Oncological Emergencies


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Oncological Emergencies

  1. 1. OncologicalOncological EmergenciesEmergencies Dr. Gary Harding MD, FRCPCDr. Gary Harding MD, FRCPC Medical Oncology FellowMedical Oncology Fellow CancerCare ManitobaCancerCare Manitoba
  2. 2. CASE 1…CASE 1…
  3. 3. Mr. SVMr. SV  ID:ID: 65 year old male with PMHx of65 year old male with PMHx of CAD and emphysemaCAD and emphysema  EC:EC: present to clinic with one weekpresent to clinic with one week history of increasing SOBhistory of increasing SOB  HPI:HPI: 3 month history of weight loss,3 month history of weight loss, decreased appetite, a change in hisdecreased appetite, a change in his chronic cough, and intermittentchronic cough, and intermittent hemoptysishemoptysis
  4. 4. On Physical ExaminationOn Physical Examination  Inspection:Inspection:
  5. 5. Respiratory ExaminationRespiratory Examination  StridorStridor  Dullness to percussion on right lowerDullness to percussion on right lower lung fieldslung fields  Increased tactile fremitus to rightIncreased tactile fremitus to right lower lung fieldslower lung fields  Decreased A/E to right lower lungDecreased A/E to right lower lung fieldsfields
  6. 6. Chest X-Ray…Chest X-Ray…
  7. 7. right pleural effusion
  8. 8. ThoracentesisThoracentesis  ExudateExudate  Gram stainGram stain – NegativeNegative  AFB stainAFB stain – NegativeNegative  CytologyCytology – non-small cell lung cancernon-small cell lung cancer Large cell typeLarge cell type
  9. 9. T1-weighted axial MRI demonstratingT1-weighted axial MRI demonstrating paratracheal soft tissue mass that invades intoparatracheal soft tissue mass that invades into the SVCthe SVC
  10. 10. Superior Vena CavaSuperior Vena Cava SyndromeSyndrome
  11. 11. DefinitionDefinition  Obstruction of blood flow in theObstruction of blood flow in the superior vena cava results in signssuperior vena cava results in signs and symptoms of SVC syndromeand symptoms of SVC syndrome
  12. 12. EtiologyEtiology  Caused by either invasion or externalCaused by either invasion or external compression of the SVC bycompression of the SVC by contiguous pathologic processcontiguous pathologic process  Right lung pathology, lymph nodes,Right lung pathology, lymph nodes, other mediastinal structures, orother mediastinal structures, or thrombosisthrombosis
  13. 13. EtiologyEtiology  Before antibiotics the most commonBefore antibiotics the most common causes were from complications ofcauses were from complications of untreated infectionuntreated infection – Syphilitic thoracic aneurysmsSyphilitic thoracic aneurysms – fibrosing mediastinitisfibrosing mediastinitis  Malignancy is presently the mostMalignancy is presently the most common causecommon cause
  14. 14. Symptoms and SignsSymptoms and Signs  As the obstruction develops venousAs the obstruction develops venous collaterals are formedcollaterals are formed  Symptom onset depends on speed ofSymptom onset depends on speed of SVC obstruction onsetSVC obstruction onset  Malignant disease can arise in weeksMalignant disease can arise in weeks to monthsto months – Not enough time to develop collateralsNot enough time to develop collaterals  Fibrosing mediastinitis can takeFibrosing mediastinitis can take years to have symptomsyears to have symptoms
  15. 15. Symptoms and SignsSymptoms and Signs  Central venous pressures remainCentral venous pressures remain high even in collateralshigh even in collaterals – High pressures cause the characteristicHigh pressures cause the characteristic clinical pictureclinical picture  Shortness of breath is the mostShortness of breath is the most common symptomcommon symptom11 1. Parish, JM, Marschke, RF Jr, Dines, DE, Lee, RE. Etiologic1. Parish, JM, Marschke, RF Jr, Dines, DE, Lee, RE. Etiologic considerations in superior vena cava syndrome. Mayo Clin Proc 1981;considerations in superior vena cava syndrome. Mayo Clin Proc 1981; 56:407.56:407.
  16. 16. Signs and SymptomsSigns and Symptoms  Facial swelling or head fullnessFacial swelling or head fullness – exacerbated by bending forward or lyingexacerbated by bending forward or lying downdown  CoughCough  Arm edemaArm edema  CyanosisCyanosis
  17. 17. Facial swelling associated with SVCFacial swelling associated with SVC Syndrome in a patient with malignancySyndrome in a patient with malignancy
  18. 18. Physical FindingsPhysical Findings  Venous distensionVenous distension – neckneck – chest wallchest wall  Pemberton’s SignPemberton’s Sign  Facial EdemaFacial Edema
  19. 19. Patient who presented with progressively enlargingPatient who presented with progressively enlarging veins over the anterior chest wall. A diagnosis of aveins over the anterior chest wall. A diagnosis of a right-sided superior sulcus (Pancoast) tumorright-sided superior sulcus (Pancoast) tumor compressing the SVC was made.compressing the SVC was made.
  20. 20. Etiology: MalignancyEtiology: Malignancy  Lung cancer is the most commonLung cancer is the most common22  Lymphoma is second most commonLymphoma is second most common  together represent 94% of casestogether represent 94% of cases 2. Escalante, CP. Causes and management of superior vena2. Escalante, CP. Causes and management of superior vena cava syndrome. Oncology (Huntingt) 1993; 7:61.cava syndrome. Oncology (Huntingt) 1993; 7:61.
  21. 21. NSCLCNSCLC  2-4% of bronchogenic cancer2-4% of bronchogenic cancer patients develop SVC syndromepatients develop SVC syndrome33  extrinsic compression or directextrinsic compression or direct invasioninvasion – primary tumor or by enlargingprimary tumor or by enlarging mediastinal nodesmediastinal nodes 3. Armstrong, BA, Perez, CA, Simpson, JR, Hederman, MA.3. Armstrong, BA, Perez, CA, Simpson, JR, Hederman, MA. Role of irradiation in the management of superior vena cavaRole of irradiation in the management of superior vena cava syndrome. Int J Radiat Oncol Biol Phys 1987; 13:531.syndrome. Int J Radiat Oncol Biol Phys 1987; 13:531.
