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Oncologic emergencies
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Oncological Emergencies

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Oncological Emergencies

  1. 1. ONCOLOGY EMERGENCIES
  2. 2. Oncological Emergencies May be presenting feature of cancer Can occur in patients with curable disease or those suitable for long term palliation Most emergencies are similar in presentation and management to “standard” medical emergencies However they may be complicated by side effects of chemotherapy (e.g. renal/liver/bone marrow impairment)
  3. 3. 1. Pulmonary embolism
  4. 4. 51 year old women 6 month history of stage III ovarian cancer Day 10 cycle 2 of carboplatin / taxol chemotherapy 2 days previously commenced on salbutamol inhaler by GP for wheeze Now has: • Pleuritic right chest pain • Dry cough • Shortness of breath when walking
  5. 5. On Examination Centrally cyanosed Distressed by pain on deep breathing Temperature : 37.5 oC Pulse rate : 120 bpm Respiratory rate : 25 per min. Blood Pressure : 110/65 mmHg No leg swelling
  6. 6. On Examination JVP : Elevated 3cms Heart sounds : Gallop rhythm “Creaking noise” at right lung base Mild wheeze bilaterally No crepitations Breath sounds vesicular
  7. 7. Investigations FBP: White cell count elevated – Neutrophils: 16 x109/l (n: 2.0-7.5) U+E: Normal Arterial Blood Gas: • PO2 : 7 kPa (n: 10-14) • PCO2 : 3 kPa (n: 4-6) • pH : 7.5 (n: 7.25-7.35)
  8. 8. COAG Screen D-Dimer: 4.0 (n: < 0.5) Other coagulation factors normal
  9. 9. Chest X-Ray
  10. 10. ECG Findings
  11. 11. Important to rule out this!
  12. 12. CT Chest
  13. 13. Pulmonary Angiogram
  14. 14. Management Oxygen: 100% Commence Low Molecular Weight Heparin (e.g. Enoxaparin) Consider either: • Commencing warfarin after 24 hours Or • Long term LMWH If haemodynamically unstable then thrombolysis via pulmonary arterial catheter
  15. 15. Summary – Pulmonary Embolism • Cancer patients are more prone to PE as they can be in a HYPERCOAGULABLE state. This can be due to cancer related blood constituent changes or pressure on vessel walls causing stasis/altered blood flow • Active cancer is on the WELLS score criteria for DVT • Symptoms: – SOB – Pleuritic chest pain – Dry cough – May have calf pain/swelling • Signs – Raised JVP – Tachycardia and tachypnoea, S1Q3T3 – “gallop rhythm” – high output states – Peripheral/central cyanosis – Vesicular breath sounds in most areas
  16. 16. Summary – Pulmonary Embolism • Investigations – ABG: decreased PaO2, decreased PaCO2 (due to reduced ventilation), can cause respiratory alkalosis – ECG: right heart strain S1Q3T3. rule out MI – D-dimer: raised (non-specific) – CTPA/VQA scan: identify non-perfused part of lung – CXR: wedge infarct • Treatment: – Oxygen therapy – Enoxaparin 1.5mg/kg/day – Consider starting warfarin for 6m – Analgesia: NSAIDs – ENOXAPARIN works best for cancer patients
  17. 17. 2. Spinal cord compression
  18. 18. Spinal Cord Compression • Mechanism – Lymphoma – mediastinal or retroperitoneal nodes or mets from vertebral bodies • Symptoms – Back Pain – syndrome insidious – Paraplegia – bowel and bladder dysfunction – 12 – 24 hr progression – Permanent when completed
  19. 19. Spinal Cord Compression • Diagnosis – Myleogram or MRI • Treatment – Steroids – Decompression Laminectomy – Chemotherapy – X- ray therapy
