Oncologic Emergencies

A 23 year old male presented with cough, facial swelling

and neck vein engorgement. Examination of the chest
showed prominence of venous collaterals and clear
breath sounds. A lymph node was palpated in the right
supraclavicular area.
What syndrome does this patient present with?

Diagnostic procedures

Superior vena cava s yndrome

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Diagnostic procedures
Contrast venography - provides important
information for determining if the vena cava is
completely obstructed or remains patent and
extrinsically compressed

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How should this patient be managed?

Immediate radiation therapy
Immediate chemotherapy
W ork up including CT scan of the chest and lymph
node biopsy
None
Management of SVC syndrome
SVCS has long been considered to be a potentially
life-threatening medical emergency
The safety of these invasive procedures in patients
with SVCS has markedly improved
Therefore, modern treatment of SVCS has become
disease specific from the outset
Diagnostic procedures

Sputum cytology
Bronchoscopy
In the presence of pleural effusion,
thoracocentesis
Biopsy of a supraclavicular node
Mediastinoscopy
Percutaneous transthoracic CT-guided fineneedle biopsy
Thoracotomy
Biopsy of the cervical lymph node revealed diffuse large
cell lymphoma. CT scans of the previously mentioned
patient showed a bulky mediastinal mass with obstruction
of the superior vena cava and large retroperitoneal lymph
nodes and splenomegaly. Bone marrow biopsy did not
show involvement.
What is the definitive treatment for this patient?
A. Chemotherapy
B. Radiotherapy
C. Monoclonal antibodies (rituximab)
D. A & B
E. All
Management of SVCS
goals of treatment of SVCS are to relieve symptoms
and to attempt the cure of the primary malignant
process
prognosis of patients strongly correlates with the
prognosis of the underlying
disease.
Medical adjuncts
Diuretics: symptomatic relief of edema, maybe
immediate but transient
Furosemide:
dose depends on state of
hydration & renal function
Steroids: may improve obstruction by decreasing
a possible inflammatory reaction associated with
tumor or with irradiation
Dexamethasone: 6 10 mg IV q 6 hours

He was given saline hydration, allopurinol and sodium

bicarbonate prior to institution of chemotherapy and
rituximab.

What metabolic complications

following treatment?
A. Tumor lysis
B. Hyperuricemia
C. Hyponatremia
D. Any of the above

are

anticipated

What are the components of tumor lysis syndrome?

Hyperuricemia
Hyperkalemia
hyperphosphatemia
hypocalcemia
Tumor Lysis Syndrome
rapid release of intracellular contents into the
bloodstream especially following chemotherapy
patients at risk: high grade lymphomas, leukemias
with high leukocyte counts
Prophylaxis for patients at risk
Adequate hydration
Alkalinize the urine
Allopurinol
Monitor Serum electrolytes, BUA, BUN, creatinine,
phosphorus, calcium for 3 4 days after
chemotherapy is initiated
Established tumor lysis
Correct electrolyte abnormalities
Hydration
Hemodialysis if appropriate in patients with renal
failure

Dialysis
A 68 year old male who was recently diagnosed to have
extensive Small cell lung cancer involving the bones of
his thoracic and lumbar vertebrae developed low back
pain, numbness and weakness of both lower
extremities.
He also complained of nausea,
abdominal discomfort and constipation. Urine output
was adequate.
What syndromes should be strongly suspected in
this patient?

A. Spinal cord compression

B. Hypercalcemia

Spinal cord compression

Compressive
indentation,
displacement,
or
encasement of the spinal cord's thecal sac by
metastatic or locally advanced cancer
posterior extension of a vertebral body mass:
compression of the anterior aspect of the spinal
cord
anterior or anterolateral extension of a mass
arising from the dorsal elements or invading the
vertebral foramen
Intramedullary spinal cord metastases produce
edema, distortion, and compression of the spinal cord
parenchyma

