Onco emergency

Three major divisions:

1) Pressure or obstruction cause by space occupying the lesion
2) Metabolic or hormonal problem (paraneoplastic syndrome)
3) Complications arising from effects of treatment (such as chemotheraphy)

Structural obstructive oncologic emergency:
1) Svc syndrome
2) Pericardial effusion or tamponade
3) Intestinal obstruction
4) Urinary obstruction
5) Spinal cord compression

1 .SVC Syndrome
Obstruction due to severe reduction in venous return from the head, neck and upper extremities (any
tumor or mass that will obstruct SVC)
Lung ca, lymphoma and metastatic tumors >90% of all SVC cases
Presentation: neck and facial swelling (especially in the eyes) dyspnea and cough, hoarseness, tongue
swelling, headaches, nasal congestion *all symptoms are due to decreased venous return
bending down or leaning forward may aggravate symptoms
pulled in upper extemities
increase pressure in upper part of the body
Prominent vascular markings, Swelling
Acute and Chronic has collaterals

Physical findings
Dilated neck veins
Increase # of collateral vein covering anterior chest wall
Cyanosis or redness of the face
Edema of the face, arm and chest

Most common malignancy in SVC : Lung, lymphoma, metastasis take note inulet n nia to )

Dx of SVC: Clinical
Most significant radiologic finding : widening of superior mediastinum or in the right side
CT Scan: most reliable view of mediastinal anatomy

Diminished or absent opacification of central veins
Structures with prominent venous circulation

MRI has no advantages over CT Scan
Basic Dx tool for SVC: X-ray

Treatment
Diuretics (furosemide)
low salt diet
head elevation and O2 may produce temporary symptomatic relief
proper history-proper treatment esp. for cancer etiologies
Radiation Therapy- primary treatment for SVC caused by Lung Ca
Chemo-effective for small cell lung ca or lymphoma
Relevant SVC-10-30% intravascular self-expanding stents
(insert stent at superior mediastinum pero super RARE!!)

2. Pericardial effusion/tamponade
5-10% of patients with Ca with malignant pericardial disease (not common site of metastasis ang heart
pero pag dito sya nag met s/s of effusion or tamponade ca cells will attack first the pericardium;then
fluid will accumulate
Lung, breast, leukemia, lymphoma, Take note daw tong apat na to! radiation pericarditis
Common symptom: dyspnea,cough,chest,pain,orthopnea,weakness
Physical Findings: pleural effusion, sinus tachycardia, jugular vein distention, peripheral edema, cyanosis
dont forget daw )

Specific Dx
PE: Paradoxical pose, decrease heart sounds, pulsus alterans, friction rub
Dimished/muffled heart sounds most common na nakikita
Dx: CXR, ECG, Echocardiography
Dx of choice or Dx tool of choice: Echocardiography or 2D echo with color Doppler dont forget din )

Cyto Exam of pericardial fluid is diagnostic

Tx: Pericardiocentesis (IMMEDIATE TREATMENT. first treatment, insert syringe with needle, aspirate the
effusion then send to cyto exam, kasi hindi lahat ng effusion Ca ang cause) creation of pericardial
window (surgical) chemotherapy

X-ray: enlarge heart ang makikita


3. Intestinal Obstruction:
Common problem in patients with advanced Ca
Colorectal and Ovarian Ca common cause
Obstruction occurs at multiple sites
Melanoma predilection for small bowell
Three causes of int. obst. Colorectal, ovarian ca and melanoma predilection

Pain most common symptom, colicky in nature
Vomiting can be intermittent or continuous
PE: abdomen with tymphany, ascites, visible peristalsis, high pitched bowel sounds, tumor mases
Dx: Eject plain abdominal film (multiple plain fluid levels, dilation of small and large bowels
CT Scan
(pag nag sususpect ka ng intestinal obstruction dapat plain lang, kasi ung contrast pwede pa mag
interact?)
Bowel loops dilated pag nag x-ray, STEP LADDER SIGN
Primary diagnostic of Choice: PLAIN ABDOMINAL FILM
Tx: Surgical evaluation, self expanding mural stents
First: Conservative management: Nasogastric decompression, antiemetics, antispasmodics, analgesic,
octreotide (somatostatin analog, decrease the secretion of intestine para d masyadong painful ang
contraction)

4. Urinary Obstruction
Common malignancy causing urinary obstruction: prostate/gyne (ovarian), Cervical ca/ metastasize die
for stomach, colon lymphomas
Radiation Therapy to pelvic tumors may cause fibrosis (dikit dikit ang ureters) and subsequent upsternal
obstruction lead to bilateral hydronephrosis renal failure
Most common symptom: flank pain

Persistent UTI, (proteinuria, hematuria)
-suspect ureteral obstruction
Dx: renal utz, Ct scan(highest detection rate)
Tx:
Urinary diversion, Obst. Flank pain, sepsis, fistula formation, immediate
Internal unilateral stents
Percutaneous nephrostomy

5. Spinal Cord Compression
(Chronic present as quadriplegic, cannot walk bed ridden, bladder and bowel control is lost)
5-10% of ca patients
Epidural tumor
Most common: Lung Ca (all ca can cause SCC pero Lung ang pinaka grabe mag affect)

(Cancer cells will eat the bone became brittle then dislodge then the spinal cord will be irriatted causing
edema and compressing the spinal cord whew!)