  20. 20. Case: 62 Year old man Locally advanced prostatic carcinoma 4 years previously – treated with radiotherapy and hormones Relapsed disease 1 year ago now receiving combined anti-androgen (Bicalutamide) and LHRH agonist (Goserelin) treatment for elevated PSA Over past 4 days: • Increasing back pain and falls at home • Constipation and urinary retention for 3 days • Commenced on MST 30mg b.d by GP
  21. 21. On Examination Orientated but distressed by pain Tone in legs: ↓ Power in legs: 4/5 bilaterally Sensation: ↓ in saddle area Anal tone: ↓ Reflexes : ↓ bilaterally Plantars: equivocal
  22. 22. Lab tests FBP : Hb : 9.8g/dl (12-18) WCC : 2.0x109/l (4.0-10.0) Plts : 90x109/l (150-450) U+E : Na+ : 145 mmol/l (135-145) K+ : 4.5 mmol/l (3.5-5.0) Ca2+: 2.4 mmol/l (2.2-2.65) Alb : 20 g/dl (35-45)
  23. 23. MRI of SPINE
  24. 24. Management Bed rest Catheterise Dexamethasone 8 mg b.d. intravenously/orally Consider urgent surgical decompression or radiotherapy Analgesia : NSAID +/- opioid Consider Ranitidine or a proton pump inhibitor (omeprazole) for gastro- protection, especially if NSAID used
  25. 25. Subsequent results Patient had Emergency Radiotherapy – 20Gy in 5 fractions over 5 days Prostatic specific antigen (PSA): 100u/ml Isotope bone scan: multiple hot spots throughout skeleton Later received I.V. Samarium for analgesic purposes
  26. 26. Radiotherapy Treatment Field
  27. 27. Positive bone scan: Prostate Cancer
  28. 28. MSCC: Refer for surgery if… Survival likely to be over 3 months Unknown primary requiring tissue diagnosis Previous radiotherapy to spine Bone fragment compressing spinal cord Single site of compression and no systemic disease
  29. 29. Summary – Spinal cord compression • Bone involvement from cancer LBTKP – Commonly: lung, breast, lung, myeloma, lymphoma – Less common: thyroid, kidney, bladder, bowel, melanoma • Can be initial presentation of malignancy: prostate, breast, myeloma • Crush fracture or tumour extension common • Occasional intramedullary METS • 66% cases: thoracic cord • Symptoms: – Back pain: within a nerve root, worse on coughing/straining – Saddle anaesthesia – Urinary retention/dribbling/incontinence – late – Constipation/dribbling/incontinence of faeces – late – Loss of power and sensation distal to area of obstruction – Limb weakness/unsteadiness when walking – Brisk reflexes early, absent reflexes late
  30. 30. • Signs: – Reduced tone in legs – Reduced reflexes late. Brisk early. – Decreased power and sensation – Reduced anal tone – Upgoing plantars (late) • Investigations – MRI whole spine – Bone scan (radioisotope) – If no Hx of malignancy, investigate for malignancy – CT chest/abd/pelvis • Management – Bed rest and catheter – DEXAMETHASONE 8MG BD IV/PO – Analgesia – Surgery or radiotherapy to METS (20Gy in 5fractions over 5days) • Indications for surgery: survival likely >3m, single site compression, no systemic disease, previous radiotherapy to spine, unknown 1o requiring Dx, bone fragment compressing cord, no response to steroids, no cancer Summary – Spinal cord compression
  31. 31. Cauda Equina Syndrome • Tumours below L1/L2 level • Symptoms: – Bilateral sciatic pain – Bladder dysfunction (retention/incontinence) – Impotence – Saddle anaesthesia – Loss of anal sphincter tone – MUST DO PR EXAM!!! – Weakness and wasting of gluteal muscles • Diagnosis by MRI spine • Rx: dexamethasone 8mg IV BD, RT, Sx
  32. 32. 3. Neutropenic sepsis