Hyperuricemia
Etiology
most often in
hematologic
malignancies:
leukemias,
high
grade
lymphomas,
myeloproliferative disorders (polycythemia vera)
drugs:
Cytotoxic agents: tiazofurin, aminothiadiazoles
Diuretics: thiazides, furosemide, ethacrynic
acid
Antituberculous:
pyrazinamide, ethambutol,
nicotinic acid
renal impairment
Renal complications and arthritis are the most
important consequences of acute or chronic
hyperuricemia
Diagnosis:
elevated serum uric acid levels
hyperuricosuria
increased serum creatinine, BUN
Prophylaxis prior to chemotherapy
Discontinue drugs that increase BUA
Alkalinization of urine: maintain urine pH >7.0
May add acetazolamide to increase effects
Allopurinol
Inhibits xanthine oxidase
Start 1 2 days prior to chemotherapy
Doses: 300 600 mg/day, continued for 1 2 wks
Acute oliguria
Determine if ureteral obstruction by urate calculi is
present, using ultrasound or CT

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SCC: Clinical presentation

majority of patients who present with spinal cord
compression have a known diagnosis of cancer
8% to 34%: initial manifestation of cancer
Early signs
Over 90%: pain localized to the spine or radicular
Pain exacerbated by movement, recumbency,
coughing, sneezing, straining
Precede neurological symptoms by weeks or
months
Intermediate signs:
Weakness
Preceded or accompanied by sensory loss
Late signs:
Autonomic dysfunction; urinary retention,
constipation
Paralysis
Irreversible

Do not use contrast agents

SCC: Physical findings

Tenderness to palpation or percussion of involved
vertebral body
Pain over the involved vertebra or distribution of
involved nerve root
Muscle weakness
Spasticity
Abnormal muscle stretch reflexes & extensor plantar
responses
Sensory loss
Palpable bladder
Diminished rectal tone
What is the most sensitive test to diagnose spinal
cord compression?
A. X ray
B. CT scan
C. MRI
D. PET
SCC: Diagnosis
Accurate history & neurologic examination
X-rays
More than 66% have bony abnormalities
erosion/loss of pedicles
partial/complete collapse of vertebral bodies
paraspinous soft tissue masses
Magnetic resonance imaging (MRI)
gold standard
neoplasms: decreased signal intensity on T1weighted images; increased signal intensity on T2weighted images
CT & myelography
diagnose & localize SCC if MRI not available
MRI: sagittal view: intramedullary metastases

SCC: Etiology
Frequent tumor types
Breast

29 %

Lung

17.2%

Prostate

14 %

Lymphoma

5 %

Renal

4.2%

Myeloma

4 %

SCC: Goals of Treatment

recovery & maintenance of normal neurological
function
local tumor control
stabilization of the spine
pain control
SCC is an emergency!
treatment delays result in irreversible paralysis, loss of
bladder & bowel function
with early diagnosis, treatment is effective in 90% of
patients
SCC: Treatment
Choice of treatment depends on
clinical presentation
availability of histologic diagnosis
rapidity of clinical course
type of malignancy
site of spinal involvement
stability of the spine
previous treatment

MRI: sagittal view: anterior compression of cauda equina

below conus medullaris from pathologic fracture of L2
vertebral body

Radiation
standard initial treatment for a radiosensitive
malignancy
Chemotherapy
selected patients with chemosensitive tumor
Steroids
as soon as the diagnosis is made
high dose IV (96 mg /day) dexamethasone for 3
days then tapering doses improved neurologic
function
most common regimen 10 mg IV

SCC: Indications for Surgery

Hypercalcemia: Diagnosis

spinal instability
retropulsion of bone fragments producing compression
previous radiotherapy at the site of compression
lack of tissue diagnosis in the setting of
neurologic deterioration.

rapid

SCC: Prognosis
Maranzano & Latini, 1995
209 patients treated with RT & steroids
ambulatory
98%
nonambulatory 60%
paraplegic
11%
able to ambulate following therapy
Outcome superior for radiosensitive malignancies:
lymphoma, myeloma vs. renal, hepatoma

Accurate history & physical examination

Identify the underlying malignancy
Determine presence or absence of bone metastases
In humoral hypercalcemia of malignancy:
serum iPTH: low or undetectable
inorganic phosphorus: low or normal
1,25-hydroxyvitamin D: low or normal

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The patient also complained of nausea, abdominal

discomfort and constipation. What is the most
probable cause of these symptoms?

