11. Oncologic emergencies

From greek.doctor
  • In case of oncological emergencies oncotherapy can be initiated without knowing the histology of the cancer
  • Increased intracranial pressure
    • Due to brain metastases or primary brain tumor
    • Urgent MRI should be made
    • ASAP treatment includes dexamethasone, forced diuresis (fluid + loop diuretics) and mannitol to reduce oedema
    • Then treat tumor
  • Spinal cord compression
    • Due to enlarging vertebral metastasis or pathologic vertebral fracture due to metastasis
    • Often from breast, lung, prostate, etc.
    • Most often involves thoracic spine
    • X-ray will show blastic or lytic lesions
    • MRi will show localization of spinal cord compression
    • ASAP treatment includes dexamethasone and spinal decompression surgery
    • Then treat tumor
  • Superior vena cava syndrome
    • Can be due to lung cancer, lymphoma etc, but also due to non-cancer conditions
    • X-ray will show mediastinal widening
    • CT with contrast will give more detailed picture
    • Hyperfractionated radiation therapy given to provide rapid tumor reduction and symptom relief
  • Malignant pleural effusion
    • Exudate, not transudate
    • Due to tumor cell implants on pleura
    • Due to metastatic breast, lung or lymphoma
    • Chest x-ray shows effusion
    • Thoracentesis shows exudate, also drains fluid
    • Chest tube can be inserted to continually drain fluid
    • Pleurodesis – procedure where the visceral and parietal pleurae are adhered together to prevent fluid accumulation
      • A sclerosing agent like doxycycline, bleomycin or talc is added to the pleural cavity
      • These agents cause the pleurae to adhere to each other
  • Airway obstruction
  • Ileus
  • Hypercalcaemia of malignancy
    • In breast, lung, or multiple myeloma
    • Due to osteolytic metastases, or due to PTH-related peptide secretion
    • Symptoms include fatigue, vomiting, altered mental status
    • Treatment involves hydration and furosemide + bisphosphonates
  • Hyponatraemia
    • Due to syndrome of inappropriate ADH, due to SCLC or other neuroendocrine tumor
    • ASAP slow infusion of hypertonic saline
  • Tumor lysis syndrome
    • Due to chemo of chemosensitive, high cell-turnover tumours, especially leukaemias, lymphomas
    • Massive cell death release causes hyperkalaemia, hyperuricaemia, hyperphosphataemia, secondary hypocalcaemia
    • Prevention is essential, by hydrating patients, possibly giving allopurinol
    • Manifest tumor lysis syndrome may require dialysis
  • Febrile neutropaenia
    • Defined as a single measurement of > 38,3°C oral or a sustained temperature of 38,0°C for 1 hour + neutropaenia (< 500/µL)
    • Take two sets of blood culture ASAP, then immediately start empiric broad-spectrum AB therapy
    • Aminoglycoside + antipseudomonal beta-lactam
  • Disseminated intravascular coagulation
    • Due to acute promyelocytic leukaemia (APML)
    • Signs of haemorrhage and thrombosis
    • All-trans retinoic acid treats APML
    • Replacement of platelets and coagulation factors may be necessary
  • Hyperviscosity syndrome
    • Due to myeloproliferative disease or ALL
    • Hyperviscous blood causes symptoms of impaired microcirculation
    • Treatment includes phlebotomy