  22. 22. Small Cell Lung CancerSmall Cell Lung Cancer  Greatest riskGreatest risk  20% will develop SVC obstruction20% will develop SVC obstruction33  more common because SCLC tendsmore common because SCLC tends to occur centrally in contrast to otherto occur centrally in contrast to other typestypes
  23. 23. LymphomaLymphoma  2-4% of patients2-4% of patients  predominantly non-Hodgkin’s lymphomapredominantly non-Hodgkin’s lymphoma44  Hodgkin’s rarely causes SVC syndromeHodgkin’s rarely causes SVC syndrome 4. Perez-Soler, R, McLaughlin, P, Velasquez, WS, et al. Clinical4. Perez-Soler, R, McLaughlin, P, Velasquez, WS, et al. Clinical features and results of management of superior vena cavafeatures and results of management of superior vena cava syndrome secondary to lymphoma. J Clin Oncol 1984; 2:260.syndrome secondary to lymphoma. J Clin Oncol 1984; 2:260.
  24. 24. LymphomaLymphoma  Extrinsic compression caused byExtrinsic compression caused by enlarging lymph nodesenlarging lymph nodes  subtypes of large B cell can besubtypes of large B cell can be intravascular and cause occlusionintravascular and cause occlusion (angiotropic)(angiotropic)  diffuse large cell and lymphoblasticdiffuse large cell and lymphoblastic are most commonly associated withare most commonly associated with SVC syndromeSVC syndrome
  25. 25. Other cancersOther cancers  ThymomaThymoma  primary mediastinal germ cellprimary mediastinal germ cell neoplasmneoplasm  solid tumors with mediastinalsolid tumors with mediastinal nodal metastasesnodal metastases – breast cancer most common typebreast cancer most common type
  26. 26. Other causesOther causes  Post radiation local vascular fibrosisPost radiation local vascular fibrosis can also be considered in oncologycan also be considered in oncology patientspatients – Thoracic radiation treatment mayThoracic radiation treatment may predate syndrome by many yearspredate syndrome by many years
  27. 27. Other causesOther causes  ThrombosisThrombosis  Indwelling central venous cathetersIndwelling central venous catheters  Subcutaneous tunneled cathetersSubcutaneous tunneled catheters have fewer thrombotic and infectioushave fewer thrombotic and infectious complicationscomplications – Can also cause pulmonary embolismCan also cause pulmonary embolism55 5. Sivaram, CA, Craven, P, Chandrasekaran, K. Transesophageal5. Sivaram, CA, Craven, P, Chandrasekaran, K. Transesophageal echocardiography during removal of central venous catheterechocardiography during removal of central venous catheter associated with thrombus in superior vena cava. Am J Cardassociated with thrombus in superior vena cava. Am J Card Imaging 1996; 10:266.Imaging 1996; 10:266.
  28. 28. DiagnosisDiagnosis  Timely identification of the cause isTimely identification of the cause is essentialessential  Radiographic studies are usefulRadiographic studies are useful  Up to 60% of patients with SVCUp to 60% of patients with SVC syndrome related to neoplasm do notsyndrome related to neoplasm do not have a known diagnosis of cancerhave a known diagnosis of cancer66 – Need a tissue biopsy for histologicNeed a tissue biopsy for histologic studiesstudies 6. Schraufnagel, DE, Hill, R, Leech, JA, Pare, JA. Superior vena caval6. Schraufnagel, DE, Hill, R, Leech, JA, Pare, JA. Superior vena caval obstruction. Is it a medical emergency?. Am J Med 1981; 70:1169.obstruction. Is it a medical emergency?. Am J Med 1981; 70:1169.
  29. 29. Radiographic StudiesRadiographic Studies  Most patients have an abnormalMost patients have an abnormal chest x-ray at presentationchest x-ray at presentation  Most common findings areMost common findings are – Mediastinal wideningMediastinal widening – Pleural effusionPleural effusion
  30. 30. CT ChestCT Chest  Preferred choicePreferred choice  IV contrastIV contrast – defines the level of obstructiondefines the level of obstruction – Maps out collateral pathwaysMaps out collateral pathways – Can identify underlying cause ofCan identify underlying cause of obstructionobstruction
  31. 31. VenographyVenography  Bilateral upper arm venograpyBilateral upper arm venograpy – superior to CT to define site ofsuperior to CT to define site of obstructionobstruction – Does not define cause unless thrombosisDoes not define cause unless thrombosis is solely responsibleis solely responsible
  32. 32. Helical CTHelical CT  With bilateral upper arm IV contrastWith bilateral upper arm IV contrast injectioninjection  Best visualization of level ofBest visualization of level of obstruction and causeobstruction and cause
  33. 33. MRIMRI  Can be useful in patients with IVCan be useful in patients with IV contrast allergiescontrast allergies
  34. 34. T1-weighted axial MRI demonstrating theT1-weighted axial MRI demonstrating the primary tumor and the paratracheal softprimary tumor and the paratracheal soft tissue mass that invades into the SVCtissue mass that invades into the SVC
  35. 35. Same patient’s MRI with differentSame patient’s MRI with different technique to further define thetechnique to further define the intramural massintramural mass
  36. 36. Histologic DiagnosisHistologic Diagnosis  EssentialEssential  Guides treatmentGuides treatment  Aids in defining prognosisAids in defining prognosis
  37. 37. Histologic DiagnosisHistologic Diagnosis  Sputum cytology, pleural fluidSputum cytology, pleural fluid cytology, biopsy of enlargedcytology, biopsy of enlarged peripheral nodesperipheral nodes  Bone marrow biopsy for NHLBone marrow biopsy for NHL  Bronchoscopy, mediastinoscopy, orBronchoscopy, mediastinoscopy, or thoracotomy are more invasive butthoracotomy are more invasive but sometimes necessarysometimes necessary
  38. 38. Treatment of OncologicTreatment of Oncologic CausesCauses
  39. 39. TreatmentTreatment  Aimed at underlying causeAimed at underlying cause  Evolution of thought has occurred inEvolution of thought has occurred in recent yearsrecent years
  40. 40.  Historically SVC syndrome wasHistorically SVC syndrome was considered a potentially life-considered a potentially life- threatening emergencythreatening emergency  Standard of care was immediateStandard of care was immediate radiotherapyradiotherapy –Zap nowZap now –Ask questions laterAsk questions later  The emergent approach is notThe emergent approach is not appropriate for most patientsappropriate for most patients
  41. 41. Newer strategiesNewer strategies
  42. 42. Emergent to UrgentEmergent to Urgent  Symptomatic obstruction is usually aSymptomatic obstruction is usually a prolonged processprolonged process  Most patients are not in immediateMost patients are not in immediate danger at presentationdanger at presentation  Most have time for a full diagnosticMost have time for a full diagnostic work upwork up
  43. 43. Emergent to UrgentEmergent to Urgent  Prebiopsy radiation can obscure thePrebiopsy radiation can obscure the diagnosisdiagnosis  Current strategies aim at accurateCurrent strategies aim at accurate diagnosis of underlying etiologydiagnosis of underlying etiology before therapybefore therapy
