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Oncologic EmergenciesOncologic Emergencies
Noel Rowan, MD, FACPNoel Rowan, MD, FACP
Comprehensive Cancer Comprehensive Cancer CenterCenter
Las Vegas, NevadaLas Vegas, Nevadacccnevada.comcccnevada.com
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
Oncologic EmergenciesOncologic Emergencies
Hematologic EmergenciesHematologic EmergenciesDICDICLeukostasisLeukostasisThrombocytopeniaThrombocytopenia
Infectious EmergenciesInfectious EmergenciesSepsis in the leukopenic patientSepsis in the leukopenic patientDisseminated Viral InfectionsDisseminated Viral InfectionsFungal and Parasitic DiseasesFungal and Parasitic Diseases
Oncologic EmergenciesOncologic Emergencies
Metabolic EmergenciesMetabolic EmergenciesHyperuricemiaHyperuricemiaHypercalcaemiaHypercalcaemiaHypoglycemiaHypoglycemiaLactic AcidosisLactic AcidosisTumor Lysis SyndromeTumor Lysis Syndrome
Orthopedic EmergenciesOrthopedic EmergenciesPathologic FracturePathologic Fracture
Oncologic EmergenciesOncologic Emergencies
WaldenstromsWaldenstroms Hyperviscosity SyndromeHyperviscosity Syndrome PlasmaphoresisPlasmaphoresis
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
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 Decreased CO because of decreased venous
returnreturn SymptomsSymptoms
DyspneaDyspnea ConfusionConfusion ComaComa Distended neck veinsDistended neck veins Pulses ParadoxesPulses Paradoxes CHFCHF
Pericardial TamponadePericardial Tamponade
DiagnosisDiagnosisEnlarged heartEnlarged heartCXR – sac-like heartCXR – sac-like heartEchoEcho
Treatment Treatment PercardiocentesisPercardiocentesisCatheter SFUCatheter SFUX-Ray TherapyX-Ray TherapySurgery – window vs. pericardiectomySurgery – window vs. pericardiectomy
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 Cyanosis – speed determines collateral pattern
on chest wallon chest wall
SVC SyndromeSVC Syndrome
DiagnosisDiagnosisChest X-ray – right sided mediastinal Chest X-ray – right sided mediastinal
massmassRadionucleotide SVC gramRadionucleotide SVC gramTissue Diagnosis – may have to waitTissue Diagnosis – may have to wait
TherapyTherapyX-ray therapy – high doseX-ray therapy – high doseSteroidsSteroidsChemotherapyChemotherapy
Increased Intracranial Increased 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
Increased Intracranial Increased Intracranial Pressure Pressure
TreatmentTreatmentSteroidsSteroidsCrainotomy – primaryCrainotomy – primaryWhole Brain Irradiation – 3000 r – 2 Whole Brain Irradiation – 3000 r – 2
weeksweeksMeningeal – MTX or ARA C ITMeningeal – MTX or ARA C IT
Spinal Cord CompressionSpinal Cord Compression
MechanismMechanismLymphoma – mediastinal or retroperitoneal Lymphoma – mediastinal or retroperitoneal
nodes or mets from vertebral bodiesnodes or mets from vertebral bodiesSymptomsSymptoms
Back Pain – syndrome insidiousBack Pain – syndrome insidiousParaplegia – bowel and bladder Paraplegia – bowel and bladder
dysfunctiondysfunction12 – 24 hr progression12 – 24 hr progressionPermanent when completedPermanent when completed
Spinal Cord CompressionSpinal Cord Compression
DiagnosisDiagnosisMyleogram or MRIMyleogram or MRI
TreatmentTreatmentSteroidsSteroidsDecompression LaminectomyDecompression LaminectomyChemotherapyChemotherapyX- ray therapyX- ray therapy
HyperuricemiaHyperuricemia
MechanismMechanismFollowing initial therapy of sensitive Following initial therapy of sensitive
tumors – gout – renal tubular damage tumors – gout – renal tubular damage and acute renal failureand acute renal failure
DiagnosisDiagnosisMonitor serum uric acid levelsMonitor serum uric acid levelsUric acid precipitate stones radiolucentUric acid precipitate stones radiolucent
HyperuricemiaHyperuricemia
TherapyTherapyDiuresisDiuresisAlkalizationAlkalizationDialysisDialysisProphylaxis -- Allopurinol 600 mg daily 2 Prophylaxis -- Allopurinol 600 mg daily 2
days before treatment and continue for days before treatment and continue for 2 weeks after treatment2 weeks after treatment
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
HypercalcaemiaHypercalcaemia
DiagnosisDiagnosisSerum Calcium level - correct for Serum Calcium level - correct for
albuminalbuminTherapyTherapy
Hydration - salineHydration - salineDiuresis - LasixDiuresis - LasixMithramycinMithramycinSteroidsSteroids
Tumor Lysis SyndromeTumor Lysis Syndrome
MechanismMechanismRapid necrosis of tumor cellsRapid necrosis of tumor cellsRelease of massive intracellular material Release of massive intracellular material
into the circulation -- metabolic loadinto the circulation -- metabolic loadAscitiesAscitiesRenal impairmentRenal impairmentArrhythmiasArrhythmias
Tumor Lysis SyndromeTumor Lysis Syndrome
DiagnosisDiagnosisPotassium increasedPotassium increasedPhosphate increasedPhosphate increasedCalcium decreasedCalcium decreasedUric Acid increasedUric Acid increasedAcidosisAcidosisAzotemiaAzotemia
Tumor Lysis SyndromeTumor Lysis Syndrome
TreatmentTreatmentCorrect acidosis, potassium, uric acidCorrect acidosis, potassium, uric acidDiuresisDiuresisDialysis if neededDialysis if needed
Prompt treatment can prevent deathPrompt treatment can prevent death
Mucositis/EsophagitisMucositis/Esophagitis
MechanismMechanismRadiation therapyRadiation therapyChemotherapyChemotherapyAntitumor antibioticsAntitumor antibioticsAntimetabolicsAntimetabolics
SymptomsSymptomsPainPainVomitingVomiting
Mucositis/EsophagitisMucositis/Esophagitis
TreatmentTreatmentHydrationHydrationMycostatin/Magic MouthwashMycostatin/Magic MouthwashKepivance (palifermin) 60 mcg/kg/d for Kepivance (palifermin) 60 mcg/kg/d for
3 days before and after chemo3 days before and after chemoGelclair (coating agent)Gelclair (coating agent)Recombinant Keratiocyte Growth FactorRecombinant Keratiocyte Growth Factor
AntibioticsAntibioticsAntiviralsAntiviralsOtherOther
Morphine Patch Morphine Patch TPN/nutritional supportTPN/nutritional support
Mucositis/EsophagitisMucositis/Esophagitis
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 DrugsNew ComplicationsNew Complications
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 DrugsNew ComplicationsNew Complications
Acniform RashAcniform Rash
New DrugsNew DrugsNew ComplicationsNew Complications
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