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Oncologic Emergencies


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Oncologic Emergencies

  1. 1. Oncologic EmergenciesOncologic Emergencies Noel Rowan, MD, FACPNoel Rowan, MD, FACP Comprehensive Cancer CenterComprehensive Cancer Center Las Vegas, NevadaLas Vegas, Nevada
  2. 2. Oncologic EmergenciesOncologic Emergencies  CardiovascularCardiovascular  Pericardial TamponadePericardial Tamponade  Superior Vena Cava SyndromeSuperior Vena Cava Syndrome  Central Nervous System EmergenciesCentral Nervous System Emergencies  Increased Intracranial PressureIncreased Intracranial Pressure  Spinal Cord CompressionSpinal Cord Compression  GastrointestinalGastrointestinal  Bowel ObstructionBowel Obstruction  Bowel PerforationBowel Perforation  AscitesAscites  Esophageal Obstruction and PerforationEsophageal Obstruction and Perforation
  3. 3. Oncologic EmergenciesOncologic Emergencies Hematologic EmergenciesHematologic Emergencies DICDIC LeukostasisLeukostasis ThrombocytopeniaThrombocytopenia Infectious EmergenciesInfectious Emergencies Sepsis in the leukopenic patientSepsis in the leukopenic patient Disseminated Viral InfectionsDisseminated Viral Infections Fungal and Parasitic DiseasesFungal and Parasitic Diseases
  4. 4. Oncologic EmergenciesOncologic Emergencies Metabolic EmergenciesMetabolic Emergencies HyperuricemiaHyperuricemia HypercalcaemiaHypercalcaemia HypoglycemiaHypoglycemia Lactic AcidosisLactic Acidosis Tumor Lysis SyndromeTumor Lysis Syndrome Orthopedic EmergenciesOrthopedic Emergencies Pathologic FracturePathologic Fracture
  5. 5. Oncologic EmergenciesOncologic Emergencies  WaldenstromsWaldenstroms  Hyperviscosity SyndromeHyperviscosity Syndrome  PlasmaphoresisPlasmaphoresis
  6. 6. Oncologic EmergenciesOncologic Emergencies  Renal EmergenciesRenal Emergencies  Ureteral Obstruction – Pelvic TumorsUreteral Obstruction – Pelvic Tumors  Respiratory EmergenciesRespiratory Emergencies  Airway ObstructionAirway Obstruction  PneumothoraxPneumothorax  EffusionEffusion  Symptomatic EmergenciesSymptomatic Emergencies  PainPain  VomitingVomiting  MucositisMucositis  DyspneaDyspnea
  7. 7. Pericardial TamponadePericardial Tamponade  MechanismMechanism  Fluid in pericardial sac due to metastaic tumorFluid in pericardial sac due to metastaic tumor  Post X-ray treatment – 4000 rPost X-ray treatment – 4000 r  Decreased CO because of decreased venous returnDecreased CO because of decreased venous return  SymptomsSymptoms  DyspneaDyspnea  ConfusionConfusion  ComaComa  Distended neck veinsDistended neck veins  Pulses ParadoxesPulses Paradoxes  CHFCHF
  8. 8. Pericardial TamponadePericardial Tamponade DiagnosisDiagnosis Enlarged heartEnlarged heart CXR – sac-like heartCXR – sac-like heart EchoEcho TreatmentTreatment PercardiocentesisPercardiocentesis Catheter SFUCatheter SFU X-Ray TherapyX-Ray Therapy Surgery – window vs. pericardiectomySurgery – window vs. pericardiectomy
  9. 9. SVC SyndromeSVC Syndrome  MechanismMechanism  Masse(s) in chest/mediastinum compress SVCMasse(s) in chest/mediastinum compress SVC  LymphomaLymphoma  Hodgkin'sHodgkin's  LungLung  BreastBreast  SymptomsSymptoms  Facial EdemaFacial Edema  Periorbital EdemaPeriorbital Edema  Cyanosis – speed determines collateral pattern onCyanosis – speed determines collateral pattern on chest wallchest wall
  10. 10. SVC SyndromeSVC Syndrome DiagnosisDiagnosis Chest X-ray – right sided mediastinal massChest X-ray – right sided mediastinal mass Radionucleotide SVC gramRadionucleotide SVC gram Tissue Diagnosis – may have to waitTissue Diagnosis – may have to wait TherapyTherapy X-ray therapy – high doseX-ray therapy – high dose SteroidsSteroids ChemotherapyChemotherapy
  11. 11. Increased IntracranialIncreased Intracranial PressurePressure  MechanismMechanism  Primary Brain TumorPrimary Brain Tumor  Metasitic TumorMetasitic Tumor  MeningesMeninges  DiagnosisDiagnosis  HeadachesHeadaches  Personality ChangesPersonality Changes  LethargyLethargy  ComaComa  PapilledemaPapilledema  Stiff neckStiff neck  Fixed pupil – tentorial herniationFixed pupil – tentorial herniation  CT/MRI of BrainCT/MRI of Brain  LP - cellsLP - cells
  12. 12. Increased IntracranialIncreased Intracranial PressurePressure TreatmentTreatment SteroidsSteroids Crainotomy – primaryCrainotomy – primary Whole Brain Irradiation – 3000 r – 2 weeksWhole Brain Irradiation – 3000 r – 2 weeks Meningeal – MTX or ARA C ITMeningeal – MTX or ARA C IT