  33. 33. 25 year old man History of testicular teratoma Currently day 14 cycle 2 of BEP chemotherapy 2 day history of sore throat Admitted with history of collapse at home; found by parents unrousable
  34. 34. On examination Drowsy, incoherent Cold peripheries Temperature: 36 oC Pulse: 134 bpm low volume Blood pressure: 75/35 mmHg Hickman line in situ Chest: clear Abdominal examination: normal
  35. 35. Immediate management Oxygen by mask Get peripheral intravenous access: take blood for : FBP/U+E/Bacterial culture/GP and hold Commence intravenous fluids eg colloid/crystalloid Cultures from : Hickman line, urine, throat, diarrhoea if present Monitor urinary output by catheter (keep >30mls/hr) Commence broad spectrum antibiotics
  36. 36. Continued management FBP : Hb : 10.1g/dl (12-18) WCC : 0.4 x109/l (4.0-10.0) Plts : 113x109/l (150-450) ANC: 0.1 X 109/l (2.0-7.5) U+E : Na : 134mmol/l (135-145) K : 3.5mmol/l (3.5-5.0) Urea: 13.7mmol/l (3.3-8.8) Creat: 167mmol/l (40-110) Blood cultures: E Coli Urine Culture: E Coli
  37. 37. Continued management Continue with broad spectrum antibiotics, with an aminoglycoside included • (BCH policy TAZOCIN and Gentamicin) Commence Granulocyte Colony Stimulating Factor (GCSF) to raise neutrophil count over 1.5x109/l • E.g. Filgrastim (Neulasta®) 30 million units s.c. daily Prophylactic GCSF next cycle of treatment
  38. 38. Result Recovered fully from infection Further 2 cycles of BEP uneventful Now disease free for 3 years and well
  39. 39. Summary – Neutropenic Sepsis • Chemotherapy can cause bone marrow suppression, leading to pancytopenia. The reduction in WCC (neutropenia) leaves the patient at risk of developing infections. This can quickly lead to sepsis and septic shock • Cannot judge sepsis by temperature!!! • Symptoms and Signs: – Drowsy, decreased level of consciousness, confusion – Cold peripheries – Tachycardia – Hypotension – May be signs of infection e.g. cough in chest infection • Investigations: – Cultures: blood, urine, throat, current lines (hickmans, catheter) – Venous access, IV fluids: colloids – Catheter to monitor urinary output – Oxygen – IV Abx in accordance with hospital guidelines – Granulocyte Colony Stimulating Factor (CGSF) if haemodynamically unstable/slow response – Give GCSF prophylactically with next dose of chemo
  40. 40. 4. Hypercalcaemia
  41. 41. Hypercalcaemia • Mechanism – Mets to bone, breast, lung, renal – Myeloma – Ectopic parathyroid hormone production • Symptoms – Nausea – Vomiting – Constipation – Urinary frequency – Lethargy – Confusion – Coma – Death
  42. 42. Hypercalcaemia • Diagnosis – Serum Calcium level - correct for albumin • Therapy – Hydration - saline – Diuresis - Lasix – Mithramycin – Steroids
  43. 43. Case: 54 year old female 1 year ago treated for non-small cell lung cancer right side Pneumonectomy and Radiotherapy to right lung field Well until 7 days ago
  44. 44. Symptoms 7 day history of general aches : commenced on MST 20mg bd by GP 5 day history of thirst, polyuria and constipation 4 day history of confusion
  45. 45. On Examination Uncooperative Dehydrated Temp: 37.0oC Blood pressure : 90/60mmhg pulse 120bpm No obvious neurological deficit Abdominal exam: Indentable mass left iliac fossa
  46. 46. Lab tests and investigations U+E Na 154mmol/l (135-145) K+: 6.0 mmol/l (3.5-5.0) Ca 3.0mmol/l (2.10-2.60) Alb 18g/dl (40) FBP normal Glucose: 3.3mmol/l Urine specific gravity: 1.050 ECG: Decreased QT interval.
