Oncologic Emergencies

vf / . .
Pressure or obstruction caused by a space occupying
Oncologic Emergencies lesion

* (Metabolic yr{hormonal problems\ paraneoplastic

syndromes) poramopiake synbune,

Complications arising from the(effects of treatment

umnplnnbonc

Structural-Obstructive Oncologic
SVC Syndrome
Emergencies
SVC Syntome = common cone

Superior Vena Cava Syndrome CL Syndrome Clinical manifestation of{SVC obstructiol with severe
reduction in venous return from the head. neck & upper
, pn \ bn extremities gyetwolian 4 sve —
Pericardial Effusion/ Tamponade Yenoaniod. <4 on
Lung Cancer, Lymphoma & Metastatic tumors{>90% of all
Intestinal Obstruction \tehndl_Oveive ov SVC cases yng € my ymphe Pear
R Pulasiste. der
irae Ost chow
Urinary Obstruction Presentation: Neck & facial swelling (around the eyes),
Dyspnea & Cough Wuks fedot Sa wing ct pose)
Spinal Cord Compression Sons (ord. Lompestia,.
et tongue swelling, headaches, nasal congestion,
bending down or lying forward may aggravate symptoms
hooreent wag} earerestion
fongee Sing "ending down or Igieg gover
ad acres

SVC Syndrome SVC Syndrome

utaea\
Characteristic Physical Findings: -- Diagnosis of SVC:(linical one )
dicted ves
Dilated neck veins A Most significant chest radiographic finding Qwideningyof the
f afateral ins (ACW)
—- N
aot S superior mediastinum (right side) . ‘
TO: Widerin a Superior mtdiastinun
Increased number of collateral veins covering the
(CT scan) provides e most reliable view of the mediastinal
anterior chest wall Eden : Foe
anatomy —_,
TT ovess - CT Scan
Cyanosis ches 1 ae
Diminished or absent opacification of central yenous
structures with cae
prominent
acta collateral venous circulation
Retr
Edema of the face, arms & chest
scan v oporipiendty .
(a) has{no advantaged over CT wninent caf ote al
pe runews demotion

SVC Syndrome
Dive
he ww gait a
Greatment) tad augation Spiqatn
b
Diuretics, low salt diet, head elevation & oxygen may
Aempaced) aynpirnet
produce temporary symptomatic relief

(Radiation Therapy}- primary treatment for SVCS caused by

ung cancer Radiation emp -lng Cw, we)
(Chemotherapy — effective when the underlying cancer is
small cell Ting cancer or lymphoma oth yng tones

Recurrent SVCs{ 10-30%; Jintravascular self

iene = ee
expanding
stents oo
wel
huet un int avasulor ga -cAynllg
Syl

hematoma at the insertion site, SVC perforation,

stent migration in the right ventricle, stent fracture,
and pulmonary embolism.
 - entargnd ear)

Pericardial Effusion/ Tamponade

pus cordial E yynie

\ (S-10%)f patients with cancer have(malignant pericardial ) irradiation, drug-induced pericarditis, including c

disease
apeutic agents such all-trans retinoic acid, arsenic
trioxide, imatinib and other abl kinase inhibitors,
Pericardial hypothyroidism, idiopathic pericarditis, infection, or
autoimmune diseases.

A Effusion Lung cancer, breast cancer, leukemias, lymphomas

ee — ———as —.
an acute inflammatory,

Radiation pericarditis Radiator Pitordiley effusive pericarditis occurring

within months of irradiation,

—_—— Dacprea, Coegh, chest pA Orierpnec

which usually resolves
spontaneously, and a chronic
effusive pericarditis that may
Common symptoms: dysp
dyspned, Cough, chest pain, orthopnea, appear up to 20 years after
radiation therapy and is

weakness —
accompanied by a thickened
pericardium

Physical Finding» vant. sinus tachyYardia, ingulr

‘venous E Chtion, peripheral Gdem
ddema, cyanosis
Plasal Agyution, Sinus Tachyead*
Wugvlar Venous Diskin, Pekan