  13. 13. Spinal Cord CompressionSpinal Cord Compression MechanismMechanism Lymphoma – mediastinal or retroperitonealLymphoma – mediastinal or retroperitoneal nodes or mets from vertebral bodiesnodes or mets from vertebral bodies SymptomsSymptoms Back Pain – syndrome insidiousBack Pain – syndrome insidious Paraplegia – bowel and bladder dysfunctionParaplegia – bowel and bladder dysfunction 12 – 24 hr progression12 – 24 hr progression Permanent when completedPermanent when completed
  14. 14. Spinal Cord CompressionSpinal Cord Compression DiagnosisDiagnosis Myleogram or MRIMyleogram or MRI TreatmentTreatment SteroidsSteroids Decompression LaminectomyDecompression Laminectomy ChemotherapyChemotherapy X- ray therapyX- ray therapy
  15. 15. HyperuricemiaHyperuricemia MechanismMechanism Following initial therapy of sensitive tumors –Following initial therapy of sensitive tumors – gout – renal tubular damage and acute renalgout – renal tubular damage and acute renal failurefailure DiagnosisDiagnosis Monitor serum uric acid levelsMonitor serum uric acid levels Uric acid precipitate stones radiolucentUric acid precipitate stones radiolucent
  16. 16. HyperuricemiaHyperuricemia TherapyTherapy DiuresisDiuresis AlkalizationAlkalization DialysisDialysis Prophylaxis -- Allopurinol 600 mg daily 2 daysProphylaxis -- Allopurinol 600 mg daily 2 days before treatment and continue for 2 weeksbefore treatment and continue for 2 weeks after treatmentafter treatment
  17. 17. HypercalcaemiaHypercalcaemia  MechanismMechanism  Mets to bone, breast, lung, renalMets to bone, breast, lung, renal  MyelomaMyeloma  Ectopic parathyroid hormone productionEctopic parathyroid hormone production  SymptomsSymptoms  NauseaNausea  VomitingVomiting  ConstipationConstipation  Urinary frequencyUrinary frequency  LethargyLethargy  ConfusionConfusion  ComaComa  DeathDeath
  18. 18. HypercalcaemiaHypercalcaemia DiagnosisDiagnosis Serum Calcium level - correct for albuminSerum Calcium level - correct for albumin TherapyTherapy Hydration - salineHydration - saline Diuresis - LasixDiuresis - Lasix MithramycinMithramycin SteroidsSteroids
  19. 19. Tumor Lysis SyndromeTumor Lysis Syndrome MechanismMechanism Rapid necrosis of tumor cellsRapid necrosis of tumor cells Release of massive intracellular material intoRelease of massive intracellular material into the circulation -- metabolic loadthe circulation -- metabolic load AscitiesAscities Renal impairmentRenal impairment ArrhythmiasArrhythmias
  20. 20. Tumor Lysis SyndromeTumor Lysis Syndrome DiagnosisDiagnosis Potassium increasedPotassium increased Phosphate increasedPhosphate increased Calcium decreasedCalcium decreased Uric Acid increasedUric Acid increased AcidosisAcidosis AzotemiaAzotemia
  21. 21. Tumor Lysis SyndromeTumor Lysis Syndrome TreatmentTreatment Correct acidosis, potassium, uric acidCorrect acidosis, potassium, uric acid DiuresisDiuresis Dialysis if neededDialysis if needed Prompt treatment can prevent deathPrompt treatment can prevent death
  22. 22. Mucositis/EsophagitisMucositis/Esophagitis MechanismMechanism Radiation therapyRadiation therapy ChemotherapyChemotherapy Antitumor antibioticsAntitumor antibiotics AntimetabolicsAntimetabolics SymptomsSymptoms PainPain VomitingVomiting
  23. 23. Mucositis/EsophagitisMucositis/Esophagitis TreatmentTreatment HydrationHydration Mycostatin/Magic MouthwashMycostatin/Magic Mouthwash Kepivance (palifermin) 60 mcg/kg/d for 3 daysKepivance (palifermin) 60 mcg/kg/d for 3 days before and after chemobefore and after chemo Gelclair (coating agent)Gelclair (coating agent) Recombinant Keratiocyte Growth FactorRecombinant Keratiocyte Growth Factor
  24. 24. AntibioticsAntibiotics AntiviralsAntivirals OtherOther Morphine PatchMorphine Patch TPN/nutritional supportTPN/nutritional support Mucositis/EsophagitisMucositis/Esophagitis
  25. 25. Avastin (Bevacizumab)Avastin (Bevacizumab) Erbitux (Cetuximab)Erbitux (Cetuximab) Tarceva (Erlotinib)Tarceva (Erlotinib) Iressa (Gefitinib)Iressa (Gefitinib) Gleevec (Imatinib)Gleevec (Imatinib) Rituxan (Retuximab)Rituxan (Retuximab) Others…..Others….. New DrugsNew Drugs New ComplicationsNew Complications
  26. 26.  AvastinAvastin  Abdominal PerforationAbdominal Perforation  Wound dehiscence after surgeryWound dehiscence after surgery  Stroke riskStroke risk  ErbituxErbitux  Acneform Rash 90%! (10% severe)Acneform Rash 90%! (10% severe)  Rituxan (Anti CD-20 antibody)Rituxan (Anti CD-20 antibody)  Anaphylactic reactionAnaphylactic reaction  TarcevaTarceva  Acneform Rash, pulmonary toxicityAcneform Rash, pulmonary toxicity  IressaIressa  Rash, pulmonary toxicityRash, pulmonary toxicity New DrugsNew Drugs New ComplicationsNew Complications
  27. 27. Acniform RashAcniform Rash New DrugsNew Drugs New ComplicationsNew Complications