Oncological Emergencies  comep OCT  2010
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Oncological Emergencies comep OCT 2010






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Oncological Emergencies  comep OCT  2010 Oncological Emergencies comep OCT 2010 Presentation Transcript

  • Malignant Spinal CorDcOMPRESSION
  • 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
    Sphincter disturbance
  • Key Symptoms
    Pain may be the only symptom
  • Case 1
    What signs would you look for?
  • Key Signs
    Power loss
    Sensory level
    Saddle anaesthesia
    Reduced anal tone
    Distended abdomen
    Urinary retention
  • Management
    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
    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
    Bone scan
    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
    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 “
    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
    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
    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
  • Case 1
    Define cardinal features of neutropenic sepsis
  • Clinical Features
    Temp as described
    May be afebrile
    Hypothermia is a serious sign
    Fever, sweats, chills
    Tachypnoea > 20/min
    Tachycardia >90bpm
    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
    Pulse 100
    Neutrophils 0.1
    How do you manage her?
  • Case 2
    Patient has temp 37.6
    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
    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
    Respiratory opinion
    Commence Septin and Prednisolone whilst awaiting results of BAL
    Consider adding in Fluconazole also
    Tazocin and Gentamicin
    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
  • SVCO
  • 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
    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 )
    Hodgkins disease
    Metastatic disease ( eg. breast )
  • 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 )
    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
    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
    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
    Hodgkins disease
    Breast, colon and others some extent
  • Potentially curable tumours
    What are they?
  • Potentally curable tumours
    Hodgkins Disease
    ??? SCLC
  • 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