  44. 44. ExceptionException to new ruleto new rule  StridorStridor – Central airway obstruction or laryngealCentral airway obstruction or laryngeal edemaedema  True medical emergencyTrue medical emergency  Immediate action neededImmediate action needed – Possible intubation and ICU admissionPossible intubation and ICU admission – Immediate therapy to target obstructionImmediate therapy to target obstruction neededneeded
  45. 45. PrognosisPrognosis…… Linked to tumor histology andLinked to tumor histology and stage at presentationstage at presentation
  46. 46. Treatment Sensitive TumorsTreatment Sensitive Tumors  NHLs, germ cells, and limited-stageNHLs, germ cells, and limited-stage small cell lung cancers usuallysmall cell lung cancers usually respond to chemotherapy and orrespond to chemotherapy and or radiationradiation  Can achieve long term remissionCan achieve long term remission with tumor specific directed therapywith tumor specific directed therapy  Symptomatic improvement usuallySymptomatic improvement usually takes 1-2 weeks after start oftakes 1-2 weeks after start of therapytherapy
  47. 47. Note: CorticosteroidsNote: Corticosteroids  Controversial issue with regards toControversial issue with regards to treatment benefit at presentationtreatment benefit at presentation
  48. 48. Non-small cell lung cancerNon-small cell lung cancer  SVC obstruction is a strong predictorSVC obstruction is a strong predictor of poor prognosisof poor prognosis  Median survival around 5 monthsMedian survival around 5 months77  Choice of therapy considersChoice of therapy considers likelihood of response to eachlikelihood of response to each modalitymodality 7. Martins, SJ, Pereira, JR. Clinical factors and prognosis in7. Martins, SJ, Pereira, JR. Clinical factors and prognosis in non-small cell lung cancer. Am J Clin Oncol 1999; 22:453.non-small cell lung cancer. Am J Clin Oncol 1999; 22:453.
  49. 49. Non-small cell lung cancerNon-small cell lung cancer  Goal usually directed to palliationGoal usually directed to palliation rather than long term remissionrather than long term remission  Palliative radiation andPalliative radiation and chemotherapy can be usedchemotherapy can be used
  50. 50. Intraluminal StentsIntraluminal Stents  Endovascular placement underEndovascular placement under fluoroscopyfluoroscopy  Patients who have recurrent diseasePatients who have recurrent disease in previously irradiated fieldsin previously irradiated fields  Tumors refractory chemotherapyTumors refractory chemotherapy  Patient too ill to tolerate radiation orPatient too ill to tolerate radiation or chemotherapychemotherapy
  51. 51. Intraluminal StentsIntraluminal Stents  Some data suggests benefit fromSome data suggests benefit from immediate stent placement in NSCLCimmediate stent placement in NSCLC at presentationat presentation88  Tends to provide more rapid relief ofTends to provide more rapid relief of symptomssymptoms  Issue of anticoagulation after is notIssue of anticoagulation after is not resolvedresolved 8. Rowell, NP, Gleeson, FV. Steroids, radiotherapy,8. Rowell, NP, Gleeson, FV. Steroids, radiotherapy, chemotherapy and stents for superior vena caval obstruction inchemotherapy and stents for superior vena caval obstruction in carcinoma of the bronchus: a systematic review. Clin Oncol (Rcarcinoma of the bronchus: a systematic review. Clin Oncol (R Coll Radiol) 2002; 14:338.Coll Radiol) 2002; 14:338.
  52. 52. CASE 2…CASE 2…
  53. 53. Mr. ECMr. EC  ID:ID: 56 year old man with history of56 year old man with history of HTN and osteoarthrtisHTN and osteoarthrtis  EC:EC: presents to family doctor withpresents to family doctor with one month history of back pain thatone month history of back pain that is not responding to Tylenolis not responding to Tylenol – Pain beginning to wake him at nightPain beginning to wake him at night – More pain with recumbancyMore pain with recumbancy – Some shooting pains down right legSome shooting pains down right leg  ROS:ROS: negativenegative
  54. 54. On examinationOn examination  vitals stable, no fevervitals stable, no fever  CVS, Respiratory, GI, GU examsCVS, Respiratory, GI, GU exams reported as normalreported as normal  Back examBack exam – InspectionInspection: normal: normal – PalpationPalpation: some pain in L1: some pain in L1 – ROMROM: normal: normal – Some pain in right leg with straight legSome pain in right leg with straight leg raisingraising
  55. 55. Investigation in ClinicInvestigation in Clinic  Lumbar Spine X-rayLumbar Spine X-ray – Some age related degenerationSome age related degeneration
  56. 56. DiagnosisDiagnosis  Sciatica vs. Back strainSciatica vs. Back strain  Treatment:Treatment: – NSAIDSNSAIDS – Few days of bed restFew days of bed rest
  57. 57. The story continues…The story continues…  Mr. EC’s pain does not resolveMr. EC’s pain does not resolve  More trials of various forms of painMore trials of various forms of pain control failcontrol fail  One month later Mr. EC awakens inOne month later Mr. EC awakens in the morning and has difficultythe morning and has difficulty supporting his weightsupporting his weight – Subjective leg muscle weaknessSubjective leg muscle weakness  Goes to HSC Emergency roomGoes to HSC Emergency room
  58. 58. In ERIn ER  Patient has objective leg weaknessPatient has objective leg weakness on physical examon physical exam  A very keen medical student does aA very keen medical student does a rectal exam and discovers a largerectal exam and discovers a large nodular prostatenodular prostate  PSA: 45.0PSA: 45.0  MRI Spine…..MRI Spine…..
  59. 59. Spinal Cord CompressionSpinal Cord Compression
  60. 60. Malignant Epidural Spinal CordMalignant Epidural Spinal Cord Compression (ESCC)Compression (ESCC)  Neoplastic invasion of the spaceNeoplastic invasion of the space between vertebrae and spinal cordbetween vertebrae and spinal cord (epidural invasion)(epidural invasion) – Usually from bone metastasesUsually from bone metastases  Compresses thecal sac of spinal cordCompresses thecal sac of spinal cord  Frequent complication of malignancyFrequent complication of malignancy  Can cause painCan cause pain  Can cause irreversible loss ofCan cause irreversible loss of neurologic functionneurologic function
  61. 61. DefinitionDefinition  Any radiological indentation of theAny radiological indentation of the thecal sacthecal sac  Tip of the spinal cord lies at the L1Tip of the spinal cord lies at the L1 vertebral levelvertebral level  Lumbosacral nerve roots form theLumbosacral nerve roots form the cauda equinacauda equina
  62. 62. EpidemiologyEpidemiology  Many cases of unrecognized ESCCMany cases of unrecognized ESCC  Difficult to define incidenceDifficult to define incidence  Autopsy review studies suggestAutopsy review studies suggest around 5% of cancer patients diearound 5% of cancer patients die with ESCCwith ESCC99 9. Barron, KD, Hirano, A, Araki, S, Terry, RD. Experiences with9. Barron, KD, Hirano, A, Araki, S, Terry, RD. Experiences with metastatic neoplasms involving the spinal cord. Neurology 1959;metastatic neoplasms involving the spinal cord. Neurology 1959; 9:91.9:91.
