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Acute Oncological Emergencies

Acute Oncological Emergencies. Dr Danny Bloomfield Locum Consultant in Acute Oncology Princess Alexandra Hospital Monday 8 th July 2013. Outline – Acute Oncological Emergencies. What are they? What do I need to know about them? How are they diagnosed? How do I manage/refer patients?.

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Acute Oncological Emergencies

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  1. Acute Oncological Emergencies Dr Danny Bloomfield Locum Consultant in Acute Oncology Princess Alexandra Hospital Monday 8th July 2013

  2. Outline – Acute Oncological Emergencies • What are they? • What do I need to know about them? • How are they diagnosed? • How do I manage/refer patients?

  3. Traditional Oncological Emergencies? • Neutropenic Sepsis • Metastatic spinal cord compression • Superior Vena Cava Obstruction • Hypercalcaemia of malignancy

  4. Traditional Oncological Emergencies? • Neutropenic Sepsis - Impending death • Metastatic spinal cord compression - Impending catastrophe • Superior Vena Cava Obstruction - May be a presenting feature of cancer • Hypercalcaemia of malignancy - Treatable cause of life-threatening deterioration

  5. Acute Oncology encompasses the management of: • Patients with acute complications from their cancer diagnosis • Patients with acute complications from their cancer treatments • Patients who present as an emergency with a suspected but undiagnosed cancer

  6. Traditional Oncological Emergencies? • Neutropenic Sepsis • Metastatic spinal cord compression • Superior Vena Cava Obstruction • Hypercalcaemia of malignancy

  7. When is a patient “septic”?

  8. DRAFT DOCUMENT – Not for clinical use

  9. Neutropenic Sepsis • Identify patients early • Give antibiotics promptly (in hospital) • Ongoing management • Admission? • Escalation of care? • GCSF? • Duration of antibiotics? • Criteria for discharge?

  10. PAH Spinal Cord Compression Pathway - DRAFT

  11. Reviews • Systematic review of the diagnosis and management of malignant extradural spinal cord compression. Journal of Clinical Oncology2005;23:2028-2037 • Malignant spinal-cord compression Lancet Oncology 2005;6:15-24

  12. Malignant Spinal Cord Compression • A common complication of cancer • 8-34% of cases arise as initial manifestation of CA • Substantial impact on quality of life • Early diagnosis is important • Urgent treatment aimed at preserving function

  13. Definition of MSCC • Compression of the dural sac and its contents (spinal cord and/or cauda equina) by an extradural tumor mass • The minimum radiological evidence for cord compression is indentation of the theca at the level of clinical features • Subclinical if there are no clinical features

  14. Modes of compressionDiagram from Cancer and its Management – Souhami & Tobias

  15. Epidemiology 1 Incidence • 2.5% of pts with terminal CA, final 5 years • Incidence varies according to 10 site & age • 0.2% in pancreatic CA - 7.9% in myeloma* • 4.4% pts aged 40-50; 0.5% pts aged > 80* • 0.23% had MSCC at CA diagnosis • Second episodes in 7-14% *Loblaw et al JCO 16:1616-1624 1998

  16. Table 1. MSCC in Ontario, 1990–1995: prevalence at diagnosis, and cumulative incidence in the 5 years preceding death from cancerLoblaw et al JCO 16:1616-1624 1998

  17. Table 3. Survival from date of first episode of MSCCLoblaw et al JCO 16:1616-1624 1998

  18. Epidemiology 2Common tumor types Bronchus Breast Brostate Bidney Blood: Multiple myeloma & NHL Breast, bronchus and brostate ~ 2/3 of total Bidney, NHL and MM ~ 5-10% each NB this is for ADULTS

  19. Epidemiology 4Localisation • 60-80% thoracic* • 15-30% lumbosacral • <10% cervical • Up to 50% have > 1 area involved *Due to natural kyphosis and the spinal cord occupying most of the intrathecal cross section

  20. Clinical symptoms of MSCC Symptom Frequency Back pain (median 6/52) 70-96% Weakness* 61-91% Sensory deficit 46-90% Autonomic dysfunction** 40-57% *2/3 of patients are non-ambulatory at diagnosis ** ~ ½ patients catheter-dependent at diagnosis

  21. Ix of suspected MSCC MRI Establishes the diagnosis Guides management decisions Sensitivity 44% - 93% Specificity 90% - 98% Can distinguish benign vs malignant cause The whole spine is imaged

  22. Other imaging modalities? • Plain X-rays? False –ve in 17% Only associated compression in 75% of vertebral crush # • Bone scan? Not in clinical setting of acute compression BUT -ve bone scan & plain X-rays: unlikely MSCC • CT? Only nowadays in planning conformal RT • Myelography? Historical (but useful) • PET Experimental

  23. Treatment of MSCC - steroids • Steroids improve functional outcome with RT* • No agreement on optimal dose/schedule • Trials compare 96-100mg/24hr v 10-16mg/24 hr • More complications with higher doses • Use 16 mg dexamethasone/24 hours (8mg bd) • Continue during RT then taper rapidly (< 2/52) • Eg. 8 mg od 3/7, 4 mg od 3/7, 2 mg od 3/7, stop? • Selected patients do not need steroids** * Sorensen et al Eur J Cancer 1994; 30A:22-27 ** Maranzano et al Int J Radiat Oncol Biol Phys 1995;32:959-67

  24. Steroid side effects • GI ulcers / bleeding / perforation • Psychosis • Osteoporosis/fractures • Myopathy • Skin thinning • Diabetes • Etc.

  25. Treatment of MSCCSurgery + RT vs RT alone Patchell et al Proc Am Soc Clin Oncol 21:1, 2003 (abstr 2) Regine WF, Tibbs PA, Young A, et al. Int J Radiat Oncol Biol Phys 2003; 57 (suppl 2): S125 Randomised trial Decompressive surgery + RT vs RT alone 30 Gy in 10# both arms 101 patients (terminated at 50% accrual) Median ambulation 126 v 35 days (p=0.006) 3/16 (19%*) v 9/16 (58%) paraparetic pts regained ambulation Better pain control Trend toward better survival with surgery (p=0.08)

  26. MSCC – Prognosis 1 • Pretreatment neurological status most important • Speed of development of motor deficits: > 14/7 better than < 14/7 (86% improved at 2 weeks vs 12%) • Length of time from diagnosis to MSCC • Radiosensitivity of the tumour • Bony compression (vs without) and degree of compression • Good: ambulatory, radiosensitive, 1 level of compression • Not good: multiple levels, brain/visceral mets/ lung CA, etc • Median survival historically 3-6 months • Recurrence occurs in 10-25% of patients • Recurrence in 50% of 2 year survivors; nearly all 3-year survivors

  27. MSCC – Prognosis 2Ambulation post RT Deficit before RTAmbulatory after RT Bony* Non-bony Ambulatory 92% 100% Assistance need 65% 94% Paraparetic 43% 60% Paraplegic** 14% 11% *bony compression not excluded ** flicker of movement only

  28. Supportive care • Analgesia • Laxatives • Bladder care • Physiotherapy

  29. Conclusions/Summary • Consider the diagnosis early – do an MRI • Optimal intervention strategy still unknown • Start steroids and plan to reduce • Consider surgery, though there is no consensus • Re-irradiation is relatively safe • Optimal screening strategy unknown

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