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Acute Oncological Emergencies Dr Danny Bloomfield Locum Consultant in Acute Oncology Princess Alexandra Hospital Monday 8th July 2013 Outline – Acute Oncological Emergencies • What are they? • What do I need to know about them? • How are they diagnosed? • How do I manage/refer patients? Traditional Oncological Emergencies? • Neutropenic Sepsis • Metastatic spinal cord compression • Superior Vena Cava Obstruction • Hypercalcaemia of malignancy Traditional Oncological Emergencies? • Neutropenic Sepsis - Impending death • Metastatic spinal cord compression - Impending catastrophe • Superior Vena Cava Obstruction - May be a presenting feature of cancer • Hypercalcaemia of malignancy - Treatable cause of life-threatening deterioration Acute Oncology encompasses the management of: • Patients with acute complications from their cancer diagnosis • Patients with acute complications from their cancer treatments • Patients who present as an emergency with a suspected but undiagnosed cancer Traditional Oncological Emergencies? • Neutropenic Sepsis • Metastatic spinal cord compression • Superior Vena Cava Obstruction • Hypercalcaemia of malignancy When is a patient “septic”? DRAFT DOCUMENT – Not for clinical use Neutropenic Sepsis • Identify patients early • Give antibiotics promptly (in hospital) • Ongoing management - Admission? - Escalation of care? - GCSF? - Duration of antibiotics? - Criteria for discharge? PAH Spinal Cord Compression Pathway - DRAFT Reviews • Systematic review of the diagnosis and management of malignant extradural spinal cord compression. Journal of Clinical Oncology2005;23:2028-2037 • Malignant spinal-cord compression Lancet Oncology 2005;6:15-24 Malignant Spinal Cord Compression • A common complication of cancer • 8-34% of cases arise as initial manifestation of CA • Substantial impact on quality of life • Early diagnosis is important • Urgent treatment aimed at preserving function Definition of MSCC • Compression of the dural sac and its contents (spinal cord and/or cauda equina) by an extradural tumor mass • The minimum radiological evidence for cord compression is indentation of the theca at the level of clinical features • Subclinical if there are no clinical features Modes of compression Diagram from Cancer and its Management – Souhami & Tobias Epidemiology 1 Incidence • 2.5% of pts with terminal CA, final 5 years • Incidence varies according to 10 site & age • 0.2% in pancreatic CA - 7.9% in myeloma* • 4.4% pts aged 40-50; 0.5% pts aged > 80* • 0.23% had MSCC at CA diagnosis • Second episodes in 7-14% *Loblaw et al JCO 16:1616-1624 1998 Table 1. MSCC in Ontario, 1990–1995: prevalence at diagnosis, and cumulative incidence in the 5 years preceding death from cancer Loblaw et al JCO 16:1616-1624 1998 Table 3. Survival from date of first episode of MSCC Loblaw et al JCO 16:1616-1624 1998 Epidemiology 2 Common tumor types Bronchus Breast Brostate Bidney Blood: Multiple myeloma & NHL Breast, bronchus and brostate ~ 2/3 of total Bidney, NHL and MM ~ 5-10% each NB this is for ADULTS Epidemiology 4 Localisation • 60-80% thoracic* • 15-30% lumbosacral • <10% cervical • Up to 50% have > 1 area involved *Due to natural kyphosis and the spinal cord occupying most of the intrathecal cross section Clinical symptoms of MSCC Symptom Back pain (median 6/52) Weakness* Sensory deficit Autonomic dysfunction** Frequency 70-96% 61-91% 46-90% 40-57% *2/3 of patients are non-ambulatory at diagnosis ** ~ ½ patients catheter-dependent at diagnosis Ix of suspected MSCC MRI Establishes the diagnosis Guides management decisions Sensitivity 44% - 93% Specificity 90% - 98% Can distinguish benign vs malignant cause The whole spine is imaged Other imaging modalities? • Plain X-rays? False –ve in 17% Only associated compression in 75% of vertebral crush # • Bone scan? Not in clinical setting of acute compression BUT -ve bone scan & plain X-rays: unlikely MSCC • CT? Only nowadays in planning conformal RT • Myelography? Historical (but useful) • PET Experimental Treatment of MSCC - steroids • • • • • • • • Steroids improve functional outcome with RT* No agreement on optimal dose/schedule Trials compare 96-100mg/24hr v 10-16mg/24 hr More complications with higher doses Use 16 mg dexamethasone/24 hours (8mg bd) Continue during RT then taper rapidly (< 2/52) Eg. 8 mg od 3/7, 4 mg od 3/7, 2 mg od 3/7, stop? Selected patients do not need steroids** * Sorensen et al Eur J Cancer 1994; 30A:22-27 ** Maranzano et al Int J Radiat Oncol Biol Phys 1995;32:959-67 Steroid side effects • GI ulcers / bleeding / perforation • Psychosis • Osteoporosis/fractures • Myopathy • Skin thinning • Diabetes • Etc. Treatment of MSCC Surgery + RT vs RT alone Patchell et al Proc Am Soc Clin Oncol 21:1, 2003 (abstr 2) Regine WF, Tibbs PA, Young A, et al. Int J Radiat Oncol Biol Phys 2003; 57 (suppl 2): S125 Randomised trial Decompressive surgery + RT vs RT alone 30 Gy in 10# both arms 101 patients (terminated at 50% accrual) Median ambulation 126 v 35 days (p=0.006) 3/16 (19%*) v 9/16 (58%) paraparetic pts regained ambulation Better pain control Trend toward better survival with surgery (p=0.08) MSCC – Prognosis 1 • Pretreatment neurological status most important • Speed of development of motor deficits: > 14/7 better than < 14/7 (86% improved at 2 weeks vs 12%) • Length of time from diagnosis to MSCC • Radiosensitivity of the tumour • Bony compression (vs without) and degree of compression • Good: ambulatory, radiosensitive, 1 level of compression • Not good: multiple levels, brain/visceral mets/ lung CA, etc • Median survival historically 3-6 months • Recurrence occurs in 10-25% of patients • Recurrence in 50% of 2 year survivors; nearly all 3-year survivors MSCC – Prognosis 2 Ambulation post RT Deficit before RT Ambulatory after RT Ambulatory Assistance need Paraparetic Paraplegic** *bony compression not excluded ** flicker of movement only Bony* Non-bony 92% 65% 43% 14% 100% 94% 60% 11% Supportive care • Analgesia • Laxatives • Bladder care • Physiotherapy Conclusions/Summary • Consider the diagnosis early – do an MRI • Optimal intervention strategy still unknown • Start steroids and plan to reduce • Consider surgery, though there is no consensus • Re-irradiation is relatively safe • Optimal screening strategy unknown Hypercalcaemia • Low threshold for checking Ca2+ in cancer patients • Rehydrate • Bisphosphonate • Treat the cancer