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Hyperuricemia

Hypercalcemia

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Hypocalcemia

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GI involvement by cancer

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Hypercalcemia: Treatment

Most common metabolic emergency

Etiology:
Myeloma
Lung cancer (epidermoid more often than SCLC)
Renal

Volume expansion & natriuresis

Incidence varies with the underlying disorder

highest with myeloma & breast : 40%
intermediate with non small cell lung cancer
uncommon in colon, prostate, SCLC

Loop diuretics

Mechanisms underlying osteolysis & subsequent

hypercalcemia: PTHrP

increase renal blood flow

enhance calcium excretion sec to ionic exchange
of calcium for sodium in the distal tubule
in theory, enhance calcium excretion
once euvolemia is achieved, may be useful in
preventing hypervolemia
Bisphosphonates
bind avidly to hydroyapatite crystals & inhibit bone
resorption
may be mediated by inhibition of osteoclasts and
activation of cytokines
inhibit recruitment & differentiation of osteoclast
precursors
Corticosteroids
of use in lymphoid malignancies bec antitumor
effect
Calcitonin
inhibits bone degradation by binding directly to
receptors on the osteoclast

Hypercalcemia: Signs and Symptoms

General

Cardiac

GI

Dehydration Weakness

Bradycardia

Anorexia

Nausea & Polyuria

vomiting
Constipation Nephrocalcinosis

Short QT
interval
Prolonged PR Ileus
interval
Wide T wave Pancreatitis

Pruritus

CNS

Hypotonia

Proximal
myopathy
Weight loss Mental
changes
Fatigue
Seizure
Coma

Atrial or
ventricular
arrhythmias

Dyspepsia

Renal

onset of action: 2 4 h
short duration of action
little response to continued treatment
dose: 2 8 U/kg sq or im q 6 12h
Mithramycin
directly inhibits osteoclasts
onset of action : 24 48 h
re- treatment necessary in 72 96 h
dose: 25 mcg/kg
Gallium nitrate

directly inhibits osteoclasts, increases bone

calcium without cytotoxic effects on bone cells
onset of action: 24 48h
dose: 100 200 mg/m2 IV infusion for 5 days
A 55 year old female presented with headache, vomiting
and dizziness. Past history revealed nonproductive
cough of 3 months duration and upper back pain
made worse during coughing. Chest CT scan should
a peripheral left mid lung mass which on biopsy
revealed adenocarcinoma.

more detailed neuroanatomic imaging and the

distinction between a neoplastic, infectious,
inflammatory, or ischemic process
Lumbar puncture
bears the risk of initiating or aggravating cerebral
herniation. The risk is considerable in mass lesions
of the posterior fossa
Treatment
Best position: head and upper trunk slightly elevated
Body temperature elevation: treated with antipyretics

Increase in intracranial pressure (ICP)

common neurologic complication of patients with
cancer involving the nervous system
mechanisms
/ large cerebral metastases
can give rise to intracranial hemorrhage
/ coagulopathies
predispose
to
subdural
hemorrhage
/ infections of the nervous system, such as fungal or
bacterial meningitis or a bacterial abscess

Serum osmolality is kept in the high normal range

Isotonic saline solutions for intravenous hydration.
Corticosteroids: effective for the initial management of
increased ICP caused by vasogenic edema

/ should be avoided if CNS lymphoma is considered

, no tissue diagnosis yet

Osmotic diuresis through infusion of hyperosmolar

agents such as mannitol or glycerol
Monitoring in the neurologic intensive care unit is
required in patients with depressed mental status
secondary to ICP elevation
most rapid method is intubation with mechanical
hyperventilation

Clinical Presentation
headache:most common complaint
nausea and vomiting
cognitive complaints such as slowness to respond and
inattentiveness
reflect frontal lobe dysfunction

Obstructive hydrocephalus constitutes a neurosurgical

emergency
Disease-specific treatment

increasingly somnolent and ultimately falls into a coma

funduscopic examination with papilledema:
patients

half of

Section III-A
Allan Louie Cruz

focal neurologic deficits can help localize the mass

/ gaze paresis to the side opposite the lesion:
involvement of the frontal center for horizontal
gaze.
/ posterior frontal masses:
contralateral
hemiparesis.
Hyponatremia: result of inappropriate secretion of
antidiuretic hormone
What examinations are indicated to document ICP
and its possible cause?
Skull X-ray
Lumbar puncture
CT scan of the brain
MRI of the brain
Imaging Studies
Unenhanced computed tomography
adequate to determine the presence of
intraventricular and subarachnoid CSF flow
obstruction , as well as uncal, transfalcian, and
transtentorial herniation
presence of intracranial hemorrhage or a
neoplastic or infectious mass lesion can be
identified
MRI and magnetic spectroscopy