  63. 63. CausesCauses  Metastatic tumor from any primaryMetastatic tumor from any primary sitesite  Tumors with predilection toTumors with predilection to metastasize to spinal columnmetastasize to spinal column  Prostate, breast, and lung carcinomaProstate, breast, and lung carcinoma – 15-20% of cases15-20% of cases  Renal cell, non-Hodgkin’s lymphoma,Renal cell, non-Hodgkin’s lymphoma, or myelomaor myeloma – 5-10% of cases5-10% of cases
  64. 64.  Vertebral metastases are moreVertebral metastases are more common than ESCCcommon than ESCC  Prostate cancerProstate cancer: 90%: 90%  Breast CancerBreast Cancer: 74%: 74%  Lung CancerLung Cancer: 45%: 45%  LymphomaLymphoma: 29%: 29%  Renal cellRenal cell: 29%: 29%  GIGI: 25%: 25% 10. Posner, JB. Neurologic Complications of Cancer. FA Davis,10. Posner, JB. Neurologic Complications of Cancer. FA Davis, Philadelphia, 1995Philadelphia, 1995
  65. 65.  ESCC can be initial presentation of aESCC can be initial presentation of a malignancymalignancy – Around 20% of casesAround 20% of cases – In many cases diagnosis is made byIn many cases diagnosis is made by biopsy of the spinal lesionbiopsy of the spinal lesion
  66. 66. Spinal LocationSpinal Location1010  Thoracic spine: 60%Thoracic spine: 60%  Lumbosacral spine: 30%Lumbosacral spine: 30%  Cervical spine: 10%Cervical spine: 10%  Specific tumor predilection is difficultSpecific tumor predilection is difficult to defineto define
  67. 67. Clinical FeaturesClinical Features
  68. 68.  Important to recognizeImportant to recognize  Early recognition leads to betterEarly recognition leads to better outcomesoutcomes  Efficacy of treatment depends mostEfficacy of treatment depends most on patient’s neurological function aton patient’s neurological function at presentationpresentation  Median time from symptoms toMedian time from symptoms to diagnosis is around 2 monthsdiagnosis is around 2 months1111  More than half of patients whoMore than half of patients who present to hospital are non-present to hospital are non- ambulatoryambulatory 11. Husband, DJ. Malignant spinal cord compression:11. Husband, DJ. Malignant spinal cord compression: Prospective study of delays in referral and treatment. BMJProspective study of delays in referral and treatment. BMJ 1998; 317:18.1998; 317:18.
  69. 69. RED FLAGS…..RED FLAGS…..
  70. 70. First Red Flag:First Red Flag: PainPain  Usually first symptomUsually first symptom1212 – 80-90% of the time80-90% of the time  Usually precedes other neurologicUsually precedes other neurologic symptoms by seven weekssymptoms by seven weeks – Increases in intensityIncreases in intensity  Severe local back painSevere local back pain  Aggravated by recumbencyAggravated by recumbency – Distension of venous plexusDistension of venous plexus  May become radicularMay become radicular 12. Bach, F, Larsen, BH, Rohde, K, et al. Metastatic spinal cord12. Bach, F, Larsen, BH, Rohde, K, et al. Metastatic spinal cord compression. Occurrence, symptoms, clinical presentations and prognosiscompression. Occurrence, symptoms, clinical presentations and prognosis in 398 patients with spinal cord compression. Acta Neurochir (Wien)in 398 patients with spinal cord compression. Acta Neurochir (Wien) 1990; 107:37.1990; 107:37.
  71. 71. Second Red Flag:Second Red Flag: MotorMotor  Weakness: 60-85%Weakness: 60-85%1313  At or above conus medularisAt or above conus medularis – Extensors of the upper extremitiesExtensors of the upper extremities  Above the thoracic spineAbove the thoracic spine – Weakness from corticospinal dysfunctionWeakness from corticospinal dysfunction – Affects flexors in the lower extremitiesAffects flexors in the lower extremities  Patients may be hyperreflexic belowPatients may be hyperreflexic below the lesion and have extensorthe lesion and have extensor plantarsplantars 13. Greenberg, HS, Kim, JH, Posner, JB. Epidural spinal cord13. Greenberg, HS, Kim, JH, Posner, JB. Epidural spinal cord compression from metastatic tumor: Results with a new treatmentcompression from metastatic tumor: Results with a new treatment protocol. Ann Neurol 1980; 8:361.protocol. Ann Neurol 1980; 8:361.
