Malignant Spinal CorDcOMPRESSION<br />MANAGEMENT<br />
The Facts<br />Incidence is variable<br />More common in breast, lung cancer and multiple myeloma<br />May occur in patien...
The Facts<br />May occur in Hodgkins, NHL, Plasmacytoma, Spinal Cord Glioma<br />May represent curable, localised disease ...
Case 1<br />45 years female<br />Previous right breast cancer 8 years ago<br />3 month history of mid lumbar back pain<br />
Key Symptoms<br />Pain – localised, severe, unremitting, escalating, positional, worsened by coughing/sneezing<br />Power ...
Key Symptoms<br />Pain may be the only symptom<br />
Case 1<br />What signs would you look for?<br />
Key Signs<br />THERE MAY BE NONE APART FROM PAIN ON MOVEMENT<br />Power loss<br />Sensory level<br />Saddle anaesthesia<br...
Management<br />Diagnosis<br />Treatment<br />Rehabilitation<br />Ongoing Care<br />
Case 1 <br />What are the key features in the history?<br />
Diagnosis - History<br />PAIN on background of known previous or current malignancy<br />Pain with no previous history of ...
Diagnosis - Examination<br />Pain on movement<br />Motor dysfunction<br />Sensory abnormalities/sensory level<br />Reflexe...
Diagnosis - Examination<br />General clinical examination<br />Breast examination<br />Chest signs<br />Palpable adenopath...
Case 1<br />How would you investigate further ?<br />
Diagnosis - Investigations<br />Plain radiology – CXR and spinal X rays<br />MRI spine<br />CT<br />Bone scan<br />(Histol...
Diagnosis - Histology<br />Crucial in all new cases<br />Some patients with SCC are curable<br />
Case 1 <br />What do you look for in the MRI report or better still, what do you ask when you discuss with the radiologist...
Diagnosis - Radiology<br />Beware of reports stating “ no SCC ” when clinical suspicion is to the contrary<br />Loss of ve...
Case 1 <br />SCC at L3<br />No other spinal metastases<br />Slight angulation of spine and degree of anterior subluxation<...
Treatment<br />Discuss with Oncologist and/or Neurosurgeon at earliest possible opportunity<br />Commence Dexamethasone 16...
Treatment<br />Role of neurosurgery – isolated lesion, unstable spine with low volume disease<br />Always discuss if in do...
Treatment - Radiotherapy<br />Generally palliative<br />May be curative <br />Provides pain relief also<br />Fractionated ...
Treatment - Chemotherapy<br />NHL, Hodgins disease, Multiple Myeloma, SCLC<br />May be used in other solid tumours where s...
Case 1<br />Describe the roles of rehab and ongoing care in this case<br />
Rehabilitation<br />Crucial role to play<br />Should begin early, pain permitting<br />Physio prevents muscle wasting and ...
Ongoing Care <br />Rehab care<br />Gradual tailing off of steroids<br />Specific anti cancer therapies<br />Bisphosphonate...
Neutropenia<br />Neutropenic Sepsis<br />
Neutropenia<br />Neutropenic Sepsis<br />
Facts<br />Incidence is variable in patients receiving chemotherapy<br />Affects adjuvant and palliative patients<br />Pot...
Case 1<br />53 years female<br />GP requests assessment in A and E<br />Receiving adjuvant chemo for breast cancer<br />10...
Presentation<br />Febrile neutropenia<br />Afebrile malaise with stomatitis and non specific symptoms<br />Please listen t...
Definition<br />Neutrophils <0.5 or <1 and falling<br />Pyrexia greater/same as 38 C on 2 occasions or 38.5 C on one occas...
Case 1<br />Define cardinal features of neutropenic sepsis<br />
Clinical Features<br />Temp as described<br />May be afebrile<br />Hypothermia is a serious sign<br />Malaise<br />Fever, ...
Be aware<br />Sepsis may occur with normal neutrophils in immunocompromised patients<br />Steroids may mask symptoms of se...
Case 1<br />Patient has temp of 37.8<br />Normotensive<br />Pulse 100<br />Neutrophils 0.1<br />How do you manage her?<br />
Case 2<br />Patient has temp 37.6<br />Clammy<br />Hypotensive BP 80/65<br />Tachycardia 130<br />O2 sats 94%<br />Neutrop...
Management<br />General clinical exam<br />Check mouth<br />Chest exam<br />Check Hickman line site if present<br />Skin l...
Management<br />IV access and fluids<br />Commence O2<br />FBC<br />U and E, LFT, Ca, CRP, glucose<br />Coag screen<br />B...
Management<br />Continue to monitor vital signs<br />Fluid balance chart<br />Catheter for urinary output<br />Consider re...
Management<br />If neutropenic sepsis in spite of Ciprofloxacin prophylaxis, give Vancomycin and Gentamicin<br />Vancomyci...
Case 2<br />Patient has dry cough<br />Fine bi basal crackles<br />O2 94% on air ( non smoker )<br />CXR shows ground glas...
Case 2<br />HRCT<br />Respiratory opinion<br />BAL<br />Commence Septin and Prednisolone whilst awaiting results of BAL<br...
GCSF<br />May not prevent sepsis<br />Have a low threshold for using in patients admitted with sepsis particulary if profo...
Prevention<br />Growth factors given prophylactically reduce but do not eliminate the risk<br />Drug dose modification<br ...
SVCO<br />
Mechanism<br />SVC compression by right upper lobe tumour <br />SVC compression by mediastinaladenopathy ( usually right p...
Case 1<br />63 years male, ex smoker of 5 years<br />3 month history of cough and weight loss<br />2 weeks of neck swellin...
Clinical Signs<br />Distended neck veins<br />Distended chest wall veins<br />Venous collaterals<br />Facial swelling/Plet...
Symptoms<br />Dyspnoea<br />Headache<br />Sensation of facial fullness worse on coughing and stooping<br />
Causes of SVCO<br />What malignant causes might you consider?<br />Any other causes?<br />
Malignant causes<br />Lung cancer ( both SCLC and NSCLC )<br />NHL<br />Hodgkins disease<br />Metastatic disease ( eg. bre...
Non malignant causes<br />SVC thrombosis secondary to central line or as a consequence of extrinsic compression<br />
Assessment of the patient<br />What does this involve ?<br />
Assessment of the patient<br />Full history including oncology history if exists<br />Assessment of severity of SVCO<br />...
Imaging<br />What do you look for on CT?<br />
Imaging<br />Mediastinal mass<br />Right upper lobe mass/disease<br />Associated thrombus<br />Collaterals<br />Associated...
Assessment of patient<br />If no previous oncology history and imaging suggestive of lung primary, arrange bronchoscopy+/-...
Management of patient<br />How do you manage?<br />
Management of patient<br />Manage as you investigate<br />Oxygen<br />Steroids – Dexamethasone  16 mg daily with gastric p...
Specific treatment<br />What tumours are chemosensitive?<br />
Chemosensitive tumours<br />SCLC<br />NHL<br />Hodgkins disease<br />Thymoma<br />Breast, colon and others some extent<br />
Potentially curable tumours<br />What are they?<br />
Potentally curable tumours<br />NHL<br />Hodgkins Disease<br />??? SCLC<br />Thymoma<br />
Radiotherapy<br />Generally palliative but may effect good relief of signs and symptoms<br />Cannot be repeated<br />
Recurrent SVCO<br />Consider chemotherapy depending on tumour type<br />Consider SVC stent<br />Consider anticoagulation<b...
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Oncological Emergencies comep OCT 2010

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Oncological Emergencies comep OCT 2010

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