This patient presented with back pain, bilateral lower limb weakness and numbness, and bowel and bladder dysfunction. MRI revealed extensive spinal metastases resulting in malignant spinal cord compression. Emergent management was required to prevent permanent neurological injury, including high-dose steroids and consideration of radiotherapy or surgery. This case highlights the importance of promptly recognizing and treating malignant spinal cord compression.

1. Emergencies in oncology
Nadun Rubasinghe

2. Topics
 Neutropenic fever
 Chemotherapy induced nausea, vomiting
 Raised ICP
 Malignant spinal cord compression
 Tumor lysis syndrome

3. Case 1
47 F - Metastatic Breast Ca
Triage Fatigue, poor oral intake, fever, Breast Ca,
Comments had chemo 6 days ago
Breast Ca – 2005, L mastectomy (ER/PR+, Her2-,
Background T1N1M0)  FEC #6.
Axillary recurrence 2008Sx excision  XRT+TC
Bone + liver mets- Jan 2012, May 2012 XRT
L/spine, On palliative paclitaxel weekly.
Fatigue, LOA, felt feverish, nausea, diarrhea,
Presentation rest of ROS -ve

4. Are we worried about this patient ?
• Why ?
– Cancer itself is a serious condition
– Metastatic disease – affecting multiple organ systems
– Recent chemotherapy – immunosuppression

5. Approach to management
• Basics –
– Vitals (SBP 95, PR 90, T 37.8)
• Examination –
– Systemic Ex – NAD including PICC site in right arm
• While assessing the patient – vomited once, had a loose BM, says
now “feels hot” !
– Repeat vitals (SBP 90, PR 99, T 38.2)

6. Approach to management
What next ?
• Bloods –
– FBC & routine bloods, C/S 2 Sets inc PICC,
– CXR, urine m/c/s, ?sputum, stool m/c/s + CD toxin
• Medications –
– IV Tazocin, IV Ondanseteron, NS, Paracetamol,
– ? Antidiarrheals (Toxic megacolon if CD+ve)

7. FBC is available
WBC = 2 , ANC=0.6, (Hb 96, PLT 112)
What does this mean ?
Grade 3 Neutropenia
- Referred to Oncology/ Medical team
Grade 1 Grade 2 Grade 3 Grade 4
ANC 1.5-2 1-1.5 0.5-1 <0.5

8. Febrile Neutropenia
• Febrile neutropenia exists when a patient with a neutrophil count
less than 1.0x109/L has a temperature > 380 C, or if a patient is
systemically unwell with a clinical suspicion of sepsis.
• The major complication of febrile neutropenia is septic shock and
treatment is directed at preventing the development of this
complication. Early recognition of septic shock is essential to patient
survival.

9. High Risk Patients – Active cancer +
• Haematological malignancy
• Myelosuppresive chemotherapy
• Concurrent chemotherapy and radiotherapy
• Age >60
• Co-morbidities eg. Diabetes, poor nutritional status.
• Bone marrow involvement of cancer
• Delayed surgical healing or open wounds
• Unwell (eg hypotensive, oliguric)
• On steroid dose >25mg prednisolone daily
• Rapidly falling neutrophil count
• History of neutropenia
• Recent hospitalisation for infection

10. Assessment
Careful history and physical examination including:
• Type of cancer and recent treatment.
• Vitals
• Physical exam focusing on: Chest, Mucous membranes, Skin,
Venous access devices, Peri-anal area, Urinary tract,
Gastrointestinal Tract
• Signs of infection may be subtle or absent as neutropenic patients
may exhibit little or no inflammatory response

11. Differential diagnoses
• Tumor fever
– Progression of the underlying malignancy can be associated with tissue necrosis
and inflammation that can yield low-grade or high fevers that do not improve with
antibiotics. Patients with hematological malignancies often present with diurnal
fevers.
• Drug fevers
– Drug fevers are typically high fevers that are often cyclical in nature.
– Drug fevers may be associated with an eosinophilia, acute interstitial nephritis, or
drug-induced hepatitis.
– They should improve with discontinuation of the offending agent.

12. Differential diagnoses
• Thromboembolism
– Malignancy is a risk factor for thrombosis, which can cause fever.
– Signs or symptoms of a deep vein thrombosis with extremity pain, erythema, or
swelling may be present.
– Additionally, signs or symptoms of a pulmonary embolism may be present with
shortness of breath, tachycardia, chest pain, hypoxaemia, and cerebral
embolism with new neurological signs or symptoms.
• Paraneoplatic syndromes
– Many malignancies are associated with the development of paraneoplastic
syndromes, which are characterised by the development of auto-antibodies,
presumed to have developed in response to tumour antigens. The resultant
syndromes can mimic the known autoimmune syndromes. In addition, there are
a number of paraneoplastic syndromes that affect the nervous system and are
well characterised and associated with particular underlying malignancies.