  47. 47. Management Immediate rehydration 4-6 litres N.saline over 24 hours Ensure urinary output>30ml/hr After 24 hours give intravenous bisphosphonate: • eg Zolendronic Acid (ZOMETA®) 4mg
  48. 48. Further Investigations CXR : mass right hilum Isotope bone scan: no bone mets CT scan : mass right hilum, new liver metastases
  49. 49. Outcome Not fit enough for chemotherapy Cared for at home by hospice homecare Managed with regular oral bisphosphonates, non steroidal anti-inflammatories and MST 20mg b.d Died at home 2 months later
  50. 50. Hypercalcaemia of Malignancy Particular Association with: • Breast cancer • lung cancer (especially non-small cell) • multiple myeloma • prostatic cancer Affects 20-40% of all patients with advanced cancer 3 Mechanisms: 1. Parathyroid hormone-related protein 2. Local osteolysis due to bone metastases. 3. Tumour production of Vitamin D metabolites. Barri Y et al. Hematol Oncol Clin North Am, 10(4):775-90
  51. 51. Summary – Hypercalcaemia • Common malignancy related causes: – Parathyroid hormone related protein – Local osteolysis due to bony metastasis – Tumour producing Vitamin D metabolites • Commonly seen with BREAST, LUNG (nonsmallcell), multiple myeloma and prostate • Affects 20-40% pts with advanced cancer • Signs and Symptoms: – Bones: bone pain, pathological fractures – Stones: polyuria, polydipsia, kidney stones – Moans: confusion, depression, decreased level of consciousness/coma – Groans: constipation, pancreatitis, epigastric pain • Investigations: – U&E: Na and K raised due to dehydration, calcium RAISED >2.6 – Cause unknown: CTCAP, CXR, – ECG: decreased QT interval • Management – 4-6l saline over 24hrs – IV bisphosphonates e.g. zolendrenic acid – Catheter to monitor urine output
  52. 52. Corrected Calcium • Corrected calcium is calculated from the measured calcium. Calcium is bound to albumin so the amount of measured calcium depends on the level of albumin. Corrected calcium estimates the calcium level if the albumin was within the normal range. • Corrected calcium = measured calcium + (40-Alb) x 0.02 • E.g. Ca 3.46, Albumin 28 – Corrected calcium = 3.46 + (40-28) x 0.02 = 3.46 + 0.24 = 3.7 mmol/l.
  53. 53. Differential Diagnosis of thirst, polyuria, constipation • Diabetes mellitus • Diabetes insipidus • Hypercalcaemia • Hypernatraemia • Psychogenic polydipsia
  54. 54. 5. Raised ICP/ Brain metastases
  55. 55. Increased Intracranial Pressure • Mechanism – Primary Brain Tumor – Metasitic Tumor – Meninges • Diagnosis – Headaches – Personality Changes – Lethargy – Coma – Papilledema – Stiff neck – Fixed pupil – tentorial herniation – CT/MRI of Brain – LP - cells
  56. 56. • Treatment – Steroids – Crainotomy – primary – Whole Brain Irradiation – 3000 r – 2 weeks – Meningeal – MTX or ARA C IT Increased Intracranial Pressure
  57. 57. Case: 45 year old women History of T2 N1 M0 grade 3 ER+ve breast cancer 4 years ago Post-surgically had 6 cycles of FEC “100” chemotherapy followed by oral tamoxifen 20mg daily Still taking tamoxifen Unwell for past 2 weeks
  58. 58. Symptoms 2 week history of irritability Persistent nausea and vomiting 2 falls at home No weakness, no double vision, no headaches
  59. 59. On Examination Bad tempered (not in keeping with previous character) Apyrexic No obvious central neurological abnormalities Peripherally : ? Upgoing left plantar BP : 160/110mmhg, pulse 45bpm
  60. 60. Lab Tests FBP: Normal U+E and calcium: Normal
  61. 61. CT Brain
  62. 62. Immediate management Dexamethasone 8mg bd intravenously/orally Arrange cranial radiotherapy Anti-epileptic drugs if required to control seizures: eg carbamazepine Advise not to drive, patient required to inform DVLA(N.I.)
