Oncological Emergencies

Август 21, 2022

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Oncological Emergencies

Содержание

2. What is Oncologic Emergency? A clinical condition resulting from a metabolic, neurologic, cardiovascular, hematologic, and/or infectious
5. METABOLIC
6. Hypercalcemia of Malignancy. Major Mechanisms: Local osteolytic hypercalcemia Osteoclastic bone resorbing cytokines In Extensive bone metastases
8. Symptoms GI : Nausea, vomiting, Anorexia,Constipation Renal Polyuria due to interference with ADH- Diabetes insipidus-like syndrome,
9. Lab Total calcium & albumin or ionized calcium Medical emergency above 10.5 mg/dL Phosphorus Creatinine, urea
13. Cиндром неадекватной секреции антидиуретического гормона (SIADH)
15. Osmotic Demyelination Syndrome Recall that during chronic hyponatremia, osmolytes are shifted out of brain cells to
18. Acute Tumor Lysis Syndrome Usually starts 6-72 h from initiation of chemo or radiotherapy Due to
19. Etiologic Factors Large Tumor burden High growth fraction High pre treatment serum LDH or Uric Acid
22. Treatment Best treatment – prevention Hydration – 3L\24h, better started 24-48 h before treatment initiation Stop
23. Stop the chemotherapy Aggressive IV hydration / diuresis CaCl2, NaHCO3, glucose / insulin, kayexalate for hyperkalemia
27. STRUCTURAL: Neurologic emergencies
28. Spinal Cord Compression
29. What is malignant spinal cord compression? Occurs when cancer cells grow in/near to spine and press
30. Most commonly seen in Breast Lung Prostate Lymphoma Myeloma About 10% of patients with cancer overall
31. Method of spread 85%From vertebral body or pedicle 10% Through intervertebral foramina (from paravertebral nodes or
32. Location Thoracic spine 60-70% Lumbosacral spine 20-30% Cervical and sacral spine less then 10% each
34. First Symptoms Pain 95% Weakness 5% Ataxia 1% Sensory loss 1% RED FLAGS…..
35. First Red Flag: Pain Usually first and most common symptom (80-90%) Usually precedes other neurologic symptoms
36. Second Red Flag: Motor Weakness: 60-85% At or above conus medularis Extensors of the upper extremities
37. Third Red Flag: Bladder & Bowel Function Loss is late finding Problems passing urine may include
38. Investigations & information needed prior to therapy MRI scan of the whole spine Can get compression
39. Treatment options include: Immobilisation Steroids & gastric protection Analgesia Surgery – decompression & stabilisation of the
40. Indications for Surgery • Unknown primary tumour • Relapse post RT • Progression while on RT
41. Surgery
45. Improvement in surgery + RT Days remained ambulatory (126 vs. 35) Percent that regained ambulation after
46. Radiation Therapy
48. Prognosis Median survival with MSCC is 6 months Ambulatory patients with radiosensitive tumours have the best
49. Superior Vena Cava Syndrome
51. Superior Vena Cava Syndrome
52. Superior Vena Cava Syndrome
54. Superior Vena Cava Syndrome
57. In rare cases can be disease presentation No time for pathology Urgent treatment without tissue diagnosis
58. Exeption: Treatment Sensitive Tumors NHLs, germ cells, and limited-stage small cell lung cancers usually respond to
59. Superior Vena Cava Syndrome
60. Superior Vena Cava Syndrome
61. Superior Vena Cava Syndrome
62. Treatment Options Radiation therapy Chemotherapy Intraluminal Stent +supportive care
63. Supportive Care: Rest Head elevation Oxygen Diuretics Anticoagulation Steroids Avoid high volume fluid infusion through upper
64. Intraluminal Stents Endovascular placement under fluoroscopy Patients who have recurrent disease in previously irradiated fields Tumors
66. Endovascular stenting and angioplasty Superior vena cava syndrome
70. Most Common type of CNS malignancy 20-40% of cancer patients will develop brain mets Most common
71. Recursive Partitioning Analysis - RPA גרורות מוחיות Brain Metastasis
72. גרורות מוחיות Brain Metastasis
73. Diagnosis: CT with and without contrast MRI – modality of choice for small lesions including leptomeningial
74. גרורות מוחיות Brain Metastasis
75. גרורות מוחיות Brain Metastasis
76. גרורות מוחיות Brain Metastasis
77. Treatment: Steroids – Dexamethasone 16mg*2 Anticonvulsant Surgery? Radiation therapy גרורות מוחיות Brain Metastasis
78. Radiation therapy WBRT=Whole Brain RT SRS=Stereotactic Radio Surgery גרורות מוחיות Brain Metastasis
79. גרורות מוחיות German Helmet Brain Metastasis
80. גרורות מוחיות Brain Metastasis
81. גרורות מוחיות Brain Metastasis
82. SRS
83. גרורות מוחיות Brain Metastasis
85. Скачать презентацию

