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ONCOLOGY EMERGENCIES

Emergencies in oncology present in various ways They may appear alone or in combination with other systemic manifestations


a. Hypercalcemia (elevated calcium level)
b. Hypercoagulable states
c. Cord compression
d. Thrombotic thrombocytopenic Purpura e. Superior Vena Cava     (SVC) syndrome

HYPERCALCEMIA

o There is elevated serum calcium

o Various forms of presentation include: confusion, lethargy,    headaches, dizziness, somnolence, coma, hypotension,    dehydration

o Common malignant conditions that predispose to this condition    are: Multiple myeloma, breast cancer, lung cancer and prostate    cancer

o There is direct bone involvement in virtually all cases

o Treatment requires intravenous fluid hydration ( Lasix) -    biphosphonates (Pamidronate/Etidronate), Gallium nitrate and Mithramycin

HYPERCOAGULABLE STATES

o Various conditions that arise from this phenomenon include deep    vein thrombosis (DVT), Pulmonary Embolism (PE), Arterial    Thrombosis. Patients present with signs and symptoms    corresponding to the organ system involved.

o Leg swelling and pain (especially in the calf), shortness of breath,    tachycardia, hypertension, chest    discomfort, cold extremities,    gangrene of the extremities

o Diagnosis requires a high index of suspicion and rapid recognition    of this potentially dangerous condition

o The use of Heparin bolus followed by heparin drip prevents further    clot formation

o Gradual but careful introduction of Warfarin (given by mouth) and    adequate monitoring of blood levels of Warfarin activity (INR)

o The use of low molecular weight heparin might help in the    management of this condition in the outpatient setting.

o If there is a contraindication to the use of anticoagulants or the    symptoms worsen despite adequate anticoagulation, a Greenfield    filter placement might be necessary.

o Some clots develop in the upper extremities in patients with    catheters. The majority of these clots do not propagate and    removal of the catheter is necessary.

CORD COMPRESSION

o The most common complaint is back pain

o Neurological symptoms include numbness, weakness and    paralysis
   
o Metastatic deposits in the spine cause destruction and collapse of    the bones with subsequent compression of nerves

o The thoracic and lumbar vertebrae are commonly affected

o Common cancers that metastasize to bones and spine include    breast, prostate, lungs, colon and renal cancers

o Treatment should be started within 24 hours

o Treatment options include, but are not limited to:

  • Radiation therapy
  • Chemotherapy
  • Use of steroids Dexamethasone 10 mg IV stat and then 4mg IVPB every six hours
  • Treatment of the underlying disease
  • Surgical decompression
  • MRI evaluation of the spine
  • Neurological assessment


THROMBOTIC THROMBOCYTOPENIC PURPURA (TTP)

o This condition predisposes to increased clot formation in the    kidneys, brain and mesentery

o Diagnosis requires some or all of the following conditions:


  • Fever
  • Renal insufficiency
  • Low platelets
  • Neurological deficits
  • Microangiopathic (hemolytic) anemia


o Symptoms depend on the organ-system involved

o Condition could be fatal if treatment is not instituted promptly

o Some chemotherapeutic agents, e.g., Mitomycin C may
   cause hemolytic-uremic syndrome

o Patients have lethargy, renal failure, multiple bruises and    hypotension

o Plasma exchange is the standard treatment of choice

o Other less effective treatments include steroid, gamma globulin    and treatment of the underlying disease

SUPERIOR VENA CAVA (SVC) SYNDROME

o Onset of this condition is gradual but sometimes it may be rapidly    progressive

o Signs and symptoms include facial swelling, cyanosis, shortness    of breath

o Swelling of the upper extremities

o raised intra-cranial pressure

o Common cancers that cause this condition are:

  • Bronchogenic tumors
  • Lymphomas
  • Germ cell tumors
  • Breast cancer with metastasis

DIAGNOSIS

o Clinically visible

o Chest x-ray shows widening of the mediastinum

o Other tests that may be necessary are EKG, CAT Scans of the    chest

o The most important diagnostic procedure to embark upon is tissue    biopsy

TREATMENT

  • High dose corticosteroid may be necessary in patients with raised intra-cranial pressure
  • Radiation therapy
  • Balloon angioplasty
  • Chemotherapy may also be used especially in tumors that are highly sensitive to chemotherapy, e.g., small cell lung cancer
  • Anticoagulation in form of urokinase or streptokinase, heparin and coumadin may be necessary in thrombotic cases
  • Tracheostomy is required in emergency situations when the patient's life is threatened.