Pericardial Effusion/ Tamponade Intestinal Obstruction

a» Porodogte4 DeOrE)
* Specific diagnostic findings: Paradoxical{Pulsd_, ) Watt ml ¢ Common problems in patients with advanced cancer
Y diminished heart sounds, pulsus alterans, friction rub
Colorectal
lores & ovarian
yan cancer Cotage )
apisis obletey
. Diagnostics; CXR,
CXR, ECG, Echocardiography as oe Obstruction occurs at{multiple sites) +? mth, sic
OE, pth yooh
* Cytologic examination of pericardial fluid is diagnostic (Melanoma)- predilection forémall bowel) Wtaniw “7
wv, . Jo . . sro Vou!
¢ Treatment: Pericardiocentesis, creation of pericardial
Pan 2 wbcky in vate can also be due to abdominal
window, chemotherapy distention, tumor masses, or
— Pain/- most common symptom; colicky in nature hepatomegaly. Vomiting can be
intermittent or continuous
Pericardial fluid may be serous, serosanguineous, or hemorrhagic, and cytologic examination of pericardial
complete obstruction usually have constipation
fluid is diagnostic in most patients. (Vomitingycan be intermittent or continuous
— —
nt)
CT scan of chest may also reveal the presence of a concomitant thoracic neoplasm.
Vomiting: Siem tH tnt / beni

Intestinal Obstruction Urinary Obstruction

stenion, ascies, perstalr” preciehe [ayntetiqie, — maliqnane’s
yace “hme Wane
: abdominal distentién with tympany, ascites, visible Patients with prostatic or gynecologic malignancies
vio high pitched bowel sounds, tumor masses cwcal a O
Acute cecal dilation to >12–14
Cervical carcinomas or metastatic disease from medpsinte dt
Diagnostics: Erect plain abdominal film (multiple air fluid
cm is considered a surgical

stomach, colon, lymphomas Pan sbnath, clon

emergency because of the high
likelihood of rupture
levels, dilation of small & large bowels)
Iynphin 4
plain olpmina| film: rmaot aie hil bata
CT scan ono gral atage ot
extent of disease and the exact nature of the obstruction and d
ferentiating benign from malignant causes of obstruction in
(Radiation therap}) to pelvic tumors may cause fibrosis
Malignant obstruction is patients who have undergone surgery for malignancy.
& subsequent ureteral oe oe
Treatment: Durpicatcval
Surgical evaluation, self expanding metal stents
Rodiatin “meany ~ zy Felt dyew.- -phreds
suggested by a mass at the
site of obstruction or prior
surgery, adenopathy, or an
ee
abrupt transition zone and placed in the gastric
irregular bowel thickening at
the obstruction site Conservative management: nasogastric decompression, outlet, duodenum,
proximal jejunum, colon,
May lead to bilateral hydronephrosi: renal fail
failure wren
or rectum may palliate
Benign obstruction is more antiemetics, antispasmodics, analgesics,
ana octreotide obstructive symptoms

Most common symptom: (Flank pail

likely when CT shows

(Jaxigackic ‘Ochstide
mesenteric vascular
changes, a large volume of
ascites, or a smooth

tak emetic,
transition zone and smooth

pilatoyal by denephronts Atom fail

bowel thickening at the
obstruction site.
ra lgesns
Bladder outlet obstruction is usually due to prostate and cervical cancers and may lead to bilateral
relieve obstructive symptoms through its inhibitory hydronephrosis and renal failure
effect on gastrointestinal secretion.
Persistent urinary tract infection, persistent proteinuria, or hematuria in patients with cancer should
Glucocorticoids have anti-inflammatory effects and raise suspicion of ureteral obstruction
may help the resolution of bowel obstruction. They slow, continuous rise in the serum creatinine level necessitates immediate evaluation
also have antiemetic effects
 associated with flank pain, sepsis, or fistula formation is an indication
for immediate palliative urinary diversion

