Oncological Emergencies comep OCT 2010Presentation Transcript
Malignant Spinal CorDcOMPRESSION MANAGEMENT
The Facts Incidence is variable More common in breast, lung cancer and multiple myeloma May occur in patient with known diagnosis of malignancy May be first presenting feature of malignancy Initial management very important
The Facts May occur in Hodgkins, NHL, Plasmacytoma, Spinal Cord Glioma May represent curable, localised disease in the above
Case 1 45 years female Previous right breast cancer 8 years ago 3 month history of mid lumbar back pain
Key Symptoms Pain – localised, severe, unremitting, escalating, positional, worsened by coughing/sneezing Power loss Paraesthesiae Sphincter disturbance
Key Symptoms Pain may be the only symptom
Case 1 What signs would you look for?
Key Signs THERE MAY BE NONE APART FROM PAIN ON MOVEMENT Power loss Sensory level Saddle anaesthesia Reduced anal tone Distended abdomen Urinary retention
Management Diagnosis Treatment Rehabilitation Ongoing Care
Case 1 What are the key features in the history?
Diagnosis - History PAIN on background of known previous or current malignancy Pain with no previous history of malignancy but with other suspicious symptoms/signs Power loss Sensory disturbance Sphincter disturbance
Diagnosis - Examination Pain on movement Motor dysfunction Sensory abnormalities/sensory level Reflexes Sphincter tone Distended abdomen Urinary retention
Diagnosis - Examination General clinical examination Breast examination Chest signs Palpable adenopathy
Case 1 How would you investigate further ?
Diagnosis - Investigations Plain radiology – CXR and spinal X rays MRI spine CT Bone scan (Histology) FBC, ESR Biochem – bone, Ca, Igs/PPE
Diagnosis - Histology Crucial in all new cases Some patients with SCC are curable
Case 1 What do you look for in the MRI report or better still, what do you ask when you discuss with the radiologist?
Diagnosis - Radiology Beware of reports stating “ no SCC ” when clinical suspicion is to the contrary Loss of vertebral height Soft tissue mass Angulation Subluxation Cord/nerve root impingement Meningeal disease
Case 1 SCC at L3 No other spinal metastases Slight angulation of spine and degree of anterior subluxation No other disease on CT How do you proceed?
Treatment Discuss with Oncologist and/or Neurosurgeon at earliest possible opportunity Commence Dexamethasone 16mg daily with gastric protection Lie “ flat “ Laxatives/catheter ANALGESIA Bone scan
Treatment Role of neurosurgery – isolated lesion, unstable spine with low volume disease Always discuss if in doubt
Treatment - Radiotherapy Generally palliative May be curative Provides pain relief also Fractionated from 1 to 5 weeks May cause nausea, diarrhoea, sore throat depending on level being treated
Treatment - Chemotherapy NHL, Hodgins disease, Multiple Myeloma, SCLC May be used in other solid tumours where site already irradiated
Case 1 Describe the roles of rehab and ongoing care in this case
Rehabilitation Crucial role to play Should begin early, pain permitting Physio prevents muscle wasting and assists improving power Physio improves morale OT important particularly for those patients returning home
Ongoing Care Rehab care Gradual tailing off of steroids Specific anti cancer therapies Bisphosphonates Analgesia Bowel and bladder care
Neutropenia Neutropenic Sepsis
Neutropenia Neutropenic Sepsis
Facts Incidence is variable in patients receiving chemotherapy Affects adjuvant and palliative patients Potentially life threatening medical emergency Occurs within 1 to 3 weeks of chemotherapy*
Case 1 53 years female GP requests assessment in A and E Receiving adjuvant chemo for breast cancer 10 days post chemo Non specific malaise for 5 days Afebrile Not acutely unwell
Presentation Febrile neutropenia Afebrile malaise with stomatitis and non specific symptoms Please listen to patient and GP
Definition Neutrophils <0.5 or <1 and falling Pyrexia greater/same as 38 C on 2 occasions or 38.5 C on one occasion or hypothermia < 36 C Clinically unwell greater
Case 1 Define cardinal features of neutropenic sepsis
Clinical Features Temp as described May be afebrile Hypothermia is a serious sign Malaise Fever, sweats, chills Tachypnoea > 20/min Tachycardia >90bpm Hypotensive May appear well perfused even if hypotensive
Be aware Sepsis may occur with normal neutrophils in immunocompromised patients Steroids may mask symptoms of sepsis Hypotension may be due to antihypertensives
Case 1 Patient has temp of 37.8 Normotensive Pulse 100 Neutrophils 0.1 How do you manage her?
