-
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