13. Important to remember
• Chemotherapy patients who present with a fever greater than 38’ C
will be assumed to be neutropenic unless there is a white cell count
within the previous 24 hours to the contrary.
• Patients three months or less after a bone marrow transplant will be
considered to be equivalent to a neutropenic patient in risk and
treated accordingly independent of the neutrophil count.

14. Initial Investigations
• Blood tests: FBE,EUC,LFT, Coags, CRP
• Peripheral & Central line blood cultures (if patient has a central
venous access device) NB. Do not flush central venous access
device before withdrawal of blood for blood cultures, Do not discard
initial blood specimen when taking blood from central venous
access devices for blood cultures, use initial sample for blood
culture
• Mid stream urine sample
• Sputum for M/C/S if patient has a productive cough
• Faeces for M/C/S and Clostridium difficile toxin if there is diarrhoea
• Swab all wounds, recent IVC site, central venous access sites
• Chest x-ray

15. Antibiotic therapy
• As early as possible, after blood cultures have been collected
• Tazocin (piperacillin & tazobactam/piptazo) 4.5 g Q6H
• ? Vancomycin
• ? Antifungal
• Discuss with oncology / medical teams

16. Few more points to remember
• Neutropenic precautions/ Neutropenic diet
• Good hygiene
• Handwashing !
• Limit visitors
• NO PR exam, PR medications
• NO IDC

17. Case 2
61 M – Colorectal Ca
Triage High stoma output, nausea, vomiting, poor
Comments oral intake
CRC, s/p AR  adj IV chemo, currently on
Background Capecitabine, also taking lactulose and senna
High stoma output, 10-12 times previous two
Presentation days, Vomited X5, fatigue

18. Approach to management
• STOP Capecitabine + Laxatives
• Basics –
– Vitals (SBP 90, PR 120, T 36.6)
• Examination –
– Dehydrated Gr2-3, Systemic Ex – NAD, stoma site - excoriation.
0 1 2 3 4
None dry mucous membranes requiring IV fluid requiring IV fluid physiologic
and/or diminished skin replacement replacement consequences requiring
turgor (brief) (sustained) ICU; hemodynamic collapse

19. Approach to management
What next ?
• Bloods –
– FBC, EUC
• Medications –
– IV fluids
– IV antiemetics
• Blood Investigations – Cr 340, K+ 2.6

20. ARF with hypokalemia
IV Fluids, potassium replacement
• Repeat EUC in 12 hours
• Cr 145, K+ 3.2,
• Mg 0.58  is this significant ?
Magnesium was corrected,
• 36 hrs later K+ 3.6, Cr 105

21. Chemotherapy induced nausea & vomiting
• CINV is a common adverse event associated with cancer treatment.
• Up to 80% of patients undergoing chemotherapy experience nausea
and vomiting.
• The desire to avoid nausea and vomiting is so strong that patients
have postponed or even refused treatment.
• Additionally, CINV can impose limitations on the patient’s ability to
function socially, maintain employment, or complete daily activities.

22. Pathophysiology of
Chemotherapy-Induced Emesis

23. Pharmacologic agents
• Corticosteroids – Dexamethasone, higher doses
• Dopamine antagonists - Maxalon
• Serotonin (5-HT3) antagonists – Ondansetron
• NK-1 receptor antagonists
– Aprepitant (Emend) - Selective antagonist of the binding of Substance P to the
neurokinin 1 (NK1) receptor (125 mg PO day 1, 80 mg PO days 2-3)

24. Case 3
77 F – Recently Dx NSCLC, awaiting full staging
Triage Headache, N/V severe in morning, newly Dx
Comments lung Ca
NSCLC, staging not done yet. Heavy smoker, no
Background other cormorbities.
Headaches, N/V worse in mornings and with
Presentation laughing, coughing, sneezing and straining,
drowsy for 2 days

25. What's going on ?
• ? Intracranial pathology

26. Approach to management
• Vital signs – Stable
• Examination – GCS 15, ? Papiledema, no neck stiffness,
reduced air entry RUZ
• Bloods – unremarkable
• CXR

27. MRI brain

28. Management
• IV dexamethasone 16 mg with PPi
• Consider IV mannitol if not responding
Further management,
• Complete staging
• Neurosurgical – Stereotactic Bx/ Cranitomy and
resection
• Ventricular shunts
• Systemic chemotherapy

29. Case 4
47 M –Malignant Pheochromycytoma, liver/ bone mets
Triage Unable to walk, LL numbness, BNO 2 days
Comments
Malignant Pheochromycytoma, liver/ bone mets
Background S/P resection of primary – right adrenal, followed by
chemo 3 months ago
Progressive LL weakness x 5-6 days, now
Presentation unable to walk at all, a/w numbness over B/L
LL, Back pain, Denies HI /recent trauma
BNO x 2 days
ARU X1 day

30. Assessment
• Vital Signs – T 38, PR 100, BP 95/55
• Back Pain 6/10
• Symmetrical B/L LL weakness, hyperreflexia, sensory impairment
B/L LL
• Rest of systemic examination - NAD