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What is Oncologic Emergency?
A clinical condition resulting from a metabolic, neurologic,

cardiovascular, hematologic, and/or infectious change caused by cancer or its treatment that requires immediate intervention to prevent loss of life or quality of life.

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METABOLIC

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Hypercalcemia of Malignancy. Major Mechanisms:
Local osteolytic hypercalcemia
Osteoclastic bone resorbing cytokines
In Extensive bone

metastases - 20%
2) Humoral hypercalcemia of malignancy
Parathyroid hormone related peptide (PTHrP) secreted systemically - 80%

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Symptoms
GI :
Nausea, vomiting, Anorexia,Constipation
Renal
Polyuria due to interference with ADH- Diabetes

insipidus-like syndrome, Polydipsia
Neurologic
Lethargy and fatigue ,Cognitive and behavioural changes ,Altered mental status to coma
Muscle weakness

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Lab
Total calcium & albumin or ionized calcium
Medical emergency above 10.5 mg/dL
Phosphorus
Creatinine,

urea
Electrolytes
50% are hypokalemic
PTH level
If elevated may be primary hyperparathyroidism (or rarely ectopic PTH production)

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Cиндром неадекватной секреции антидиуретического гормона (SIADH)

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Osmotic Demyelination Syndrome
Recall that during chronic hyponatremia, osmolytes are shifted out

of brain cells to avoid shift of water into cells and brain edema
With rapid correction of [Na], brain cells not able to reaccumulate these osmolytes quickly enough resulting in water shift out of cells hence cell shrinkage and concentrated ion damage1

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Acute Tumor Lysis Syndrome
Usually starts 6-72 h from initiation of chemo

or radiotherapy
Due to rapid release of cell contents into blood stream
Most common tumor cause:
Leukemias
Lymphomas
Small cell ca

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$Etiologic Factors Large Tumor burden High growth fraction High pre treatment$

Etiologic Factors
Large Tumor burden
High growth fraction
High pre treatment serum LDH

or Uric Acid
Preexisting renal insufficiency

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$Treatment Best treatment – prevention Hydration – 3L\24h, better started 24-48$

Treatment
Best treatment – prevention
Hydration – 3L\24h, better started 24-48 h

before treatment initiation
Stop nephrotoxic drugs
Monitoring of electrolyte levels
Urine alkalinization Ph >7.5
Allopurinol

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Stop the chemotherapy
Aggressive IV hydration / diuresis
CaCl2, NaHCO3, glucose / insulin,

kayexalate for hyperkalemia
Rasburicase
Emergency hemodialysis
If K > 6, urate > 10, creat. > 10, or unable to tolerate diuresis

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STRUCTURAL:
Neurologic emergencies

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Spinal Cord Compression

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What is malignant spinal cord compression?
Occurs when cancer cells grow in/near

to spine and press on the spinal cord & nerves
Results in swelling & reduction in the blood supply to the spinal cord & nerve roots
The symptoms are caused by the increasing pressure (compression) on the spinal cord & nerves

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Most commonly seen in
Breast
Lung
Prostate
Lymphoma
Myeloma
About 10% of patients with cancer overall
What types

of cancer cause it?

