Oncologic Emergencies

Transcription

1 Oncologic Emergencies Francis L. Counselman, M.D., CPE, FACEP Department of Emergency Medicine Eastern Virginia Medical School Norfolk, Virginia Superior Vena Cava Syndrome Compression of SVC by mediastinal or pulmonary mass or intraluminal occlusion by thrombosis 1

2 Epidemiology Male:Female ratio 2.5:1 Average age 56yo Approx 60% of patients without history of cancer Incidence 5-15% of all Lung CA 5% of all Lymphomas 1% of all Pulmonary Mets 2

3 Etiology Malignancy: Most common Mediastinal fibrosis Aortic aneurysm Granulomatous infection Goiter Iatrogenic: 20-40% Radiation fibrosis Malignancies and SVC Lung 75% Lymphoma 10-15% Metastatic 10% Breast Thymus Testicular 3

4 Symptoms Gradual onset Malignancy: more rapid progression Benign: slower progression 75% have signs/symptoms more than one week Symptoms worse upon awakening Symptoms Headache 80% Dyspnea 65% Cough 55% Nausea/vomiting Dysphagia Tightness of shirt collar Visual changes 4

5 Symptoms Altered mental status Syncope Swollen arms Hoarseness Orthopnea Stridor Seizure Weight loss Physical Exam Dilated neck veins 80% Thoracic vein distention 74% Face/upper torso edema 70% Cyanosis of upper body 44% Plethora 14% 5

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7 Physical Exam Worsening of symptoms with arms above head (Pemberton s sign) Paralyzed true vocal cords Tachypnea Horners syndrome Abdominal vein distention 7

8 Imaging CXR Venogram Radionuclide scan Contrast chest CT scan Ultrasound Echocardiography MRI 8

9 CXR Mediastinal widening 64% Pleural effusion 25% Right hilar mass Bilateral diffuse infiltrates 9

10 CXR Cardiomegaly Anterior mediastinal mass Upper lobe collapse Calcified paratracheal nodes Normal CXR in 16% of SVC Syndrome 10

11 Venogram Gold standard (old) Advantages Disadvantages Contrast Chest CT Scan 92% sensitivity; 96% specificity Location/extent of tumor or thrombus Info for needle biopsy Plan radiation portals 11

12 Ultrasound of Subclavian Veins Quick, noninvasive, inexpensive and no radiation Indirect evaluation of SVC patency Echocardiography Transesophageal Bedside procedure No contrast material Differentiates between intravascular obstruction and extravascular compression 12

13 Magnetic Resonance Imaging Contrast 94% sensitivity 100% specificity Limited use 13

14 Management Initiate diagnostic workup Can better plan appropriate treatment with histologic diagnosis Management Elevate head of bed Oxygen Steroids? Diuretics IV access 14

15 Management Upper airway obstruction Cerebral edema Rare but life-threatening Require endovenous stent placement and radiation therapy Management Radiation therapy Subjective response within 72h Objective response within 7 to 14 days 15

16 Management Thrombolytic therapy/anticoagulation Common with indwelling catheters Contraindicated if brain mets Management Chemotherapy Surgery Endovascular stents 16

17 Hypercalcemia of Malignancy Most common metabolic complication Occurs in 10-30% of all CA patients In ED: malignancy (44%) followed by hyperparathyroidism (20%) Differential Diagnosis PAM P SCHMIDT 17

18 Primary Diagnosis Primary Hyperparathroidism Addisons Disease Multiple Myeloma Pagets Disease Differential Diagnosis Sarcoidosis Cancer Hyperthyroidism Mild-Alkali Syndrome Immobilization D Vitamin Toxicity Thiazide Diuretics 18

19 Pathophysiology Tumor secretion of PTH-related protein Responsible 80% of time Stimulates osteoclast mediated bone resorption Stimulates renal tubular reabsorption of calcium Pathophysiology Local bone destruction from mets with osteoclast activating factors Tumor production of Vitamin D analogues 19

20 Solid Tumors with Bone Mets Breast 42% Lung 15% Prostate Clinical Presentation Consider in all patients with malignant disease who feel sick Bones, stones, moans and groans 20

21 Clinical Presentation Weakness Lethargy Fatigue Dehydration Gastrointestinal Anorexia Nausea/vomiting Constipation Abdominal pain Obstipation Ileus 21

22 Renal Polyuria Polydypsia Dehydration Nocturia Nephrolithiasis Nephrocalcinosis Neurologic Anxiety Agitation Depression Impaired concentration Fatigue 22

23 Neurologic Increased sleep requirements Altered level of consciousness* Decreased DTRs Ataxia Cardiovascular Hypertension Arrhythmias Vascular calcifications EKG abnormalities Digitalis sensitivity 23

