Acute Oncology Presentations Caused by DiseaseDr Omar DinConsultant Clinical OncologistWeston Park HospitalAcute Oncology Study Day 9th October 2013

Types of EmergencyBiochemical HypercalcaemiaHyponatraemia (SIADH)

Obstructive/structural SVCORaised ICPPathological fractureSpinal Cord CompressionAirway ObstructionPericardial EffusionPleural effusionAscites

Treatment RelatedFebrile neutropeniaTumour Lysis SyndromeExtravasationDiarrhoeaNausea/vomiting

Case 159 year old lady6 month history of lumbar back painReferred to rheumatologyBone scan

Case 1Admitted DrowsyDehydratedAbdominal painWorsening back painBP 90/60P 110

Case 1BloodsHb 9.8Na 135K 4.0Urea 9.4Creat 135Ca 5.3Alk Phos 347

Malignant HypercalcaemiaCa >2.6 mmol/lCauses:Bone metastasesPTH-RP: breast, renal, lung, head and neck, myeloma, lymphoma(Primary Hyperparathyroidism)

Hypercalcaemia - Symptoms

ConstipationFatigueNausea/vomitingConfusionPolyuriaPolydipsiaAbdominal painDehydration

Hypercalcaemia - TreatmentIV Fluids - 3L normal saline over 24 hrs

IV BisphosphonatesZolendronic Acid (most potent)PalmidronateStop frusemide whilst dehydrated, Ca/Vit DCalcitonin for resistant casesTreat underlying cause

BloodsHb 10.1Na 118K 4.2Urea 4.0Creat 60

9am Cortisol 500TSH 2.1Glucose 4.5Lipids normalSerum osmolality 260Urine osmolality 368Urine Na 98

SIADHSyndrome of inappropriate ADH secretionExcess ADH leading to water retention and low serum sodium due to dilutional effect.Low serum sodium and reduced plasma osmolality cf. urine osmolalityUrine Na >20mmol

SIADHCancer; SCLC, NHL, HD, thymoma, sarcomaCNS disease (infection, trauma)Chest disease (infection)Drugs (thiazide, anti-epileptics, PPI, cytotoxics)Symptoms:nil, fatigue, nausea/vomiting, confusion, coma

SIADH - treatmentEnsure Addisons and Thyroid disease excluded (cortisol, TSH)Fluid restriction 1l in 24 hours, daily U&EDemeclocycline 600-1200mg/day dividedDiscussion with endocrinologyNewer agents eg Tolvaptan (vasopressin receptor antagonists)In EMERGENCY ONLY i.e. coma/fitting D/W Critical care. May need transfer to HDU for slow IV NaCl 1.8% - caution with osmotic demyelinationTreat underlying cause eg chemo for SCLC

Case 378 year old ladyBreast cancer 2008, node +, Her2 +Admitted via A & EHeadacheFacial and arm swellingSOBOEFixed raised JVPConjunctival oedema

Superior Vena Cava ObstructionDefinition; compression, invasion or occasionally intraluminal obstruction of the superior vena Causes; SCLC, NSCLC, lymphoma account for 90% cases. Others include thymoma and germ cell.

Often insidious onsetCompensatory collaterals over chest wallNeck/face swellingHeadacheDizzinessSyncopeConjunctival oedema

DiagnosisTimely identification of the cause is essentialCT ChestUp to 60% of patients with SVC syndrome related to neoplasia do not have a known diagnosis of cancerNeed a tissue biopsy to guide subsequent management

Histological DiagnosisSputum cytology, pleural fluid cytology, biopsy of enlarged peripheral nodes

Bone marrow biopsy for NHL

Bronchoscopy, mediastinoscopy, or thoracotomy are more invasive but sometimes necessary

TreatmentO2Dexamethasone/PPISVC StentAnticoagulation if thrombusDoes not require urgent radiotherapy GET DIAGNOSISStridor may require ICU admission

Histopathology

Treatment depends on causeRT vs chemotherapy (SCLC, lymphoma, germ cell)

Case 464 year old manHaematuriaPS 0No PMH

Case 4CT right renal mass, nodes, small volume lung metastasesDeveloped loin painPalliative nephrectomyObstructive LFTsBiliary stricture - stentedDeveloped pain in left shoulder

Pathological Fracturebroken bone caused by disease leading to weakness of the bonemetastatic tumours: breast, lung, thyroid, kidney, prostateprimary malignant tumours: chondrosarcoma, osteosarcoma, Ewing's tumourBloods: FBC, PSA, myeloma screen. CXR. Mammogram

Pathological FractureOrthopaedic opinion stabilisation/reamings/biopsyPost operative radiotherapy 20Gy in 5 fractionsMirels Risk

8=15% risk9=33% risk>9=High risk

123SiteUpper limbLower limbPeritrochanterPainMildModerateSevereLesionBlasticMixedLyticSize2/3

Case 4Treated with sunitinibShortly afterwards developed reduced visual acuitySeen by opthalmologyUrgent phone call

Choroidal MetastasesChoroid: vascular layer in and around eyeBreast, lung, prostate, kidney, thyroid, GI, lymphoma, leukaemiaSymptoms: flashing lights, visual disturbanceUrgent treatment: Radiotherapy to save vision20Gy in 5 fractions

Brain MetastasesLung, breast, melanomaHeadache, nausea, vomiting, seizures, change in behaviour, focal neurological deficitCT/MRIDexamethasone up to 16mg/dayRisk of hydrocephalus neurosurgeons ?shuntMultiple mets whole brain RTSolitary met excision or stereotactic radiosurgery

Case 6

Pericardial effusionObstruction of lymphatic drainage or fluid from tumour on pericardiumTamponade tachycardia, hypotension, JVP, oedemaEchocardiogramUrgent discussion with cardiothoracicsPercardiocentesis fluid for cytologyPericardial windowComplete pericardial strippingTreat underlying cause

Case 7

Lymphangitis CarcinomatosaBreathlessness, dry cough, haemoptysisdiffuse infiltration and obstruction of pulmonary parenchymal lymphatic channels by tumourBreast, lung, colon, stomach80% adenoCXR diffuse reticulonodular shadowingCT or High Resolution CT

Lymphangitis CarcinomatosaTreatment of underlying conditionDexamethasoneChemotherapyEndocrine TherapyPrognosis poor 50% die within 3 months of first symptom

The End