31. What's going on ?
• Septic screen – negative
• Fever - ? Tumor fever
• Neurological symptoms – MRI
 Extensive skeletal metastasis
 Extradural soft tissue component cause severe canal narrowing
and cord compression at T6, T7 and T10 levels

32. Malignant spinal cord compression
Grading score of MSCC
Grade Severity
0 Involvement of the vertebral body without epidural space
1 Subarachnoid space impingement with no spinal cord deformation
2 Obliterated subarachnoid space and spinal cord deformation
3 Spinal cord deformation with no cerebrospinal seen

33. MSCC – Red flags
• Pain –lower back pain, worse on recumbent position
• Motor - May be hyperreflexic below the lesion and have
extensor plantars
• Sensory – ascending numbness and parasthesias
• Bladder/ bowel involvement – Usually late, autonomic
neuropathy presents usually as urinary retension

34. Management
• IDC
• Dexamaehtasone 8 mg TDS
• Angioembolisation of vertebral tumour
• T6 and T7 decompression corpectomy and fusion
• Tolerated procedure well with post op Hb of 98
• Sent to HDU for closer monitoring
• Well and stable, sent to general WD - POD 5
• Later on had a course of RT to T10

35. Case 5
57F – Newly diagnosed DLBCL
Triage Requested admission for staging and cycle 1 of
Comments RCHOP
HTN, Newly Dx DLBCL
Background
No specific complaints on admission, except
Presentation some LN+

36. Management
• CT – T/A/P
• PET CT
• BM
• 2DECHO
• Hydration and Allopurinol prior to chemotherapy
• Then proceeded with chemotherapy
• Why hydration and allopurinol ?

37. Tumor lysis syndrome
• Metabolic derangements caused by the massive and
abrupt release of cellular components into blood after
rapid lysis of malignant cells.
• ↑phosphate, ↑K, ↑uric acid, ↓Ca
• Uric acid crystals/ Ca/ PO4 in renal tubules  impaired
renal function, ARF, even death
• ↑phosphate leads to ↓Ca  tetany, seizures, arrhythmia
• ↑K  life-threatening arrhythmia

38. High risk patients
• High tumor cell proliferation rate, large tumor burden,
tumor chemosensitivity
• ALL, AML, NHL, Burkitt’s Lymphoma (heme malignancies)
>>>Small cell >> Hodgkin’s disease, Multiple Myeloma,
>Solid Tumors ( breast, GI, prostate etc.)
• Signs and Symptoms are non-specific - Can occur
before chemo, but usually within 12 to 72hrs after
starting chemo

39. Signs and symptoms
• Nausea • Sudden death
• Vomiting
• Diarrhea
• Anorexia
• Syncope
• Lethargy
• Edema
• Fluid overload
• Cramps

40. Monitoring
• Vitals, ECGs
• Electrolytes, renal functions
• Uric acid, LDH

41. Management
• “The best management is prevention.”
• FLUIDS and HYDRATION
– Aggressive hydration and diuresis
– Improve intravascular volume, renal blood flow, GFR (decrease
[solute] in distal nephron/renal microcirculation)
– +/- diuretics (contraindicated in hypovolemia and obstructed
uropathy)

42. Allopurinol
• Competitive inhibitor of xanthine
oxidase which decreases
conversion of purine metabolites
to uric acid. Used
prophylactically for TLS
• Prophylactic option for patients
with a risk of TLS

43. References
1. Clostridium difficile diarrhea induced by cancer chemotherapy
www.Archinte.Jamanetwork.Com/article.Aspx?Articleid=616556
2. Loperamide related toxic megacolon in clostridium difficile colitis.
www.Ncbi.Nlm.Nih.Gov/pmc/articles/pmc2429653/
3. Common toxicity criteria (ctc) www.Eortc.Be/services/doc/ctc/ctcv20_4-30-992.Pdf
4. Febrile neutropenia management guidelines
www.Gha.Net.Au/uploadlibrary/394074071febrile_neutropenia_management_guidelines0210.Pdf
5. Mechanism of hypokalemia in magnesium deficiency
www.jasn.Asnjournals.Org/content/18/10/2649.Abstract
6. Antiemetics: american society of clinical oncology clinical practice guideline update
www.Asco.Org/ascov2/practice+%26+guidelines/guidelines/clinical+practice+guidelines/antiemetics%3a+
american+society+of+clinical+oncology+clinical+practice+guideline+update
7. Brain metastases
www.aans.org/Patient%20Information/Conditions%20and%20Treatments/Brain%20Metastasis.aspx
8. Emergency treatment of malignant extradural spinal cord compression: an evidence-based guideline.
www.jco.ascopubs.org/content/16/4/1613.full.pdf
9. The Tumor Lysis Syndrome www.nejm.org/doi/full/10.1056/NEJMra0904569
10. Allopurinol www.nlm.nih.gov/medlineplus/druginfo/meds/a682673.html

44. Thank You!