Percutaneous nephrostomy offers an alternative approach for

drainage

nephrostomy is associated with a significant rate of pyelonephritis

Urinary Obstruction Urinary Obstruction

Penisead Retanee <7 vue) absbection
TE
* Persistent urinary tract infection, persistent proteinuria, Treatment: ypdelaieq
hematuria in patients with cancer should raise suspicion
— — 4. 4. ww
Obstruction, flank pain, sepsis, fistula formation —
of ureteral obstruction
slow tontines rit, ; ceohnine betl 7 iene, eal indication for immediate palliative urinary diversion
¢ Aslow continuous rise in the serum creatinine level / iaive yrvo uae
necessitates immediate evaluation Internal ureteralGtents) paliaire vneor

. @izgnostics) Renal Ultrasound, nuclear scan, CT scan Percutaneous Nephrostomy

perutonent Me roshs A
co feral US te

p flJokar Stan
Of stan
{

Spinal Cord Compression Spinal Cord Compression

fee compression of the spinal cord and/
or cauda equina by an extradural
Cord injury develops when metastases to the
vertebral body or pedicle enlarge and compress
direct extension
tumor mass
of a paravertebral 2 ele the underlying dura

(5-10% )f cancer patients lesion through the

intervertebral fi horacic spine)— most commog site (70%)
first manifestation of malignancy in foramen Dl.
Epidural Tumor) tf! dra Yyeor ~10% of patients
Followed byfiumbosacral spine (20%)
Most common malignancy | Lung cancer) lymphoma,
myeloma, or
(Corvical sping (10%),
Metastatic tumor involves the vertebral column more pediatric > ID
often than any other part of the bony skeleton wena! bans
neoplasm SCC: When metastasis to vertebral body or pedicle ue
Boy grove Intramedullary enlarge & compress the underlying dura vertebral 5b |
Lung, Breast, Prostate cancer, multiple myelomas, metastases can be
seen in lung cancer, enlooe SLsomp
Lymphomas, melanomas, renal cell carcinomas, breast cancer, renal Direct extension of paravertebral lesion through the
genitourinary cancers Lung wv ink mnjtlome Gat cancer, melanoma,
and lymphoma, and intervertebral foramen

dnote are frequently

associated with brain
metastases and
leptomeningeal
disease.

feeling of tight, band-

like constriction

Spinal Cord Compression Metabolic Emergencies

around the thorax
and abdomen

~
hy poraeemioy
most common paraneoplastic syndrome

Most common initial symptom: localized back pain &

tenderness due to involvement of vertebra by tumor
+ V Hypercalcemia '

Inyyo glycan
oO

Painjis present for days or months _—<——

before other neurologic * v Hypoglycemia es
Cain) “)
y fdreval. HD
* Y Adrenal Insufficienc
indings appear atdn cal vosah ow

Loss of bowel or Cains exacerbated by coughing or sneezing onal ene 7

bladder control may be
the presenting
symptom but usually (ain)worsens when the patient is supine worst soping
occurs late in the
course
(Lhermitte’s sig) a tinglinglectrical sensatiodown the
ack, upper & lower limbs upon flexing or extending the
ataxia of gait without
motor and sensory
involvement due to
fiéck (early sign of SCC) a
Unite sign
involvement of the
spinocerebellar tract

pain induced by
straight leg raising,
neck flexion, or
vertebral percussion
may help to determine
the level of cord
compression

Hypercalcemia Hypercalcemia
Cm.c)

Most common paraneoplastic syndrome M6 paameoplasllt Treatment: Rehydration J

. . / . sto gS
Associated with pone
bone metast
metastasis bore metasie s Bisphosphonates y
lV infegen
Breast carcinoma, lung cancer, renal cell carcinoma Zoledronic acid Vv ‘a
oo rena ced co
Hematologic malignancies peeast ca, ung Ca, TN Pamidronate v
——-

Symptoms: anorexia, nausea, constipation, muscle

weakness, fatigue Aner fia, MOV SO | onctingtion
—_ mocce, weaned, ates
Mental obtundation, coma
-_ mental sobndation, om,
 Hyperurecemia and high serum levels of lactate dehydrogenase (LDH >1500 U/
L), both of which correlate with total tumor burden, also correlate with the risk of
TLS.