  72. 72.  Weakness tends to be symmetricalWeakness tends to be symmetrical  Progressive weakness is followed byProgressive weakness is followed by lost of gait function then paralysislost of gait function then paralysis  The severity of weakness is greatestThe severity of weakness is greatest with thoracic metastaseswith thoracic metastases
  73. 73. Third Red Flag:Third Red Flag: SensorySensory  Less common than motor findingsLess common than motor findings  Still present in majority of casesStill present in majority of cases  Ascending numbness and parathesiasAscending numbness and parathesias
  74. 74. Fourth Red Flag:Fourth Red Flag: Bladder andBladder and Bowel FunctionBowel Function  Loss is late findingLoss is late finding  Autonomic neuropathy presentsAutonomic neuropathy presents usually as urinary retensionusually as urinary retension – Rarely sole findingRarely sole finding
  75. 75. Radiologic InvestigationRadiologic Investigation
  76. 76.  Diagnosis depends on ability toDiagnosis depends on ability to demonstrate a mass compressing thedemonstrate a mass compressing the thecal sacthecal sac  Plain radiographs are not enoughPlain radiographs are not enough  Historically this involved invasiveHistorically this involved invasive proceduresprocedures  Advent of MRI has allowed non-Advent of MRI has allowed non- invasive diagnosisinvasive diagnosis  Clinical examination is not reliable inClinical examination is not reliable in determining level of lesiondetermining level of lesion
  77. 77.  Entire imaging of spine is idealEntire imaging of spine is ideal – Focused CT imaging can miss clinicallyFocused CT imaging can miss clinically unapparent lesionsunapparent lesions  Myelography and MRI are better thanMyelography and MRI are better than plain X-Rays, bone scans and CT forplain X-Rays, bone scans and CT for diagnosisdiagnosis
  78. 78. Plain Spine RadiographsPlain Spine Radiographs  Easiest and cheapestEasiest and cheapest  Need large bony destruction orNeed large bony destruction or vertebral collapse to be diagnosticvertebral collapse to be diagnostic  High false negative rateHigh false negative rate  Not recommended to confirmNot recommended to confirm diagnosisdiagnosis
  79. 79. MRI vs. CT MyelographyMRI vs. CT Myelography
  80. 80.  Both image thecal sac and displayBoth image thecal sac and display indentation and encirclingindentation and encircling  CT myelography involves a lumbarCT myelography involves a lumbar puncturepuncture – Contraindicated in brain metastases,Contraindicated in brain metastases, thrombocytopenia, or coagulopathythrombocytopenia, or coagulopathy – Can diagnose leptomeningealCan diagnose leptomeningeal metastasesmetastases – Available in Winnipeg in middle of theAvailable in Winnipeg in middle of the nightnight
  81. 81. MRIMRI  Images whole spineImages whole spine  High detailHigh detail  Spares lumbar punctureSpares lumbar puncture  Patients in pain must lie stillPatients in pain must lie still
  82. 82.  Roughly equivalent in terms ofRoughly equivalent in terms of sensitivity and specificitysensitivity and specificity  Presently no large comparativePresently no large comparative studies b/c MRI in the US hasstudies b/c MRI in the US has become so readily availablebecome so readily available  MRI standard of care in centers thatMRI standard of care in centers that have accesshave access
  83. 83. Bone ScanBone Scan  More sensitive than plain radiographMore sensitive than plain radiograph  Visualizes entire skeletonVisualizes entire skeleton  Can miss neoplasms that do notCan miss neoplasms that do not have increased blood flowhave increased blood flow
  84. 84. CT Scan aloneCT Scan alone  Does not visualize spinal cord andDoes not visualize spinal cord and epidural space clearlyepidural space clearly
  85. 85. Intramedullary MetastasesIntramedullary Metastases  Less commonLess common  Often present with hemicordOften present with hemicord symptomssymptoms – Unilateral weakness below lesionUnilateral weakness below lesion – Contralateral diminution of pain andContralateral diminution of pain and temperature sensationtemperature sensation – Can progress to bilateral dysfunctionCan progress to bilateral dysfunction
  86. 86. Radiation MyelopathyRadiation Myelopathy  Can mimic ESCCCan mimic ESCC  MR imaging can make distinctionMR imaging can make distinction
  87. 87. MRI of epidural spinal cord compression in aMRI of epidural spinal cord compression in a women with past history of breast cancer.women with past history of breast cancer.
  88. 88. TreatmentTreatment
  89. 89. Treatment delays…….Treatment delays…….  2 month median delay in treatment2 month median delay in treatment from onset of back painfrom onset of back pain1111  14 day delay in treatment from onset14 day delay in treatment from onset of neurological symptomsof neurological symptoms1111
  90. 90. Why the delay?Why the delay?  Patient factorsPatient factors  General practitioner factorsGeneral practitioner factors  Hospital factorsHospital factors EDUCATIONEDUCATION
  91. 91. Treatment ObjectivesTreatment Objectives  Pain controlPain control  Avoidance of complicationsAvoidance of complications  Preserve or improve neurologicalPreserve or improve neurological functionfunction
  92. 92. Pain managementPain management  CorticosteroidsCorticosteroids – Decrease edemaDecrease edema  OpiatesOpiates – Needed to decrease pain for comfortNeeded to decrease pain for comfort and examination purposesand examination purposes
  93. 93. Bed RestBed Rest  NoNo  NoNo  NoNo  NoNo
  94. 94. AnticoagulationAnticoagulation  Cancer is a hypercoaguable stateCancer is a hypercoaguable state  High burden of tumor in metastaticHigh burden of tumor in metastatic diseasedisease  Possible value in prophylaxis againstPossible value in prophylaxis against venous thromboembolismvenous thromboembolism  If patient not mobile subcutaneousIf patient not mobile subcutaneous heparin or compression devices isheparin or compression devices is indicatedindicated
  95. 95. Prevention of ConstipationPrevention of Constipation  FactorsFactors – Autonomic dysfunctionAutonomic dysfunction – Limited mobilityLimited mobility – Opiate analgesicOpiate analgesic  Risk of perforationRisk of perforation – Masked by corticosteroidsMasked by corticosteroids  Bowel regimen neededBowel regimen needed
  96. 96. CorticosteroidsCorticosteroids
  97. 97.  Part of standard regimenPart of standard regimen  Limited data on benefit vs. sideLimited data on benefit vs. side effectseffects  Many studies suggesting lower dosesMany studies suggesting lower doses can be effectivecan be effective – No randomized trialsNo randomized trials
  98. 98. Corticosteroid RecommendationsCorticosteroid Recommendations  High dose dexamethasone and halfHigh dose dexamethasone and half dose every three daysdose every three days  Pain with minimal neurologicalPain with minimal neurological dysfunction can have lower dosedysfunction can have lower dose  Small asymptomatic lesions canSmall asymptomatic lesions can forgo steroidsforgo steroids
  99. 99. Radiation TherapyRadiation Therapy
  100. 100.  Definitive choiceDefinitive choice  Portal 8 cm widePortal 8 cm wide  Centered on spineCentered on spine  Extends one to two vertebral bodiesExtends one to two vertebral bodies above and below the epiduralabove and below the epidural metastasismetastasis
  101. 101.  Relieves pain in most casesRelieves pain in most cases  Post-neurological function usuallyPost-neurological function usually determines responsedetermines response  Response most associated withResponse most associated with tumor type and radiosensitivity; eg.tumor type and radiosensitivity; eg. lymphomalymphoma  Dosing 20 to 40 Gy in 5 to 20Dosing 20 to 40 Gy in 5 to 20 fractionsfractions  PopularPopular – 30 Gy in 10 fractions30 Gy in 10 fractions
  102. 102. SurgerySurgery  Changing roleChanging role  Historically posterior vertebralHistorically posterior vertebral decompression was donedecompression was done – No survival benefit with or withoutNo survival benefit with or without radiationradiation1515 15. Findlay, GF. Adverse effects of the management of malignant15. Findlay, GF. Adverse effects of the management of malignant spinal cord compression. J Neurol Neurosurg Psychiatry 1984;spinal cord compression. J Neurol Neurosurg Psychiatry 1984; 47:761.47:761.
