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Oncologic Emergencies

Oncologic Emergencies. Noel Rowan, MD, FACP Comprehensive Cancer Center Las Vegas, Nevada cccnevada.com. Oncologic Emergencies. Cardiovascular Pericardial Tamponade Superior Vena Cava Syndrome Central Nervous System Emergencies Increased Intracranial Pressure Spinal Cord Compression

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Oncologic Emergencies

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  1. Oncologic Emergencies Noel Rowan, MD, FACP Comprehensive Cancer Center Las Vegas, Nevada cccnevada.com

  2. Oncologic Emergencies • Cardiovascular • Pericardial Tamponade • Superior Vena Cava Syndrome • Central Nervous System Emergencies • Increased Intracranial Pressure • Spinal Cord Compression • Gastrointestinal • Bowel Obstruction • Bowel Perforation • Ascites • Esophageal Obstruction and Perforation

  3. Oncologic Emergencies • Hematologic Emergencies • DIC • Leukostasis • Thrombocytopenia • Infectious Emergencies • Sepsis in the leukopenic patient • Disseminated Viral Infections • Fungal and Parasitic Diseases

  4. Oncologic Emergencies • Metabolic Emergencies • Hyperuricemia • Hypercalcaemia • Hypoglycemia • Lactic Acidosis • Tumor Lysis Syndrome • Orthopedic Emergencies • Pathologic Fracture

  5. Oncologic Emergencies • Waldenstroms • Hyperviscosity Syndrome • Plasmaphoresis

  6. Oncologic Emergencies • Renal Emergencies • Ureteral Obstruction – Pelvic Tumors • Respiratory Emergencies • Airway Obstruction • Pneumothorax • Effusion • Symptomatic Emergencies • Pain • Vomiting • Mucositis • Dyspnea

  7. Pericardial Tamponade • Mechanism • Fluid in pericardial sac due to metastaic tumor • Post X-ray treatment – 4000 r • Decreased CO because of decreased venous return • Symptoms • Dyspnea • Confusion • Coma • Distended neck veins • Pulses Paradoxes • CHF

  8. Pericardial Tamponade • Diagnosis • Enlarged heart • CXR – sac-like heart • Echo • Treatment • Percardiocentesis • Catheter SFU • X-Ray Therapy • Surgery – window vs. pericardiectomy

  9. SVC Syndrome • Mechanism • Masse(s) in chest/mediastinum compress SVC • Lymphoma • Hodgkin's • Lung • Breast • Symptoms • Facial Edema • Periorbital Edema • Cyanosis – speed determines collateral pattern on chest wall

  10. SVC Syndrome • Diagnosis • Chest X-ray – right sided mediastinal mass • Radionucleotide SVC gram • Tissue Diagnosis – may have to wait • Therapy • X-ray therapy – high dose • Steroids • Chemotherapy

  11. Increased Intracranial Pressure • Mechanism • Primary Brain Tumor • Metasitic Tumor • Meninges • Diagnosis • Headaches • Personality Changes • Lethargy • Coma • Papilledema • Stiff neck • Fixed pupil – tentorial herniation • CT/MRI of Brain • LP - cells

  12. Increased Intracranial Pressure • Treatment • Steroids • Crainotomy – primary • Whole Brain Irradiation – 3000 r – 2 weeks • Meningeal – MTX or ARA C IT

  13. Spinal Cord Compression • Mechanism • Lymphoma – mediastinal or retroperitoneal nodes or mets from vertebral bodies • Symptoms • Back Pain – syndrome insidious • Paraplegia – bowel and bladder dysfunction • 12 – 24 hr progression • Permanent when completed

  14. Spinal Cord Compression • Diagnosis • Myleogram or MRI • Treatment • Steroids • Decompression Laminectomy • Chemotherapy • X- ray therapy

  15. Hyperuricemia • Mechanism • Following initial therapy of sensitive tumors – gout – renal tubular damage and acute renal failure • Diagnosis • Monitor serum uric acid levels • Uric acid precipitate stones radiolucent

  16. Hyperuricemia • Therapy • Diuresis • Alkalization • Dialysis • Prophylaxis -- Allopurinol 600 mg daily 2 days before treatment and continue for 2 weeks after treatment

  17. Hypercalcaemia • Mechanism • Mets to bone, breast, lung, renal • Myeloma • Ectopic parathyroid hormone production • Symptoms • Nausea • Vomiting • Constipation • Urinary frequency • Lethargy • Confusion • Coma • Death

  18. Hypercalcaemia • Diagnosis • Serum Calcium level - correct for albumin • Therapy • Hydration - saline • Diuresis - Lasix • Mithramycin • Steroids

  19. Tumor Lysis Syndrome • Mechanism • Rapid necrosis of tumor cells • Release of massive intracellular material into the circulation -- metabolic load • Ascities • Renal impairment • Arrhythmias

  20. Tumor Lysis Syndrome • Diagnosis • Potassium increased • Phosphate increased • Calcium decreased • Uric Acid increased • Acidosis • Azotemia

  21. Tumor Lysis Syndrome • Treatment • Correct acidosis, potassium, uric acid • Diuresis • Dialysis if needed • Prompt treatment can prevent death

  22. Mucositis/Esophagitis • Mechanism • Radiation therapy • Chemotherapy • Antitumor antibiotics • Antimetabolics • Symptoms • Pain • Vomiting

  23. Mucositis/Esophagitis • Treatment • Hydration • Mycostatin/Magic Mouthwash • Kepivance (palifermin) 60 mcg/kg/d for 3 days before and after chemo • Gelclair (coating agent) • Recombinant Keratiocyte Growth Factor

  24. Mucositis/Esophagitis • Antibiotics • Antivirals • Other • Morphine Patch • TPN/nutritional support

  25. New DrugsNew Complications • Avastin (Bevacizumab) • Erbitux (Cetuximab) • Tarceva (Erlotinib) • Iressa (Gefitinib) • Gleevec (Imatinib) • Rituxan (Retuximab) • Others…..

  26. New DrugsNew Complications • Avastin • Abdominal Perforation • Wound dehiscence after surgery • Stroke risk • Erbitux • Acneform Rash 90%! (10% severe) • Rituxan (Anti CD-20 antibody) • Anaphylactic reaction • Tarceva • Acneform Rash, pulmonary toxicity • Iressa • Rash, pulmonary toxicity

  27. New DrugsNew Complications • Acniform Rash

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