High leukocyte and platelet counts may artificially elevate potassium levels
(“pseudohyperkalemia”) due to lysis of these cells after the blood is drawn

Hyperkalemia in

Treatment-Related Emergencies Tumor Lysis Syndrome

patients with renal
failure may rapidly
become life
threatening by
causing ventricular
fumor lysis Jynbomd ovina arrhythmias and
sudden death.
c
Fumo Lyas JSnbiats tae . emia release of
Tumor Lysis Syndrome ¥ Combinations of hyperuricemia, hyperkalemia, Iyper ha
———_—_ intracellular

hyperphosphatemia, lactic acidosis & pocaleer iy protebtn phosphate pools by

Human Antibody tntusion

Infusion Ke:
Reactions 4 4 \% sale
tumor lysis,
uman Antibody produces a
reciprocal
Caused by(destructiopof a larg’ number of rapidlyy-A. depression in serum
Hemolytic-Uremic Syndrome Hu $ gutter proliferating neoplastic cells — thypoea atin G calcium, which
v causes severe
estneton: poronesplashe cells neuromuscular
Neutropenia & Infection N xl Few Acute renal Failure develops as a result of the
irritability and tetany

doit syndrome Aurk peed fx:

Pulmonary Infiltrates Pi

Typhlitis ‘ Most frequently associated with the treatment of

Burkitt’s Lymphoma, Acute Lymphoblastic Leukemia after treatment with

Hemorrhagic Cystitis He & high-grade Lymphomas byt nucleosides like

most fra qually
ve
fludarabine and is
increased in frequency
ose: file ly aploasic in lymphoid neoplasms
treated with venetoclax,
Soh - ad a bcl-2 antagonist

allopurinol and aggressive hydration

Febuxostat, a potent nonpurine selective xanthine oxidase inhibitor, is indicated for treatment of
hyperuricemia

Tumor Lysis Syndrome Typhlitis

f Vv Neutropenic enterocolitis Museo peaic eniunath)
Owing to the acidic
local environment, uric Usually occurs during or shortly (1-5 days) after aan
\np oman Ourtcrnsis y
chemotherapy
acid can precipitate in
the tubules, medulla,
and collecting ducts of Inflammation & necrosis of the cecum & surrounding tissues
the kidney, leading to
renal failure. a Hy peruricemia> effective treatment kills malignant cells Patients with acute leukemia treated with(ghemotherapy
Lactic acidosis and
dehydration may & leads to increased serum uric acid levels from the yl om peukemie ( chesn
turnover of nucleic acids A yt aud kwal 3 Taxanes
RCO?
contribute to the
precipitation of uric
acid in the renal
tubules. The finding of
uric acid crystals in the > nvcltit 0° Right lower quadrant abdominal pain, with rebound
urine is strong
evidence for uric acid tenderness, tense & distended abdomen ina setting of fever
nephropathy. The ratio
of urinary uric acid to ollv, ibesot 2 & neutropenia ——a
urinary creatinine is >1 — QLB ab mieal
in patients with acute 4 frebount -pndons
x tts
hyperuricemic

tose ge Kelened abdomen iH ate

nephropathy and <1 in
patients with renal
failure due to other
causes.

Typhlitis Hemorrhagic Cystitis

Watery diarrhea often containing sloughed mucosa & Cyclophosphamide Cryo

aor roid
bacteremia are common ore 3b pum, &
wotey darn ~> swale Ifosfamide Vosjo ht
pageant
Bleeding may occur puting
Acrolein — strong chemical irritant that is excreted in
CT.scan: marked bowel wall thickening in the cecum with the urine — Reretetn
bowel7 wall
7 edema tH soe: gorktd bowel—wat itering
————— . 1

Prolonged contact or high concentrations may lead to

Tx: Rapid nstitution
institution ofof broad
broad spectrum
spectrum anti
antibiotics .
NGT Tt Rapid ontbiole bladder irritation & hemorrhage — f Wodde iottabion de bower’x
. v Y
If no improvement by 24h after start of antibiotic: eaey ( Sympjom) apis hema frequepcy, dyguria,
Surgery uming, urgency, incoffinence, nocturia
eee —_— — —— —_