  103. 103.  Better techniques today allowBetter techniques today allow aggressive approachaggressive approach  Gross spinal tumor resection withGross spinal tumor resection with vertebral reconstruction now possiblevertebral reconstruction now possible  Experienced surgeon requiredExperienced surgeon required
  104. 104.  Recent controlled trial comparingRecent controlled trial comparing aggressive surgery followed byaggressive surgery followed by radiation vs. radiation aloneradiation vs. radiation alone1616  Improvement in surgery+radsImprovement in surgery+rads – Days remained ambulatory (126 vs. 35)Days remained ambulatory (126 vs. 35) – Percent that regained ambulation afterPercent that regained ambulation after therapy (56% vs. 19%)therapy (56% vs. 19%) – Days remained continent (142 vs. 12)Days remained continent (142 vs. 12) – Less steroid dose, less narcoticsLess steroid dose, less narcotics – TrendTrend to increase survivalto increase survival 16. Patchell, R, Tibbs, PA, Regine, WF, et al. A randomized trial of16. Patchell, R, Tibbs, PA, Regine, WF, et al. A randomized trial of direct decompressive surgical resection in the treatment of spinaldirect decompressive surgical resection in the treatment of spinal cord compression caused by metastasis (abstract). proc Am Soccord compression caused by metastasis (abstract). proc Am Soc Clin Oncol 2003; 22:1.Clin Oncol 2003; 22:1.
  105. 105. ChemotherapyChemotherapy  Can be successful in chemosensitiveCan be successful in chemosensitive tumorstumors – Hodgkin’s lymphomaHodgkin’s lymphoma – Non-Hodgkin’s lymphomaNon-Hodgkin’s lymphoma – NeuroblastomaNeuroblastoma – Germ cellGerm cell – Breast cancer (hormonal manipulation)Breast cancer (hormonal manipulation) – Prostate cancer (hormonalProstate cancer (hormonal manipulation)manipulation)
  106. 106. BisphosphonatesBisphosphonates  RecommendedRecommended  Decrease pathologic fractures inDecrease pathologic fractures in bony diseasebony disease – Multiple myelomaMultiple myeloma – Breast cancerBreast cancer
  107. 107. PrognosisPrognosis  Median survival with ESCC is 6Median survival with ESCC is 6 monthsmonths1414  Ambulatory patients withAmbulatory patients with radiosensitive tumors have the bestradiosensitive tumors have the best prognosisprognosis 14. Sorensen, PS, Borgesen, SE, Rohde, K, et al. Metastatic epidural14. Sorensen, PS, Borgesen, SE, Rohde, K, et al. Metastatic epidural spinal cord compression. Results of treatment and survival. Cancerspinal cord compression. Results of treatment and survival. Cancer 1990; 65:1502.1990; 65:1502.
  108. 108. Treatment DelayTreatment Delay  EducationEducation  EXPERIENCEEXPERIENCE  EducationEducation  EXPERIENCEEXPERIENCE
  109. 109. Case 3: Mrs. HCCase 3: Mrs. HC  ID:ID: 75 year old female living alone75 year old female living alone with no significant past medicalwith no significant past medical historyhistory  EC:EC: brought to ER by paramedicsbrought to ER by paramedics after neighbor called b/c she wasafter neighbor called b/c she was found in her apartment unresponsivefound in her apartment unresponsive  No collateral historyNo collateral history
  110. 110. ExaminationExamination  Fluctuating level of consciousnessFluctuating level of consciousness  Vitals normal, no feverVitals normal, no fever  DehydratedDehydrated  Coarse upper airway soundsCoarse upper airway sounds  No other pertinent findingsNo other pertinent findings
  111. 111. InvestigationsInvestigations  CBC normalCBC normal  Mildly elevated BUN and CrMildly elevated BUN and Cr  Normal LFTsNormal LFTs  Standard electrolytes normalStandard electrolytes normal
  112. 112.  Concern of pneumoniaConcern of pneumonia  Chest x-ray ordered……Chest x-ray ordered……
  113. 113. Multiple Pulmonary MetastasisMultiple Pulmonary Metastasis
  114. 114.  Calcium checkedCalcium checked – 4.54.5
  115. 115. HypercalcemiaHypercalcemia
  116. 116. SymptomsSymptoms  Usually nonspecificUsually nonspecific  Many times patients present withMany times patients present with very high calcium levelvery high calcium level  Most research done inMost research done in hyperparathyroidismhyperparathyroidism
  117. 117. GastrointestinalGastrointestinal  Constipation is most commonConstipation is most common1515 – Exacerbated or confused with narcoticExacerbated or confused with narcotic effectseffects – Related to autonomic dysfunctionRelated to autonomic dysfunction  AnorexiaAnorexia  Vague abdominal painVague abdominal pain  Rarely can lead to pancreatitisRarely can lead to pancreatitis 15. Heath, H 3d. Clinical spectrum of primary15. Heath, H 3d. Clinical spectrum of primary hyperparathyroidism: Evolution with changes in medical practicehyperparathyroidism: Evolution with changes in medical practice and technology. J Bone Miner Res 1991; 6(Suppl 2):S63.and technology. J Bone Miner Res 1991; 6(Suppl 2):S63.
