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
SIADH
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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
SIADH - treatment
• 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
Case 3
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78 year old lady
Breast cancer 2008, node +, Her2 +
Admitted via A & E
Headache
Facial and arm swelling
SOBOE
Fixed raised JVP
Conjunctival oedema
Superior Vena Cava Obstruction
• 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.
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Often insidious onset
Compensatory collaterals over chest wall
Neck/face swelling
Headache
Dizziness
Syncope
Conjunctival oedema
Diagnosis
• 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
Histological Diagnosis
• 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
Treatment
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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)
Case 4
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64 year old man
Haematuria
PS 0
No PMH
Case 4
• CT right renal mass, nodes, small volume lung
metastases
• Developed loin pain
• Palliative nephrectomy
• Obstructive LFTs
• Biliary stricture - stented
• Developed pain in left shoulder
Pathological Fracture
• 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
Pathological Fracture
• Orthopaedic opinion –
stabilisation/reamings/biopsy
• Post operative radiotherapy – 20Gy in 5
fractions
• Mirel’s Risk
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Site
Upper limb
Lower limb
Peritrochanter
Pain
Mild
Moderate
Severe
Lesion
Blastic
Mixed
Lytic
Size
<1/3
1/3-2/3
>2/3
8=15% risk
9=33% risk
>9=High risk
Case 4
• Treated with sunitinib
• Shortly afterwards developed reduced visual
acuity
• Seen by opthalmology
• Urgent phone call
Choroidal Metastases
• 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
Brain Metastases
• 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
Case 6
Pericardial effusion
• 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
Case 7
Lymphangitis Carcinomatosa
• 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
Lymphangitis Carcinomatosa
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Treatment of underlying condition
Dexamethasone
Chemotherapy
Endocrine Therapy
Prognosis poor – 50% die within 3 months of
first symptom
The End