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Method of spread
85%From vertebral body or pedicle
10% Through intervertebral foramina (from

paravertebral nodes or mass)
4% Intramedullary spread
1%(Low) Direct spread to epidural space (Batson’s plexus)

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Location
Thoracic spine 60-70%
Lumbosacral spine 20-30%
Cervical and sacral spine less then 10%

each

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First Symptoms
Pain 95%
Weakness 5%
Ataxia 1%
Sensory loss 1%
RED FLAGS…..

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First Red Flag: Pain
Usually first and most common symptom
(80-90%)
Usually precedes

other neurologic symptoms by weeks to month
Severe local back pain
Aggravated by lying down
Pain may feel like a 'band' around the chest or abdomen (radicular)

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Second Red Flag: Motor
Weakness: 60-85%
At or above conus medularis
Extensors of the

upper extremities
Above the thoracic spine
Weakness from corticospinal dysfunction
Affects flexors in the lower extremities
Patients may be hyper reflexic below the lesion and have extensor plantars

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Third Red Flag: Bladder & Bowel Function
Loss is late finding
Problems passing

urine
may include difficulty controlling bladder function
passing very little urine
or passing none at all
Constipation or problems controlling bowels
Autonomic neuropathy presents usually as urinary retention
Rarely sole finding

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Investigations & information needed prior to therapy
MRI scan of the whole

spine
Can get compression at multiple levels
Knowledge of cancer type & stage
Knowledge of patient fitness
Current neurological function
Have they lost power in their legs?
Can they walk?
Do they need a catheter?
Do they have pain?

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Treatment options include:
Immobilisation
Steroids & gastric protection
Analgesia
Surgery – decompression &

stabilisation of the spine
Radiotherapy
Chemotherapy e.g. lymphoma
Hormonal manipulation e.g. prostate Ca

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Indications for Surgery
• Unknown primary tumour
• Relapse post RT
• Progression while

on RT
• Intractable pain
Instability of spine
• Patients with a single level of cord compression who have not been totally paraplegic for longer than 48 hours
Prognosis >3 months

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Surgery

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Improvement in surgery + RT
Days remained ambulatory (126 vs. 35)
Percent that

regained ambulation after therapy (56% vs. 19%)
Days remained continent (142 vs. 12)
Less steroid dose, less narcotics
Trend to increase survival

Patchell, R, Tibbs, PA, Regine, WF, et al. A randomized trial of direct decompressive surgical resection in the treatment of spinal cord compression caused by metastasis (abstract). proc Am Soc Clin Oncol 2003; 22:1.

RCT comparing surgery followed by RT vs. RT alone

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Radiation Therapy

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Prognosis
Median survival with MSCC is 6 months
Ambulatory patients with radiosensitive tumours

have the best prognosis
Likely to remain mobile

MSCC is a poor prognostic indicator in cancer patients
Need better detection rates

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Superior Vena Cava Syndrome

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Superior Vena Cava Syndrome

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Superior Vena Cava Syndrome

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Superior Vena Cava Syndrome

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In rare cases can be disease presentation
No time for pathology
Urgent

treatment without tissue diagnosis
Median survival – 6 month
2 year survivale – 15%

Superior Vena Cava Syndrome

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Exeption: Treatment Sensitive Tumors
NHLs, germ cells, and limited-stage small cell lung

cancers usually respond to chemotherapy and or radiation
Can achieve long term remission with tumor specific directed therapy
Symptomatic improvement usually takes 1-2 weeks after start of therapy

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Superior Vena Cava Syndrome

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Superior Vena Cava Syndrome

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Superior Vena Cava Syndrome

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Treatment Options
Radiation therapy
Chemotherapy
Intraluminal Stent
+supportive care

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Supportive Care:
Rest
Head elevation
Oxygen
Diuretics
Anticoagulation
Steroids
Avoid high volume fluid infusion through upper

extremities

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Intraluminal Stents
Endovascular placement under fluoroscopy
Patients who have recurrent disease in previously

irradiated fields
Tumors refractory chemotherapy
Patient too ill to tolerate radiation or chemotherapy

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Endovascular stenting and angioplasty
Superior vena cava syndrome