  118. 118. Renal DysfunctionRenal Dysfunction  NephrolithiasisNephrolithiasis – More common in hyperparathyroidismMore common in hyperparathyroidism  Nephrogenic diabetes insipidusNephrogenic diabetes insipidus – Defect in concentrating abilityDefect in concentrating ability – Polyuria and polydipsiaPolyuria and polydipsia  Chronic renal failureChronic renal failure – Longstanding high calciumLongstanding high calcium Calcifcation, degeneration, and necrosis ofCalcifcation, degeneration, and necrosis of tubulestubules
  119. 119. NeuropsychiatircNeuropsychiatirc  AnxietyAnxiety  DepressionDepression  Cognitive dysfunctionCognitive dysfunction – DeleriumDelerium – PsychosisPsychosis – HallucinationsHallucinations – SomnolenceSomnolence – ComaComa
  120. 120. CardiovascularCardiovascular  Short QT intervalShort QT interval  Supraventricualr arrhythmiasSupraventricualr arrhythmias  Ventricular arrhythmiasVentricular arrhythmias
  121. 121. Physical FindingsPhysical Findings  Usually not specificUsually not specific  Dehydration secondary to diuresisDehydration secondary to diuresis caused by the hypercalcemiacaused by the hypercalcemia  Corneal deposition of calciumCorneal deposition of calcium – ““band keratopathy” on slit lamp examband keratopathy” on slit lamp exam
  122. 122. EpidemiologyEpidemiology  Occurs in about 10 to 20% ofOccurs in about 10 to 20% of patients with cancerpatients with cancer  Both solid tumors and leukemiasBoth solid tumors and leukemias  Most commonMost common – BreastBreast – LungLung – Multiple myelomaMultiple myeloma
  123. 123. PathogenesisPathogenesis
  124. 124. Three mechanismsThree mechanisms  Osteolytic metastases with localOsteolytic metastases with local cytokine releasecytokine release  Tumor secretion of parathyroidTumor secretion of parathyroid hormone-related protein (PTHrP)hormone-related protein (PTHrP)  Tumor production of calcitriolTumor production of calcitriol
  125. 125. Osteolytic MetastasesOsteolytic Metastases
  126. 126.  Breast cancerBreast cancer  Non-small cell lung cancerNon-small cell lung cancer  Cytokines releasedCytokines released – Tumor necrosis factorTumor necrosis factor – Interleukin-1Interleukin-1 – Stimulate osteoclast precursorStimulate osteoclast precursor differentiation into mature osteoclastsdifferentiation into mature osteoclasts Leading to more bone breakdown andLeading to more bone breakdown and release of calciumrelease of calcium
  127. 127. PTH-Related ProteinPTH-Related Protein  Most common in patients with non-Most common in patients with non- metastatic tumorsmetastatic tumors  Called humoral hypercalcemia ofCalled humoral hypercalcemia of malignancymalignancy  Secretion of PTH itself is a rare eventSecretion of PTH itself is a rare event  PTHrP binds to same receptor as PTHPTHrP binds to same receptor as PTH and stimulates adeynylate cyclaseand stimulates adeynylate cyclase activityactivity – Increased bone resorptionIncreased bone resorption – Increases kidney calcium reabsorptionIncreases kidney calcium reabsorption and phosphate excretionand phosphate excretion
  128. 128. CalcitriolCalcitriol  Hodgkin’s disease (mechanism inHodgkin’s disease (mechanism in majority)majority)  Non-Hodgkin’s (mechanism in 1/3)Non-Hodgkin’s (mechanism in 1/3)  Usually responds to glucocorticoidUsually responds to glucocorticoid therapytherapy
  129. 129. DiagnosisDiagnosis
  130. 130.  Clinical symptomology withClinical symptomology with – History of cancerHistory of cancer – Risk factors for cancerRisk factors for cancer – Suppressed PTHSuppressed PTH  Some centers can test for PTHrP toSome centers can test for PTHrP to confirm Dx of humoral hypercalcemiaconfirm Dx of humoral hypercalcemia  High PTHrP may predict response toHigh PTHrP may predict response to pamidronatepamidronate1616 – Less of a responseLess of a response 16. Gurney, H, Grill, V, Martin, TJ. Parathyroid hormonerelated16. Gurney, H, Grill, V, Martin, TJ. Parathyroid hormonerelated protein and response to pamidronate in tumourinducedprotein and response to pamidronate in tumourinduced hypercalcemia. Lancet 1993; 341:1611.hypercalcemia. Lancet 1993; 341:1611.
  131. 131.  Malignancy must be ruled out inMalignancy must be ruled out in patients that present with a verypatients that present with a very high calcium and no other obvioushigh calcium and no other obvious causecause
  132. 132. TreatmentTreatment
  133. 133. AimsAims  Lower serum calcium concentrationLower serum calcium concentration  Treat complications if presentTreat complications if present  Treat underlying diseaseTreat underlying disease
  134. 134. VolumeVolume  Large volume of normal SalineLarge volume of normal Saline administrationadministration  Expands intravascular volumeExpands intravascular volume  Increases calcium excretionIncreases calcium excretion – Inhibition of proximal tubule and loopInhibition of proximal tubule and loop reabosrptionreabosrption – Reduces passive reabsorption of calicumReduces passive reabsorption of calicum  Follow fluid status b/c of danger ofFollow fluid status b/c of danger of fluid overloadfluid overload
  135. 135. Inhibition of Bone ResorptionInhibition of Bone Resorption  Three therapiesThree therapies – CalcitoninCalcitonin – BisphosphonatesBisphosphonates – Gallium nitrateGallium nitrate  Historical therapyHistorical therapy – Antitumor antibiotic plicamycinAntitumor antibiotic plicamycin (mithramycin)(mithramycin) Multiple serious side effectsMultiple serious side effects No longer manufacturedNo longer manufactured
  136. 136. CalcitoninCalcitonin  Salmon calcitoninSalmon calcitonin  Increases renal excretion of calciumIncreases renal excretion of calcium  Decreases bone reabsorption byDecreases bone reabsorption by interfering with osteoclastinterfering with osteoclast maturationmaturation  Weak agentWeak agent  Works the fastestWorks the fastest
  137. 137. BisphosphonatesBisphosphonates  Adsorb to the surface of boneAdsorb to the surface of bone hyroxyapatitehyroxyapatite  Interfere with osteoclast activityInterfere with osteoclast activity  Cytotoxic to osteoclastsCytotoxic to osteoclasts  Inhibit calcium release from boneInhibit calcium release from bone  Three commonly usedThree commonly used – PamidronatePamidronate – Zoledronic acidZoledronic acid – Etidronate (1Etidronate (1stst generation, weaker)generation, weaker)
  138. 138. BisphosphonatesBisphosphonates  More potent than calcitoninMore potent than calcitonin  Maxium effect occurs in 2 to 4 daysMaxium effect occurs in 2 to 4 days  Trend to use of IV zoledronic acid inTrend to use of IV zoledronic acid in the acute situationthe acute situation  Both are can be renal toxicBoth are can be renal toxic – More potent than pamidronateMore potent than pamidronate – Administered over a shorter period ofAdministered over a shorter period of time (15 minutes vs. 2 hours)time (15 minutes vs. 2 hours)
  139. 139. Prophylactic BisphosphonatesProphylactic Bisphosphonates  Pamidronate use in patients withPamidronate use in patients with known lytic lesionsknown lytic lesions1717 – Less episodes of hypercalcemiaLess episodes of hypercalcemia – Less pathologic fracturesLess pathologic fractures – Less painLess pain – Less spinal cord compressionLess spinal cord compression – Less need for radiation or surgeryLess need for radiation or surgery 17. Hortobagyi, GN, Theriault, RL, Porter, L, et al for the Protocol 1917. Hortobagyi, GN, Theriault, RL, Porter, L, et al for the Protocol 19 Aredia Breast Cancer Study Group. Efficacy of pamidronate inAredia Breast Cancer Study Group. Efficacy of pamidronate in reducing skeletal complications in patients with breast cancer and lyticreducing skeletal complications in patients with breast cancer and lytic bone metastases. N Engl J Med 1996; 335:1785.bone metastases. N Engl J Med 1996; 335:1785.
