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

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!!