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Most Common type of CNS malignancy
20-40% of cancer patients will develop

brain mets
Most common types: Breast, Lung, Melanoma, Colorectal Ca
Highest risk for bleeding
RCC
Melanoma
Choriocarcinoma
Papillary thyroid
Lung Cancer

Brain Metastasis

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Recursive Partitioning Analysis - RPA
גרורות מוחיות
Brain Metastasis

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גרורות מוחיות
Brain Metastasis

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Diagnosis:
CT with and without contrast
MRI – modality of choice for small

lesions including leptomeningial spread
If no previous history of malignancy - consider total body imaging

גרורות מוחיות

Brain Metastasis

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גרורות מוחיות
Brain Metastasis

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גרורות מוחיות
Brain Metastasis

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גרורות מוחיות
Brain Metastasis

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Treatment:
Steroids – Dexamethasone 16mg*2
Anticonvulsant
Surgery?
Radiation therapy
גרורות מוחיות
Brain Metastasis

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Radiation therapy
WBRT=Whole Brain RT
SRS=Stereotactic Radio Surgery
גרורות מוחיות
Brain Metastasis

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גרורות מוחיות
German
Helmet
Brain Metastasis

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גרורות מוחיות
Brain Metastasis

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גרורות מוחיות
Brain Metastasis

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SRS

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Oncological Emergencies

Содержание

What is Oncologic Emergency?A clinical condition resulting from a metabolic, neurologic,

METABOLIC

Hypercalcemia of Malignancy. Major Mechanisms:Local osteolytic hypercalcemiaOsteoclastic bone resorbing cytokinesIn Extensive bone

SymptomsGI : Nausea, vomiting, Anorexia,ConstipationRenalPolyuria due to interference with ADH- Diabetes

LabTotal calcium & albumin or ionized calciumMedical emergency above 10.5 mg/dL PhosphorusCreatinine,

Cиндром неадекватной секреции антидиуретического гормона (SIADH)

Osmotic Demyelination SyndromeRecall that during chronic hyponatremia, osmolytes are shifted out

Acute Tumor Lysis SyndromeUsually starts 6-72 h from initiation of chemo

Etiologic FactorsLarge Tumor burdenHigh growth fraction High pre treatment serum LDH

Treatment Best treatment – preventionHydration – 3L\24h, better started 24-48 h

Stop the chemotherapyAggressive IV hydration / diuresisCaCl2, NaHCO3, glucose / insulin,

STRUCTURAL:Neurologic emergencies

Spinal Cord Compression

What is malignant spinal cord compression?Occurs when cancer cells grow in/near

Most commonly seen inBreastLungProstateLymphomaMyelomaAbout 10% of patients with cancer overallWhat types

Method of spread85%From vertebral body or pedicle10% Through intervertebral foramina (from

Location Thoracic spine 60-70%Lumbosacral spine 20-30%Cervical and sacral spine less then 10%

First Symptoms Pain 95% Weakness 5% Ataxia 1% Sensory loss 1%RED FLAGS…..

First Red Flag: PainUsually first and most common symptom (80-90%)Usually precedes

Second Red Flag: MotorWeakness: 60-85%At or above conus medularisExtensors of the

Third Red Flag: Bladder & Bowel FunctionLoss is late findingProblems passing

Investigations & information needed prior to therapyMRI scan of the whole

Treatment options include:ImmobilisationSteroids & gastric protection Analgesia Surgery – decompression &

Indications for Surgery • Unknown primary tumour• Relapse post RT• Progression while

Surgery

Improvement in surgery + RTDays remained ambulatory (126 vs. 35)Percent that

Radiation Therapy

PrognosisMedian survival with MSCC is 6 monthsAmbulatory patients with radiosensitive tumours

Superior Vena Cava Syndrome

Superior Vena Cava Syndrome

Superior Vena Cava Syndrome

Superior Vena Cava Syndrome

In rare cases can be disease presentationNo time for pathology Urgent

Exeption: Treatment Sensitive TumorsNHLs, germ cells, and limited-stage small cell lung