  140. 140. Newly discovered side effect…Newly discovered side effect…  Osteonecrosis of the jawOsteonecrosis of the jaw  Recent case reports of jaw boneRecent case reports of jaw bone necrosis in patients on pamidronatenecrosis in patients on pamidronate  EDUCATION neededEDUCATION needed
  141. 141. Gallium NitrateGallium Nitrate  EffectiveEffective  More potential for nephrotoxicityMore potential for nephrotoxicity  Rarely usedRarely used
  142. 142. DialysisDialysis  Last resortLast resort  Dialysis fluid with little or no calciumDialysis fluid with little or no calcium is effectiveis effective  Useful when patients can’t tolerateUseful when patients can’t tolerate large volume resuscitationlarge volume resuscitation  If calcium needs to be correctIf calcium needs to be correct emergentlyemergently
  143. 143. Recommendations in symptomaticRecommendations in symptomatic situationsituation  Volume expansionVolume expansion  Salmon calcitoninSalmon calcitonin  IV zoledronic acid or pamidronateIV zoledronic acid or pamidronate  Close follow up of calcium level andClose follow up of calcium level and symptomssymptoms
  144. 144. Transitions inTransitions in TreatmentTreatment
  145. 145. ChemotherapyChemotherapy  Two rolesTwo roles  Direct treatment of cancerDirect treatment of cancer  Palliation of symptomsPalliation of symptoms
  146. 146. Palliative ChemotherapyPalliative Chemotherapy  Goal is not cureGoal is not cure  GoalsGoals – Control of tumorControl of tumor – Preservation of functionPreservation of function – Help tumor symptomsHelp tumor symptoms PainPain DsypneaDsypnea PruritisPruritis Poor appetitePoor appetite Weight lossWeight loss
  147. 147. Fine BalanceFine Balance  Chemotherapy can be very toxicChemotherapy can be very toxic  Ratio: benefit vs. toxicityRatio: benefit vs. toxicity  Host factors and tumor factorsHost factors and tumor factors  Delicate balance in palliativeDelicate balance in palliative situationsituation  Want medications that affect tumorWant medications that affect tumor but do not heavily affect hostbut do not heavily affect host
  148. 148. Psychology of CancerPsychology of Cancer  Psychological evolution during cancerPsychological evolution during cancer treatmenttreatment  Many people have fought very hardMany people have fought very hard with their diseasewith their disease  Chemotherapy for “relief” not “cure”Chemotherapy for “relief” not “cure” can be difficult concept for patientscan be difficult concept for patients  ART of medicineART of medicine
  149. 149. EvolutionEvolution  Chemotherapeutic protocols thatChemotherapeutic protocols that have less side effectshave less side effects  molecular targeted therapiesmolecular targeted therapies – Attack tumor specificallyAttack tumor specifically – Less effect on hostLess effect on host
  150. 150.  Breast cancerBreast cancer  Colon CancerColon Cancer  Prostate cancerProstate cancer  Lung cancerLung cancer
  151. 151. Breast CancerBreast Cancer  Aromatase inhibitors for ER positiveAromatase inhibitors for ER positive tumorstumors – Anastrozole, Letrozole, ExemestaneAnastrozole, Letrozole, Exemestane  Trastuzumab (Herceptin)Trastuzumab (Herceptin) – Humanized monoclonal antibodyHumanized monoclonal antibody targeting Her-2/neu protein on breasttargeting Her-2/neu protein on breast cancer cellscancer cells – Inhibits growth factor signalInhibits growth factor signal transductiontransduction – Tolerated quite wellTolerated quite well
  152. 152. Colon CancerColon Cancer  Capecitabine (Xeloda)Capecitabine (Xeloda)  Oral drug that is transformed into 5-Oral drug that is transformed into 5- FU with three enzymatic reactionsFU with three enzymatic reactions – Final enzyme is at higher levels in tumorFinal enzyme is at higher levels in tumor cellscells – Contributes to drug’s less toxic sideContributes to drug’s less toxic side effect profileeffect profile Less stomatitis, less myelosupressionLess stomatitis, less myelosupression
  153. 153. Targeted GI TherapiesTargeted GI Therapies  BevacizumabBevacizumab – Monoclonal antibody toMonoclonal antibody to vascularvascular endotheial growth factor receptorendotheial growth factor receptor – Some cardiac toxicitySome cardiac toxicity  CetuximabCetuximab – Monoclonal antibody toMonoclonal antibody to humanhuman epidermal growth factor receptorepidermal growth factor receptor – Skin toxicitySkin toxicity
  154. 154. Prostate CancerProstate Cancer  LHRH analoguesLHRH analogues  Leuprolide (Lupron)Leuprolide (Lupron)  Goserelin (Zoladex)Goserelin (Zoladex)  Stop testosterone production withStop testosterone production with limited side effectslimited side effects
  155. 155. Lung CancerLung Cancer  In stage IV disease patients whoIn stage IV disease patients who receive Cisplatin based doubletreceive Cisplatin based doublet chemotherapy live longer and feelchemotherapy live longer and feel better than best supportive carebetter than best supportive care  Hard to balance side effectsHard to balance side effects
  156. 156. Gefitinib (Iressa)Gefitinib (Iressa)  Targets epidermal growth factorTargets epidermal growth factor receptor (tyrosine kinase smallreceptor (tyrosine kinase small molecule inhibitor)molecule inhibitor)  May have a role in the palliation ofMay have a role in the palliation of advanced non small cell lung canceradvanced non small cell lung cancer patientspatients
  157. 157. Palliative Care DebatePalliative Care Debate  Do not accept any patient on “active”Do not accept any patient on “active” therapytherapy  This needs to be further elucidatedThis needs to be further elucidated  Patients being palliated withPatients being palliated with chemotherapy or targeted therapieschemotherapy or targeted therapies still have other palliative care issuesstill have other palliative care issues and needsand needs  Should a patient still on Xeloda forShould a patient still on Xeloda for breast or colon cancer not bebreast or colon cancer not be admitted to St. Boniface 8A?admitted to St. Boniface 8A?
  158. 158. Thank youThank you
  159. 159. Any questions?Any questions?