IM 3B: ONCOLOGY Chest radiograph

ONCOLOGIC EMERGENCIES CT scan

SOURCE: 2017 PPT For patients with known cancer, appropriate treatment after CT scan of the
February 2017 Thorax should be done
For those without history or malignancy detailed evaluation should be done
ONCOLOGIC EMERGENCIES o Rule out benign causes
Classified into 3 groups o Determine a specific diagnosis to direct the appropriate therapy
Pressure or obstruction caused by a space occupying lesion
Metabolic or hormonal problems TREATMENT:
Treatment related complications Symptomatic relief
o Diuretics with low salt diet
SUPEROIOR VENA CAVA SYNDROME o Head elevation
- Clinical manifestation of: o Oxygen
Glucocorticosteroids for shrinking lymphoma masses
Superior vena cava obstruction
Radiation therapy primary treatment for SVCS caused by NSCLC and
With severe reduction in venous return from the head, neck and upper
extremities other solid tumors
Chemotherapy for chemoresponsive tumors (small cell lung cancer,
ETIOLOGY: lymphomas, germ cell tumors)
Stenting
Malignant majority
o Lung cancer 85%
o Lymphoma HYPERCALCEMIA
o Metastatic tumors testicular, breast cancers Occur in 20% of patients with cancer
Benign at least 40% Paraneoplastic
Ectopic Hormone Typical Tumor types
o Intravascular devices (permanent central venous access catheters) syndrome
o Benign tumors Hypercalcemia of Parathyroid hormone-related Squamous cell (head and neck, lung,
malignancy protein (PTHrP) skin), breast, genitourinary
o Aortic aneurysm
1,25-dihydroxyvitamin D Lymphomas
PTH (rare) Lung, ovary
CLINICAL MANIFESTATIONS:
PGE2 (rare) Renal, lung
PRESENTATION: PE FINDINGS: Most commonly cause by overproduction of PTHrP (from bone metastasis)
- Neck and facial swelling Dilated neck veins
Other common cause: excess production of 1, 25-dihydroxyvitamin D
Dyspnea Collateral veins
Cough covering anterior chest
Others: Hoarseness, tongue swelling, CLINICAL MANIFESTATION:
wall
Cyanosis Maybe found in cancer patients during routine lab tests
headaches, nasal congestion, epistaxis,
Edema of face, arms, Markedly increased calcium(>3.5 mmol/L [14 mg/dL])
dysphagia, pain, hemoptysis, dizziness,
o Fatigue
syncope, lethargy and chest
Bending forward aggravates symptoms o Mental status change
o Dehydration
o Symptom of nephrolithiasis
Severe cases
Proptosis
Glossal, laryngeal edema DIAGNOSIS:
Obtundation Known malignancy Metabolic alkalosis
Recent onset of hypercalcemia Suppressed PTH
DIAGNOSIS: Very high calcium levels Elevated PTHrP
CLINICAL!!! Hypercalciuria Elevated 1,25 dihydroxyvitamin
Hypophosphatemia D (lymphoma)

IM 3B: Oncology -Prevention and early detection , KJ Briones 1 of 2

TREATMENT: TLS:
Saline rehydration (200-500 mL/hr) Related to tumor burden and renal function
o To dilute calcium and promote calciuresis High tumor burden:
Forced diuresis with Furosemide (20-80mg IV) o LDH > 1500 U/L
o To promote calcium excretion (little value except in life threatening o Hyperuricemia
hypercalcemia) Hb
Oral phosphorus Baseline levels/ kidney function should be obtained
o To attain serum phosphorus > 1 mmol/L Rule out other causes of renal failure (obstructive uropathy)
Bisphosphonates Pamidronate, Zolendronate, Etidronate Monitor urine output
o Can reduce serum calcium in 1-2 days and suppress calcium
release for several weeks PREVENTION AND TREATMENT:
Dialysis Most important steps
o When saline rehydration and bisphosphonates are not possible o Recognition of risk
romtoo slow in onset o Prevention
Calcitonin (2-8U/kg SC q6-12h) Prevention
o When rapid correction is needed o Lower uric acid Allopurinol
Glucocorticoid for lymphomas, MM, leukemias o Urinary Alkalization
Use of sodium bicarbonate is controversial (increases uric
TUMOR LYSIS SYNDROME: acid solubility but decreases calcium phosphate)
Caused by rapid proliferating neoplastic cells o Aggressive hydration
Characterized by Others
o Hyperuricemia o Rasburicase (recombinant urate oxidase)
o Hyperkalemia Used when uric acid cannot be lowered by standard
o Hyperphosphatemia allopurinol
o Hypocalcemia Used when renal failure is present
Acidosis may occur and acute renal failure may develop Acts rapidly but may cause hypersensitivity reaction
Most often associated with the treatment of Burkitts Lymphoma, Acute
lymphoblastic Leukemia, other rapidly proliferating tumors
Consequence of treatment usually 1-5 days after chemotherapy
Rarely, spontaneous necrosis of malignancies causes TLS

Hyperuricemia:
Turnover of nucleic acid from tumor cell lysis after an effective treatment
Uric acid can precipitate in the tubules, medulla and collecting ducts -> renal
failure
Presence of uric acid crystals in the urine > uric acid nephropathy

Hyperphosphatemia Hypokalemia
Caused by release of intracellular Release of intracellular
phosphate pools by tumor lysis potassium from tumor cell
Produce hypocalcemia lysis
o Deposition of calcium Life threatening
phosphate in the kidney o Ventricular
and hyperphosphatemia arrythmias
Renal failure o Sudden death

IM 3B: Oncology -Prevention and early detection , KJ Briones 2 of 2