  63. 63. Whole head Radiotherapy Field
  64. 64. Outcome Improved overnight on dexamethasone Given radiotherapy over one week (20 Gray in 5 fractions) CT scan: multiple lung and liver mets Bone scan : multiple bone mets Managed with MST, reducing dose of steroids and bisphosphonates until death 3 months later
  65. 65. Brain Metastases 20-40% of patients with advanced cancer Tenfold more common than brain primary Overall survival 6 months Most often associated with: • Lung cancer • Breast Cancer • Melanoma But increasing with other cancers! Patchell RA. Cancer Investigation 1996;14:169-77
  66. 66. Neurosurgical Intervention Indications: 1. Solitary brain metastasis and controlled systemic disease, especially renal cell cancer, teratoma or sarcoma 2. Unknown diagnosis (Solitary Brain lesion). May not be cancer 3. Rapidly deteriorating condition 4. Hydrocephalus (shunting)
  67. 67. Summary – Raised ICP/Brain Mets • Raised ICP: space-occupying lesion, hydrocephalus, benign intra-cranial HTN • Brain M increasing in prevalence since people are surviving longer with cancer • 20-40% pts with advanced disease: • Particularly LUNG, BREAST, MELANOMA • Symptoms: – Headaches- worse in the morning and on stooping – N&V – worse in morning – Confusion, altered behaviour – Focal neurological signs – Seizures • Investigations – CT brain • Management – DEXAMETHASONE 8MG BD IV/PO: shrink mass/inflammation to reduce risk of coning – whole brain radiotherapy if 2+ METS – Anti-epileptics for seizures: carbamazepine – ***can’t drive ever again OSCE!!!!!!!!!!! – Surgery: solitary met with controlled systemic disease, unknown diagnosis need sample, rapid deterioration, hydrocephalus (shunting)
  68. 68. 6. Chemotherapy related thrombocytopenia
  69. 69. 26 year old man Receiving CHOP chemotherapy for stage IIIA non-Hodgkins lymphoma Currently day 15, cycle 3 of treatment Admitted with severe epistaxis
  70. 70. On Examination Obvious nose bleed, left side Temperature: 36oc BP : 120/55mmHg Multiple petechiae over trunk and limbs
  71. 71. Petechiae
  72. 72. Immediate management Pressure on soft part of nose Get IV access Send FBP, U+E, Coag screen, D-dimer Group and cross match 2 units
  73. 73. Results FBP : Hb: 7.9 g/dl (12-18) WCC: 0.1 x109/l (4.0-10.0) Plts : 3 x109/l (150-450) ANC: < 0.1 x109/l (2.0-7.5) U+E: Normal Coagulation screen: Normal D-Dimer: 1.0
  74. 74. Management 6 donor platelets immediately, aim to raise platelet count over 10x109/l. (over 20 if uraemic or infected) Transfuse 2 units packed red cells, aim to raise Hb over 10g/dl If required cauterise nose If DIC : correct coagulation abnormality with fresh frozen plasma and treat underlying cause
  75. 75. Outcome Bleeding stopped with platelet transfusion Received 6 cycles of CHOP in total Now 5 years from treatment. Well, no evidence of recurrent disease
  76. 76. Summary – Chemo Thrombocytopenia • Bone marrow suppression leads to thrombocytopenia, leucopenia and anaemia • Signs & Symptoms – Increased tendency to bleed, difficult to stop – Petechiae – Large haemorrhage  hypovolaemic shock • Investigations – FBC – Coag screen – D-dimer: raised may indicate DIC • Management – Give platelets until above 10, 20 if septic – May need packed red cells if haemorrhage – If DIC: fresh frozen plasma required • DIC occurs when the coagulation and fibrinolysis systems are dysregulated. This can commonly occur in lung, pancreas, stomach and prostate cancer, as well as APL. Many small clots form and are subsequently broken down. This process leads to the consumption of clotting factors and platelets leading to increased risk of bleeding.