Superior Vena Cava Syndrome

Superior Vena Cava Syndrome

Superior Vena Cava Syndrome

Treatment OptionsRadiation therapyChemotherapyIntraluminal Stent +supportive care

Supportive Care:Rest Head elevation OxygenDiureticsAnticoagulationSteroidsAvoid high volume fluid infusion through upper

Intraluminal StentsEndovascular placement under fluoroscopyPatients who have recurrent disease in previously

Endovascular stenting and angioplastySuperior vena cava syndrome

Most Common type of CNS malignancy20-40% of cancer patients will develop

Recursive Partitioning Analysis - RPAגרורות מוחיותBrain Metastasis

גרורות מוחיותBrain Metastasis

Diagnosis:CT with and without contrastMRI – modality of choice for small

גרורות מוחיותBrain Metastasis

גרורות מוחיותBrain Metastasis

What is Oncologic Emergency?
A clinical condition resulting from a metabolic, neurologic,

Hypercalcemia of Malignancy. Major Mechanisms:
Local osteolytic hypercalcemia
Osteoclastic bone resorbing cytokines
In Extensive bone

Symptoms
GI :
Nausea, vomiting, Anorexia,Constipation
Renal
Polyuria due to interference with ADH- Diabetes

Lab
Total calcium & albumin or ionized calcium
Medical emergency above 10.5 mg/dL
Phosphorus
Creatinine,

Osmotic Demyelination Syndrome
Recall that during chronic hyponatremia, osmolytes are shifted out

Acute Tumor Lysis Syndrome
Usually starts 6-72 h from initiation of chemo

Etiologic Factors
Large Tumor burden
High growth fraction
High pre treatment serum LDH

Treatment
Best treatment – prevention
Hydration – 3L\24h, better started 24-48 h

Stop the chemotherapy
Aggressive IV hydration / diuresis
CaCl2, NaHCO3, glucose / insulin,

STRUCTURAL:
Neurologic emergencies

What is malignant spinal cord compression?
Occurs when cancer cells grow in/near

Most commonly seen in
Breast
Lung
Prostate
Lymphoma
Myeloma
About 10% of patients with cancer overall
What types

Method of spread
85%From vertebral body or pedicle
10% Through intervertebral foramina (from

Location
Thoracic spine 60-70%
Lumbosacral spine 20-30%
Cervical and sacral spine less then 10%

First Symptoms
Pain 95%
Weakness 5%
Ataxia 1%
Sensory loss 1%
RED FLAGS…..

First Red Flag: Pain
Usually first and most common symptom
(80-90%)
Usually precedes

Second Red Flag: Motor
Weakness: 60-85%
At or above conus medularis
Extensors of the

Third Red Flag: Bladder & Bowel Function
Loss is late finding
Problems passing

Investigations & information needed prior to therapy
MRI scan of the whole

Treatment options include:
Immobilisation
Steroids & gastric protection
Analgesia
Surgery – decompression &

Indications for Surgery
• Unknown primary tumour
• Relapse post RT
• Progression while

Improvement in surgery + RT
Days remained ambulatory (126 vs. 35)
Percent that

Prognosis
Median survival with MSCC is 6 months
Ambulatory patients with radiosensitive tumours

In rare cases can be disease presentation
No time for pathology
Urgent

Exeption: Treatment Sensitive Tumors
NHLs, germ cells, and limited-stage small cell lung

Treatment Options
Radiation therapy
Chemotherapy
Intraluminal Stent
+supportive care

Supportive Care:
Rest
Head elevation
Oxygen
Diuretics
Anticoagulation
Steroids
Avoid high volume fluid infusion through upper

Intraluminal Stents
Endovascular placement under fluoroscopy
Patients who have recurrent disease in previously

Endovascular stenting and angioplasty
Superior vena cava syndrome

Most Common type of CNS malignancy
20-40% of cancer patients will develop

Recursive Partitioning Analysis - RPA
גרורות מוחיות
Brain Metastasis

גרורות מוחיות
Brain Metastasis

Diagnosis:
CT with and without contrast
MRI – modality of choice for small

גרורות מוחיות
Brain Metastasis

גרורות מוחיות
Brain Metastasis