Case 2 Patient has temp 37.6 Clammy Hypotensive BP 80/65 Tachycardia 130 O2 sats 94% Neutrophils 0.01 How do you manage her?
Management General clinical exam Check mouth Chest exam Check Hickman line site if present Skin lesions eg. herpetic, unhealed wounds Perianal area eg. fissures, haemarrhoids Arrange CXR
Management IV access and fluids Commence O2 FBC U and E, LFT, Ca, CRP, glucose Coag screen Blood cultures MSSU, sputum if possible, swab Hickman line Commence IV Tazocin 4.5g 6 hourly and IV Gentamicin as per nomogram If Penicillin allergy, commence IV Vancomycin as per nomogram plus Gentamicin and Ciprofloxacin Discuss with microbiology if in doubt or for advice
Management Continue to monitor vital signs Fluid balance chart Catheter for urinary output Consider repeat FBC, coag, renal function in sick patient Monitor Gentamicin / Vancomycin levels Monitor haematology and biochemistry daily Commence GCSF in sick or unstable patients
Management If neutropenic sepsis in spite of Ciprofloxacin prophylaxis, give Vancomycin and Gentamicin Vancomycin in suspected line sepsis and remove line Clarithromycin if suspected atypical pneumonia Fluconazole in suspected fungaemia
Case 2 Patient has dry cough Fine bi basal crackles O2 94% on air ( non smoker ) CXR shows ground glass appearance and reticular shadowing How would you proceed? What are your thoughts? Receiving palliative chemotherapy for metastatic breast cancer
Case 2 HRCT Respiratory opinion BAL Commence Septin and Prednisolone whilst awaiting results of BAL Consider adding in Fluconazole also Tazocin and Gentamicin Clarithromycin Consider HDU transfer for assisted ventilation if necessary
GCSF May not prevent sepsis Have a low threshold for using in patients admitted with sepsis particulary if profoundly neutropenic or unwell
Prevention Growth factors given prophylactically reduce but do not eliminate the risk Drug dose modification Oral hygiene Education
Mechanism SVC compression by right upper lobe tumour SVC compression by mediastinaladenopathy ( usually right paratracheal or pre carinal )
Case 1 63 years male, ex smoker of 5 years 3 month history of cough and weight loss 2 weeks of neck swelling What other clinical features might you look for? What other symptoms might he describe?
Clinical Signs Distended neck veins Distended chest wall veins Venous collaterals Facial swelling/Plethoric/conjunctival injection Arm swelling (uni and bilateral) Cyanosis in more advanced cases Hypoxic in more advanced cases
Symptoms Dyspnoea Headache Sensation of facial fullness worse on coughing and stooping
Causes of SVCO What malignant causes might you consider? Any other causes?
Malignant causes Lung cancer ( both SCLC and NSCLC ) NHL Hodgkins disease Metastatic disease ( eg. breast ) Mesothelioma Thymoma
Non malignant causes SVC thrombosis secondary to central line or as a consequence of extrinsic compression
Assessment of the patient What does this involve ?
Assessment of the patient Full history including oncology history if exists Assessment of severity of SVCO General clinical exam ( palpable adenopathy ) CXR Discuss with on call oncology team Discuss with respiratory physicians if first presentation and CXR suspicious of primary lung lesion Meanwhile organise CT CAP
Imaging What do you look for on CT?
Imaging Mediastinal mass Right upper lobe mass/disease Associated thrombus Collaterals Associated tracheal/main airway compression
Assessment of patient If no previous oncology history and imaging suggestive of lung primary, arrange bronchoscopy+/- mediastinoscopy If no previous oncology history and imaging suggestive of malignancy, ?origin, discuss with oncology and cardiothoracics, re mediastinoscopy. If imaging, age and history suggestive of lymphoma/Hodgkins, discuss with Haem Biopsy /FNA of palpable nodes
Management of patient How do you manage?
Management of patient Manage as you investigate Oxygen Steroids – Dexamethasone 16 mg daily with gastric protection Consider SVC stent insertion +/- thrombolysis to buy time whilst awaiting tissue diagnosis
Specific treatment What tumours are chemosensitive?
Chemosensitive tumours SCLC NHL Hodgkins disease Thymoma Breast, colon and others some extent
Potentially curable tumours What are they?
Potentally curable tumours NHL Hodgkins Disease ??? SCLC Thymoma
Radiotherapy Generally palliative but may effect good relief of signs and symptoms Cannot be repeated
Recurrent SVCO Consider chemotherapy depending on tumour type Consider SVC stent Consider anticoagulation