Oncological emergencies

The presentation was made at Oncology Nursing Conference held at All India Institute of Medical Sciences (AIIMS), New Delhi in March 2016.

1. STRUCTURAL ONCOLOGICAL EMERGENCIES 02.03.2016 Dr Alok Gupta Assistant Professor Medical Oncology AIIMS, New Delhi

2. Mr. EC ID: 56 year old man with history of HTN and osteoarthrtis EC: presents to family doctor with one month history of back pain that is not responding to Analgesics. Pain beginning to wake him at night More pain with recumbancy Some shooting pains down right leg

3. On examination vitals stable, no fever CVS, Respiratory, GI, GU exams reported as normal Back exam Inspection : normal Palpation : some pain in L1 Movement : normal Some pain in right leg with straight leg raising

4. Investigation in Clinic Lumbar Spine X-ray Some age related degeneration

5. Diagnosis Sciatica vs. Back strain Treatment: NSAIDS Few days of bed rest

6. The story continues… Mr. EC’s pain does not resolve More trials of various forms of pain control fail One month later Mr. EC awakens in the morning and has difficulty supporting his weight Subjective leg muscle weakness Goes to Emergency room

7. Spinal Cord Compression

8. Causes Metastatic tumor from any primary site Tumors with predilection to metastasize to spinal column Prostate, breast, and lung carcinoma 15-20% of cases Renal cell, non-Hodgkin’s lymphoma, or myeloma 5-10% of cases

9. ESCC can be initial presentation of a malignancy Around 20% of cases In many cases diagnosis is made by biopsy of the spinal lesion

10. Spinal Location Thoracic spine: 60% Lumbosacral spine: 30% Cervical spine: 10% Specific tumor predilection is difficult to define

11. First Red Flag: Pain Usually first symptom 12 80-90% of the time Usually precedes other neurologic symptoms by weeks Increases in intensity Severe local back pain Aggravated by recumbency Distension of venous plexus May become radicular 12. Bach, F, Larsen, BH, Rohde, K, et al. Metastatic spinal cord compression. Occurrence, symptoms, clinical presentations and prognosis in 398 patients with spinal cord compression. Acta Neurochir (Wien) 1990; 107:37.

12. Second Red Flag: Motor Weakness: 60-85% 13 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 hyperreflexic below the lesion and have extensor plantars 13. Greenberg, HS, Kim, JH, Posner, JB. Epidural spinal cord compression from metastatic tumor: Results with a new treatment protocol. Ann Neurol 1980; 8:361.

13. Weakness tends to be symmetrical Progressive weakness is followed by loss of gait function and then paralysis The severity of weakness is greatest with thoracic metastases

14. Third Red Flag: Sensory Less common than motor findings Still present in majority of cases Ascending numbness and paresthesias

15. Fourth Red Flag: Bladder and Bowel Function Late finding Autonomic neuropathy presents usually as urinary retension Rarely sole finding

16. Treatment Objectives Pain control Avoidance of complications Preserve or improve neurological function

17. Pain management Corticosteroids Decrease edema Opiates Needed to decrease pain for comfort and examination purposes

18. Treatment of underlying malignancy

19. Chemotherapy Can be successful in chemosensitive tumors Hodgkin’s lymphoma Non-Hodgkin’s lymphoma Neuroblastoma Germ cell Breast cancer (hormonal manipulation) Prostate cancer (hormonal manipulation)

20. Bisphosphonates Recommended Decrease pathologic fractures in bony disease Multiple myeloma Breast cancer

21. Relieves pain in most cases Post-neurological function usually determines response Response most associated with tumor type and radiosensitivity ; eg . lymphoma Dosing 20 to 40 Gy in 5 to 20 fractions Popular 30 Gy in 10 fractions Radiation

22. Surgery Changing role Historically posterior vertebral decompression was done Better techniques today allow aggressive approach Gross spinal tumor resection with vertebral reconstruction now possible 15. Findlay, GF. Adverse effects of the management of malignant spinal cord compression. J Neurol Neurosurg Psychiatry 1984; 47:761.

23. Mr. SV ID: 65 year old male with Hx of CAD and emphysema EC: present to clinic with one week history of increasing SOB HPI: 3 month history of weight loss, decreased appetite, a change in his chronic cough, and intermittent hemoptysis

24. On Physical Examination Inspection:

25. Respiratory Examination Stridor Dullness to percussion on right lower lung fields Increased tactile fremitus to right lower lung fields Decreased A/E to right lower lung fields

26. Chest X-Ray…

27. right pleural effusion

28. T1-weighted axial MRI demonstrating paratracheal soft tissue mass that invades into the SVC

29. Superior Vena Cava Syndrome

30. Signs and Symptoms Facial swelling or head fullness exacerbated by bending forward or lying down Cough Arm edema Cyanosis

31. Etiology: Malignancy Lung cancer is the most common 2 Lymphoma is second most common together represent 94% of cases 2. Escalante, CP. Causes and management of superior vena cava syndrome. Oncology (Huntingt) 1993; 7:61.

32. Thank You