Oncological Emergencies

Superior Vena Cava Syndrome

  • Obstruction of blood flow through the SVC
  • Development of extensive venous collateral circulation ( azygus vein commonly)

Increased Intracranial Pressure

pathophysiology

Etiology

Malignancy (60-86%)

  • Small cell lung carcinoma (38%)
  • Squamous cell lung carcinoma(26%)
  • Lymphoma(8%):diffuse large cell lymphoma or lymphoblastic lymphoma
  • Thymoma
  • Germ cell tumors
  • Breast cancer in metastatic stage

Nonmalignant conditions

SVC thrombosis in the era intravascular
devices (central vein catheters, pacemakers)

Paediatric population

  • Jatrogenic causes (cardiovascular surgery, SVC catheterization for parenteral nutrition)
  • Lymphomas
  • ALL

symptoms

  • Dyspnea – most common (63% of pats) test
  • Sensation of fullness in the head and facial swelling (50% of pts)
  • Cough (24% of pts)
  • Arm swelling (18% of pts)
  • Chest pain (15% of pts)
  • Dysphagia (9% of pts)

Physical findings (test)

  • Venous distension of neck (66%) and chest wall (54%)
  • Facial edema (46%)
  • Plethora (19%)
  • Cyanosis (19%)

Diagnostic procedures

  • CXR – mass in 84% of pts
  • CT
  • Sputum cytology (positive in 50% of pts)
  • Thoracocentesis
  • Biopsy of supraclavicular node
  • Bronchoscopy + transchbronchial needle aspiration biopsy
  • Mediastinoscopy
  • Percutaneous transthoracic CT-guided fine- needle biopsy

Treatment

  • BASED on HISTOLOGIC DIAGNOSIS
  • 2 goals:
    relieve symptoms
    cure of the primary malignancy

SVCS in SCLC

  • Chemotherapy: RR(response rate)=93 %, usually used as initial modality , treatment of choice
  • Radiotherapy: RR=94%
  • the risk of SVCS recurrence significantly lower when CHT+RT
  • Relief after 7-10 days

SVCS in NSCLC

  • Chemotherapy: RR=59%
  • Radiotherapy: RR=64%
  • Endovascular stent insertion

SVCS in NHL

  • No treatment modality was superior in achieving clinical improvement
  • Rarely an emergency
  • Complete staging work-up before! therapy
  • Chemotherapy = treatment of choice
  • Consolidation radiotherapy – large cell lymphoma with mediastinal masses ≥ 10 cm

radiation therapy

  • Optional treatment for most pts with SVCS
  • Initial treatment if histologic diagnosis can not be established and the clinical status of the patient is deteriorating
  • Fractination schedule: 20Gy/5 fractions or 30Gy/10 fractions
  • Treatment volume: gross tumor, mediastinal,hilar +/- supraclavicular lymph nodes
  • Altarnative to paliative RT: endovascular stenting +/- thrombolysis

surgery

  • Considered ONLY after other therapeutic maneuvers with RT, CHT and stenting have been exhausted in case of malignancy-induced SVCS
  • Experience - limited

General measures

  • Bed rest with the head elevated
  • Oxygen administration 3-4L/M
  • Diuretic therapy
  • Reduced-salt diet
  • Steroids (6-10 mg dexamethasone PO or IV every 6 hours)
  • not expandable intracranial volume
  • Monro-Kellie hypothesis
  • reduced cerebral perfusion leading to intermittent symptoms with orthostasis in pts with brain tumors

Mechanisms

  • volume changes in brain parenchyma: primary or secondary brain tumors, edema, indirect neurological complications of cancer
  • vasogenic edema: ↑ leakage of plasma filtrate into brain tissue through leaky capillaries of the brain tumor
  • cytotoxic edema: ischemic injury, cytotoxic chemotherapy agents
  • break down of the ADP- dependent transmembranous ion transport system → intracellular entrapment of water
  • imbalance between cerebrospinal fliud production and absorption:
    mass lesions in proximity to bottlenecks of CSF flow → obstructive or noncommunicating hydrocephalus
    carcinomatosis or meningitis block CSF reabsorption

Increase in cerebral parenchymal pressure

  • brain metasatses:
    adults: lung cancer, breast cancer, melanoma
    children: RMS, Ewing sarcoma
    associated with hemorrhage: melanoma, choriocarcinoma, renal cell carcinoma, papillary thyroid carcinoma

Venous outflow obstructions

  • Dural venous sinus thrombosis
  • Metastases at the base of skull
  • Mediastinal masses

symptoms

  • headache - with max. intensity in the morning
  • nausea/ vomiting
  • somnolentia, coma
  • seizures

physical findings

  • papilledema (50% of pts) test
  • Focal neurological deficits
  • Head tilt, neck stiffness and unilateral forced eye closure – hernitation of one cerebellar tonsil
  • Kocher-Cushing syndrome
  • cushing's triad: high systolic p, low plus, low respiration (all 3 indicate ICP)

Diagnostic algorithm

  • Brain CT, MRI
  • Lumbar puncture
  • Transcranial Doppler sonography

Treatment

  • Head up position
  • Corticosteroids–effective for vasogenic edema
    (doses – moderate: 6-10 mg dexamethasone every 6 hours to high doses: up to 100 mg/d), avoid if CNS lymphoma is suspected)
  • Osmotic diuresis: 20-25 % mannitol (0,75-1 g/kg body wieght followed by 0,25 t0 0,5 g/kg body weight every 3-6 hours) or glycerol, target serum osmolality: 300 mOsm/L
  • Intubation with mechanical hyperventilation
  • pC02= 25-30 mm Hg
  • External ventriculostomy or ventriculoperitoneal shunt – in case of obstructive hydrocephalus
  • Mts – craniotomy+resection, stereotactic radiotherapy, WBRT
  • Leptomeningeal carcinomatosis – RT, intrathecal ChT

Hypercalcemia

  • Most common paraneoplastic syndrome
  • 10-20% of pts with advanced cancer
  • Most frequently: multiple myeloma, cancer of the breast, kidney, lung, head and neck

symptoms

  • Nausea/vomiting
  • Constipation
  • Polyuria
  • Disorientation
  • coma

pathogenesis

  • Focal bone destruction (osteolytic)
  • Humoral paraneoplastic syndrome - PTHrp

Treatment

  • Asymptomatic pts with serum Ca ≤ 3,25 mmol/L - conservative management
  • Symptomatic pts or those with serum Ca > 3,25 mmol/L – immediate aggressive measures
  • IV hydratation with isotonic saline (1-2 l/2 hours + 20-40 mg IV FSD)
  • Bisphosphonates (pamidronate, zoledronate):
    inhibit bone resorption via effects on osteoclasts, administered IV, side effects: fever
  • Gallium nitrate: inhibits bone resorption, inhibits tubular Ca resorption, inhibits PTH secretion, in hyperCa refractory to the bisphosphonates
  • Calcitonin: inhibits bone resorption, promotes Ca and Na secretion