Acute Oncology Presentations Caused by Disease

1. Acute Oncology Presentations
Caused by Disease
Dr Omar Din
Consultant Clinical Oncologist
Weston Park Hospital
Acute Oncology Study Day
9th October 2013

2. Types of Emergency
Biochemical
Hypercalcaemia
Hyponatraemia (SIADH)
Obstructive/structural
SVCO
Raised ICP
Pathological fracture
Spinal Cord Compression
Airway Obstruction
Pericardial Effusion
Pleural effusion
Ascites
Treatment Related
Febrile neutropenia
Tumour Lysis Syndrome
Extravasation
Diarrhoea
Nausea/vomiting

3. Case 1
• 59 year old lady
• 6 month history of lumbar back pain
• Referred to rheumatology
• Bone scan

5. Case 1
• Admitted
• Drowsy
• Dehydrated
• Abdominal pain
• Worsening back pain
• BP 90/60
• P 110

6. Case 1
• Bloods
• Hb 9.8
• Na 135
• K 4.0
• Urea 9.4
• Creat 135
• Ca 5.3
• Alk Phos 347

7. Malignant Hypercalcaemia
• Ca >2.6 mmol/l
• Causes:
– Bone metastases
– PTH-RP: – breast, renal, lung, head and neck,
myeloma, lymphoma
– (Primary Hyperparathyroidism)

8. Hypercalcaemia - Symptoms
• Constipation
• Fatigue
• Nausea/vomiting
• Confusion
• Polyuria
• Polydipsia
• Abdominal pain
• Dehydration

9. 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

10. • Bloods
– Hb 10.1
– Na 118
– K 4.2
– Urea 4.0
– Creat 60

11. • 9am Cortisol 500
• TSH 2.1
• Glucose 4.5
• Lipids normal
• Serum osmolality 260
• Urine osmolality 368
• Urine Na 98

12. 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

13. SIADH
• 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

15. 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

17. Case 3
• 78 year old lady
• Breast cancer 2008, node +, Her2 +
• Admitted via A & E
• Headache
• Facial and arm swelling
• SOBOE
• Fixed raised JVP
• Conjunctival oedema

20. 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.
• Often insidious onset
• Compensatory collaterals over chest wall
• Neck/face swelling
• Headache
• Dizziness
• Syncope
• Conjunctival oedema

21. 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

22. 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

23. Treatment
• 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)

24. Case 4
• 64 year old man
• Haematuria
• PS 0
• No PMH

25. 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

27. 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

28. Pathological Fracture
• Orthopaedic opinion –
stabilisation/reamings/biopsy
• Post operative radiotherapy – 20Gy in 5
fractions
• Mirel’s Risk
1 2 3
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

29. Case 4
• Treated with sunitinib
• Shortly afterwards developed reduced visual
acuity
• Seen by opthalmology
• Urgent phone call

30. 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

31. 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

33. Case 6

34. 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

35. Case 7

36. 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

37. Lymphangitis Carcinomatosa
• Treatment of underlying condition
• Dexamethasone
• Chemotherapy
• Endocrine Therapy
• Prognosis poor – 50% die within 3 months of
first symptom

38. The End