  77. 77. Bone Marrow Suppression • Major dose limiting factor in chemotherapy • RBC survive 120days, platelets 8days, neutrophils 1-2days so early problems are neutropenia and thrombocytopenia • Neutropenia particularly if line/catheter in/previous infection/open wound… • Management of neutropenic pt: – Blood cultures (peripheral and central if line in) – Sputum culture – Urine analysis and culture – CXR – Physical exam, swabs • Treatment: – Wide spectrum Abx e.g. IV tazocin • Low Hb: consider packed cells, investigate cause, rule out DIC
  78. 78. Lines • Hickman: – under clavicle – Tunnel catheter – Into subclavian vein, down to superior vena cava • PICC: – Peripherally inserted central catheter
  79. 79. 7. Superior Vena Cava Syndrome
  80. 80. SVC Syndrome • Mechanism – Masse(s) in chest/mediastinum compress SVC – Lymphoma – Hodgkin's – Lung – Breast • Symptoms – Facial Edema – Periorbital Edema – Cyanosis – speed determines collateral pattern on chest wall
  81. 81. • Acute or sub-acute • Increased venous pressure • Facial oedema, plethora • Dilation of veins on chest wall and neck • Development of collateral veins • Moderate to severe resp distress • Conjunctival oedema
  82. 82. • CNS complaints - headache, drowsy, visual disturbances • Dyspnoea • Cough • Cyanosis • Chest pain • Aggravated by changes in position - stooping / bending forward • Dysphagia
  83. 83. SVC Syndrome • Diagnosis – Chest X-ray – right sided mediastinal mass – Radionucleotide SVC gram – Tissue Diagnosis – may have to wait • Therapy – X-ray therapy – high dose – Steroids – Chemotherapy
  84. 84. • T Cell Leukaemia / Lymphoma • Kaposi Sarcoma
  85. 85. Case: 67 year old man History of stage IV non small cell lung cancer currently receiving Gemcitabine/ Carboplatin chemotherapy 2 day history of headache (worse when stooping) and “puffy hands”
  86. 86. On Examination Plethoric face Dilated veins over chest wall and upper limbs Arms and neck swollen
  87. 87. CXR: widening of the upper mediastinum
  88. 88. SVC Venogram: Catheter in external Jugular vein
  89. 89. Investigation CXR: widening of the upper mediastinum Venogram: Extrinsic compression of SVC CT scan with contrast: dilated collateral veins. Mass in right upper mediastinum (investigation of choice)
  90. 90. Management 28% Oxygen via mask Dexamethasone 8mg i.v. b.d Arrange urgent stenting if diagnosis is NSCLC Consider Radiotherapy Urgent chemotx rather than XRT if chemosensitive tumour
  91. 91. Outcome Had urgent stenting and good symptomatic relief Followed by radiotherapy to mediastum and primary tumour site Chemotherapy discontinued as disease progression on treatment Lived a further 5 months before dying of a right lower lobar pneumonia
  92. 92. SVC Obstruction Caused by: 1. Extrinsic compression due to tumour or nodes (90%) – breast cancer, lung cancer (right upper lobe), lymphoma, thymoma 2. Thrombus (10%) – central line, pacing wire.
  93. 93. Management options SVC Stenting if NSCLC or previous XRT Radiotherapy Urgent chemotherapy if chemosensitive tumour Thrombolysis and anticoagulation if due to clot Arke YS. Seminars in Oncology 2000;27:262-74
  94. 94. Summary – SVC obstruction • Obstruction of the SVC occurs commonly with lung tumours and lymphomas which can press on SVC (right sided tumours) • Signs & Symptoms – Raised JVP – Puffy face and arms – Dilated veins on chest wall – Plethoric face – Headache (worse on stooping), visual disturbance (papilloedema) • Investigations – CXR: widened mediastinum/lung tumour – SVC venogram – CT with contrast • Management – Oxygen – Dexamethasone 8mg BD – Stent/radiotherapy/chemotherapy as appropriate • External compression: breast cancer, lung cancers, lymphoma, thymoma 90% • Internal thrombosis: central line, pacing wire 10% • DDx: heart failure, tamponade, external jugular vein compression
  95. 95. Stridor • Benign or malignant causes: – Non-malignant: foreign body, tracheal stenosis, vocal palsy – Malignant: primary respiratory tract tumours, bronchial (carina) tumours/ thyroid, mediastinal lymphadenopathy or MET • Signs and Symptoms – Goitre – Weight loss – Clubbing • Investigations – CXR: widening of mediastinum, 1o lung cancer – Bronchoscopy: biopsy/cytology – CT scan – Mediastinoscopy • Treatment: – Dexamethasone 8mg IV BD – Tumour debulking: radio/surgery
  96. 96. Obstruction • Intestinal – Pelvic cancers: ovarian 6-42%, cervical 5%, colonic 10-30% – May be complete, subacute or functional – Signs & symptoms: N&V, colicky pain, constipation, disyension, dehydration, projectile vomiting – Inv: erect and supine abdominal x-ray, barium studies, MRI – Treatment: IV fluid, NG tube, surgery/radiotherapy • Urinary Tract – Causes: bladder, prostate, cervis, pelvic cancers – Symptoms: asymptomayic, pain – Inv: abdominal US, cystoscopy
  97. 97. Misc.
