Acute Oncology Presentations Caused by Disease

1. Acute Oncology Presentations Caused by Disease Dr Omar Din Consultant Clinical Oncologist Weston Park Hospital Acute Oncology Study Day 9th October 2013

2. Types of Emergency Treatment Related Febrile neutropenia Tumour Lysis Syndrome Extravasation Diarrhoea Nausea/vomiting Biochemical Hypercalcaemia Hyponatraemia (SIADH) Obstructive/structural SVCO Raised ICP Pathological fracture Spinal Cord Compression Airway Obstruction Pericardial Effusion Pleural effusion Ascites

3. Case 1 • 59 year old lady • 6 month history of lumbar back pain • Referred to rheumatology • Bone scan

5. Case 1 • Admitted • Drowsy • Dehydrated • Abdominal pain • Worsening back pain • BP 90/60 • P 110

6. Case 1 • Bloods • Hb 9.8 • Na 135 • K 4.0 • Urea 9.4 • Creat 135 • Ca 5.3 • Alk Phos 347

7. Malignant Hypercalcaemia • Ca >2.6 mmol/l • Causes: • Bone metastases • PTH-RP: – breast, renal, lung, head and neck, myeloma, lymphoma • (Primary Hyperparathyroidism)

8. Hypercalcaemia - Symptoms • Constipation • Fatigue • Nausea/vomiting • Confusion • Polyuria • Polydipsia • Abdominal pain • Dehydration

9. Hypercalcaemia - Treatment • IV Fluids - 3L normal saline over 24 hrs • IV Bisphosphonates • Zolendronic Acid (most potent) • Palmidronate • Stop frusemide whilst dehydrated, Ca/Vit D • Calcitonin for resistant cases • Treat underlying cause

10. Bloods • Hb 10.1 • Na 118 • K 4.2 • Urea 4.0 • Creat 60

11. 9am Cortisol 500 • TSH 2.1 • Glucose 4.5 • Lipids normal • Serum osmolality 260 • Urine osmolality 368 • Urine Na 98

12. SIADH • Syndrome of inappropriate ADH secretion • Excess ADH leading to water retention and low serum sodium due to dilutional effect. • Low serum sodium and reduced plasma osmolality cf. urine osmolality • Urine Na >20mmol

13. SIADH • Cancer; SCLC, NHL, HD, thymoma, sarcoma • CNS disease (infection, trauma) • Chest disease (infection) • Drugs (thiazide, anti-epileptics, PPI, cytotoxics) • Symptoms: nil, fatigue, nausea/vomiting, confusion, coma

15. SIADH - treatment • Ensure Addison’s and Thyroid disease excluded (cortisol, TSH) • Fluid restriction 1l in 24 hours, daily U&E • Demeclocycline 600-1200mg/day divided • Discussion with endocrinology • Newer 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 demyelination • Treat underlying cause eg chemo for SCLC

17. Case 3 • 78 year old lady • Breast cancer 2008, node +, Her2 + • Admitted via A & E • Headache • Facial and arm swelling • SOBOE • Fixed raised JVP • Conjunctivaloedema

20. Superior Vena Cava Obstruction • Definition; 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 onset • Compensatory collaterals over chest wall • Neck/face swelling • Headache • Dizziness • Syncope • Conjunctival oedema

21. Diagnosis • Timely identification of the cause is essential • CT Chest • Up to 60% of patients with SVC syndrome related to neoplasia do not have a known diagnosis of cancer • Need a tissue biopsy to guide subsequent management

22. Histological Diagnosis • Sputum cytology, pleural fluid cytology, biopsy of enlarged peripheral nodes • Bone marrow biopsy for NHL • Bronchoscopy, mediastinoscopy, or thoracotomy are more invasive but sometimes necessary

23. Treatment • O2 • Dexamethasone/PPI • SVC Stent • Anticoagulation if thrombus • Does not require urgent radiotherapy – GET DIAGNOSIS • Stridor – may require ICU admission • Histopathology • Treatment depends on cause • RT vs chemotherapy (SCLC, lymphoma, germ cell)

24. Case 4 • 64 year old man • Haematuria • PS 0 • No PMH

25. Case 4 • CT right renal mass, nodes, small volume lung metastases • Developed loin pain • Palliative nephrectomy • Obstructive LFTs • Biliary stricture - stented • Developed pain in left shoulder

27. Pathological Fracture • broken bone caused by disease leading to weakness of the bone • metastatic tumours: breast, lung, thyroid, kidney, prostate • primary malignant tumours: chondrosarcoma, osteosarcoma, Ewing's tumour • Bloods: FBC, PSA, myeloma screen. • CXR. • Mammogram

28. Pathological Fracture • Orthopaedic opinion – stabilisation/reamings/biopsy • Post operative radiotherapy – 20Gy in 5 fractions • Mirel’s Risk 8=15% risk 9=33% risk >9=High risk

29. Case 4 • Treated with sunitinib • Shortly afterwards developed reduced visual acuity • Seen by opthalmology • Urgent phone call

30. Choroidal Metastases • Choroid: vascular layer in and around eye • Breast, lung, prostate, kidney, thyroid, GI, lymphoma, leukaemia • Symptoms: flashing lights, visual disturbance • Urgent treatment: Radiotherapy to save vision • 20Gy in 5 fractions

31. Brain Metastases • Lung, breast, melanoma • Headache, nausea, vomiting, seizures, change in behaviour, focal neurological deficit • CT/MRI • Dexamethasone up to 16mg/day • Risk of hydrocephalus – neurosurgeons ?shunt • Multiple mets – whole brain RT • Solitary met – excision or stereotactic radiosurgery

33. Case 6

34. Pericardial effusion • Obstruction of lymphatic drainage or fluid from tumour on pericardium • Tamponade – tachycardia, hypotension, JVP, oedema • Echocardiogram • Urgent discussion with cardiothoracics • Percardiocentesis – fluid for cytology • Pericardial window • Complete pericardial stripping • Treat underlying cause

35. Case 7

36. Lymphangitis Carcinomatosa • Breathlessness, dry cough, haemoptysis • diffuse infiltration and obstruction of pulmonary parenchymal lymphatic channels by tumour • Breast, lung, colon, stomach • 80% adeno • CXR – diffuse reticulonodular shadowing • CT or High Resolution CT

37. Lymphangitis Carcinomatosa • Treatment of underlying condition • Dexamethasone • Chemotherapy • Endocrine Therapy • Prognosis poor – 50% die within 3 months of first symptom

38. The End