24 Musculoskeletal Bone pain Diagnosis Serum calcium EKG Urinalysis Serum chloride Parathyroid hormone (PTH) 24

25 Serum Calcium Asymptomatic < 12mg/dl ph Albumin level Rate of rise Serum Calcium Ionized serum calcium level If measure total calcium: Corrected Ca = measured Ca + (0.8 x [4-albumin]) Moderate: 12 to 14 mg/dl Severe: >14mg/dl 25

26 EKG QT interval shortening Prolongation of PR Prolongation of QRS AV block Coving of ST-T segments 26

27 Urinalysis Decreased specific gravity Increased glucose Increased Na Increased K Increased Mg Proteinuria Serum Chloride Cl <100mEQ/L indicates hypercalcemia secondary to PTHrP Less responsive to bisphosphonates 27

28 Parathyroid Hormone (PTH) - Level < 20pg/mL not consistent with primary hyperparathyroidism - If negative, consider ordering PTH-related peptide (PTHrp) Management Treat underlying cause Rehydration Diuresis Electrolyte balance Specific measures 28

29 Treatment Asymptomatic or mildly symptomatic with Ca <12mg/dL does not require immediate treatment Level >14mg/dL requires treatment, regardless of symptoms Rehydration IV NS 200 to 500 cc/hr 100 to 150 cc/hr urine output 29

30 Diuresis Rehydrate first Lasix no longer routine Consider if edema or CHF Electrolyte Balance Potassium Magnesium 30

31 Calcitonin Increases renal calcium excretion. Decreases bone resorption Fast acting 4 IU/kg IM or SQ If responds, repeat every 6 to 12 hours Bisphosphonates First line therapy Inhibits osteoclast mediated bone resorption More potent than calcitonin Max effect in 2-4 days 31

32 Bisphosphonates Zoledronic acid 4mg IV over 15min* Pamidronate 60-90mg IV over 2 to 4 hours Management Concurrent administration IV NS Calcitonin IM or SQ Zoledronic acid (ZA) IV 32

33 Dialysis Hemodialysis Peritoneal dialysis Renal failure Spinal Cord Compression 5% of all CA patients Peak age: 55 to 65yo 80% have dx of CA Prognosis time dependent First described in

34 Sites of Metastasis 60% Thoracic 30% Lumbosacral 10% Cervical Location of Metastasis Vertebral column 90% Paravertebral space 10% Epidural space < 5% 34

35 Primary Cancer Breast 20 to 30% Lung 15 to 20% Prostate 15 to 20% Lymphoma Renal Multiple myeloma Back Pain 95% of cases Gradual and progressive Precedes other symptoms by 2 months Dull, aching, constant DJD v Metastatic disease 35

36 Pain Localized initially Referred or radicular Increased with cough, sneeze, weight bearing Pain at night Clinical Presentation Numbness Parasthesias Coldness 36

37 Clinical Presentation Autonomic dysfunction Indicates T10-T12 involvement Present 50% at time of diagnosis Poor prognostic sign Clinical Presentation Weakness Initial complaint 36% Very poor prognostic sign 37

38 Physical Exam Vertebral tenderness 33% Straight leg raise Neck flexion Neurologic exam hyperresponsive DTRs 38

39 Diagnosis Plain films Myelogram Bone scan Spinal CT scan MRI Plain Films 80% sensitivity Vertebral body collapse Osteolytic lesion Osteoblastic lesion Paraspinal mass 39

40 Spinal CT Scan Transaxial plane only Excellent detail Preferred with myelogram 40

41 Magnetic Resonance Imaging Gold standard 95% accuracy No contrast material No ionizing radiation Images in multiple plains 41

42 Imaging Guidelines for Patient with history of CA and Back Pain High suspicion or abnormal neuro exam emergent Low suspicion and normal neuro exam outpatient imaging within 48 to 72 hours and consult Management Consultation Steroids Radiation Surgery Chemotherapy 42

43 Steroids Relieves pain Reduces edema Reduces inflammation Short-term benefit Dexamethasone 10mg IV bolus then 16 mg/day (bid to QID) If dense paresis, consider 96 mg IV, then 24mg IV QID 43

44 Radiation Therapy Definitive treatment Pain relief in 70 to 80% of cases Better prognosis if initiated prior to paraplegia Radiation Therapy 81% ambulatant pretreat remained ambulatory post RT 17% nonambulant pretreat became ambulatory post RT 73% had improvement in pain 44

45 Surgery Decompress spinal cord and nerve roots Radiation therapy Indications in development Rarely helpful Chemotherapy 45