  98. 98. Tumor Lysis Syndrome • An oncologic emergency caused by very sudden and rapid tumour cell death in which the intracellular contents are released causing metabolic abnormalities and acute kidney injury • May occur spontaneously, or with the initiation of chemotherapy
  99. 99. Tumor Lysis Syndrome • Mechanism – Rapid necrosis of tumour cells – Release of massive intracellular material into the circulation - metabolic load – Ascites – Renal impairment – Arrhythmias
  100. 100. Patient’s at risk of TLS • Tumours with rapid rate of growth / high cell turnover - high LDH • High bulk of malignant disease - high tumour burden, widespread mets, bm involvement • Advanced stage of disease • Renal impairment at time of diagnosis • Laboratory evidence of tumour lysis syndrome
  101. 101. Tumor Lysis Syndrome • Diagnosis – Potassium increased – Phosphate increased – Calcium decreased – Uric Acid increased – Acidosis – Azotemia
  102. 102. Tumor Lysis Syndrome • Treatment – Correct acidosis, potassium, uric acid – Diuresis – Dialysis if needed • Prompt treatment can prevent death
  103. 103. Mucositis/Oesophagitis • Mechanism – Radiation therapy – Chemotherapy – Antitumor antibiotics – Antimetabolics • Symptoms – Pain – Vomiting
  104. 104. Mucositis/Oesophagitis • Treatment – Hydration – Mycostatin/Magic Mouthwash – Kepivance (palifermin) 60 mcg/kg/d for 3 days before and after chemo – Gelclair (coating agent) – Recombinant Keratiocyte Growth Factor
  105. 105. • Antibiotics • Antivirals • Other – Morphine Patch – TPN/nutritional support Mucositis/Oesophagitis
  106. 106. • Avastin (Bevacizumab) • Erbitux (Cetuximab) • Tarceva (Erlotinib) • Iressa (Gefitinib) • Gleevec (Imatinib) • Rituxan (Retuximab) • Others….. New Drugs New Complications
  107. 107. • Avastin – Abdominal Perforation – Wound dehiscence after surgery – Stroke risk • Erbitux – Acneform Rash 90%! (10% severe) • Rituxan (Anti CD-20 antibody) – Anaphylactic reaction • Tarceva – Acneform Rash, pulmonary toxicity • Iressa – Rash, pulmonary toxicity New Drugs New Complications
  108. 108. • Acniform Rash New Drugs New Complications
  109. 109. Emergencies • Cardiovascular – Pericardial Tamponade – Superior Vena Cava Syndrome • Central Nervous System Emergencies – Increased Intracranial Pressure – Spinal Cord Compression • Gastrointestinal – Bowel Obstruction – Bowel Perforation – Ascites – Esophageal Obstruction and Perforation
  110. 110. Emergencies • Hematologic Emergencies – DIC – Leukostasis – Thrombocytopenia • Infectious Emergencies – Sepsis in the leukopenic patient – Disseminated Viral Infections – Fungal and Parasitic Diseases
  111. 111. Emergencies • Metabolic Emergencies – Hyperuricemia – Hypercalcaemia – Hypoglycemia – Lactic Acidosis – Tumor Lysis Syndrome • Orthopedic Emergencies – Pathologic Fracture
  112. 112. Emergencies • Waldenstroms – Hyperviscosity Syndrome – Plasmaphoresis
  113. 113. Emergencies • Renal Emergencies – Ureteral Obstruction – Pelvic Tumors • Respiratory Emergencies – Airway Obstruction – Pneumothorax – Effusion • Symptomatic Emergencies – Pain – Vomiting – Mucositis – Dyspnea
  114. 114. Pericardial Tamponade • Mechanism – Fluid in pericardial sac due to metastaic tumor – Post X-ray treatment – 4000 r – Decreased CO because of decreased venous return • Symptoms – Dyspnea – Confusion – Coma – Distended neck veins – Pulses Paradoxes – CHF
  115. 115. Pericardial Tamponade • Diagnosis – Enlarged heart – CXR – sac-like heart – Echo • Treatment – Percardiocentesis – Catheter SFU – X-Ray Therapy – Surgery – window vs. pericardiectomy
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