Download Acute Oncological Emergencies

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
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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