Tumor involves the vertebral column, more often than any other part of the bony skeleton
Lung, breast, prostate ca, multiple myeloma, lymphomas, melanoma, renal cell ca, gut ca

Most common: Thoracic spine 70%
2
nd
: Lumbosacral spine 20%
Least common: Cervical spine10%
SCC: metastasis to vertebral body, (pedicle enlarge, and compress the underlying pleura, direct extension
through the foramen)
Direct extremities is paravertebral lesion through inter foramen
Localized back pain to involve vertebra by tumor (back pain na di nawawala dapat ipa MRI daw, kasi
days or months bago maging visible ang neuro symptoms.. Cord compression longer than 3 months or
2months irreversible na, quadriplegic na ang patient.. bukas papa MRI na ko huhuhu joke!)
Pain is exacerbated by coughing / sneezing
Pain worsens when supine

Lhermittes sign: tingling electrical sensation down the back, upper &lower limbs upon flexing on
extending the neck (early sign of SCC)


Metabolic:
1) Hypercalcemia
2) Lactic acidosis

1. Hypercalcemia
Most common para neoplastic syndrome associated with bone metastasis (hmmm baka itanung daw)

Seen in: Bone, Breast, lung, renal ca, hema malig such as leukemia and lymphoma

Symptoms: anorexia, nausea, constipation, muscle weakness, fatigue
mental obtundation, coma(in worse cases)

Tx: Rehydration (with PNSS solution)
Bisphosphonates
1. Zolledronic acid
2. Panidronnate

2. Lactic acidosis
Rare but potentially fatal metabolic
Sepsis with circulatory failure(hypotension) is a common detrimental event in many malignancy

Leukemia, lymphoma, liver ca
tachypnea, tachycardia, poor mental sattus and hepatomegaly at PE
Serum level of lactic acid
Serum lactic acidosis of 90-180 mg/dl
Tx: underlying disease
Na bicarb
Prognosis is poor

Tx related emergency
1. Tumor lysis syndrome
2. Human antibody infusion reactions
3. Hus
4. Typhilitis
5. Hemorrhagic cystitis

1. Tumor Lysis syndrome
Hyperuricemia(#1 na iisipin mo) hyperkalemia, hyperphosphatemia, lactic acidosis and hypocalcemia

Dystraction of large number of rapidly proliferating neoplastic levels
Acute renal failure develops as a management of syndrome
Most frequently associated with treatment of burkitts lymphoma, acute lymphoblastic leukemia & high
grade lymphomas (dont forget)
1-5 days after chemotherapy
Hyperuricemia effective treatment malignant occur and leads to increase serum uric acid
Urica cid can precipitate at kidney the cause kidney failure
Turnover of nucleic acids
Tumor biopsies and renal function
Hyperuricemia
>1,700 u/l both converts with increased bleeding and increased risk of TVS
(Pretreatment dapat pag mataas ang Serum LDH sa may lymphoma high risk sa Tumor lysis sundrome)

Tx: recog of risk and prevent
Allopurinol, urinary alakalinization, aggressive, hydration (Na bicarb), rasburicase pag mataas pa din ang
uric acidkahit nagbigay kna nung tatlong prior treatments (recombinant urate oxidase)

Important daw to:
NSS at 3,000 ml/day
Urine pH of 7.0 increase normal
Allopurinol 300mg/m2 per day
Serum chem.
Target:
Serum uric acid <8mg/dl
Serum crea <1.6 mg/dl
Ph >7.0

2. Human antibody infusion reactions
Rituximab-for lymphoma, trastuzumab for breast (tandaan!!) (iv incorp to, monitor mo muna
for 15mins baka kasi hindi compatible ang drug)

fever,chills, nausea, asthenia, headache, bronchospasm, hypotension
Patho:alevation immune effector proteases (cell and complement)
Treatment: Dipenhydramine (Benadryl) and acetaminophen (given before giving the rituximab
or trastuzumab)
Reaction Occurs: Infusion should be stopped and retained at half of infusion rate after
symptoms have subside 15mins. Give the treatment again
+ Reaction: stop the infusion then challenge
3. HUS
Mitomycin= most common
Cisplatin, bleomycin, gemcitabine
gastric, colorectal and braest ca
Onset: 4-8weeks after last dose of chemo
Lab findings: anemia, schistocytes, serum crea, increase blood cell proliferation
Patho: deposition of fibrin in the walls of capillaries and arterioles (dont forget daw! )
Urinary: hematuria, proteinuria, cast, hyaline
Tx: immunoperfusion(best Treatment) plasmapheresis and plasma exchange
Case fatality is increase
Few months-death

4. Typhilitis (neutropenia+inflame of cecum)
Neutropenic enterocolitis (decrease white count, low immune system, infection in cecum)
Inflammation and necrosis of cecum with acute leukemia treated with chemotherapy
Taxanes
Neo abdominal pain with rebound tenderness tense and distended abdomen primary of fever
and neutropenia

Watery diarrhea and bleeding
CT Scan-bowel wall thickening in cecum
Tx; antibiotics
NGT
No improvement after 24 hours surgery (wag kalimutan)

5. Hemorrhagic Cystitis
Cyclophosphamide
Ifosfamide-most common chemo agent in HUS acrolein-irritant to bladder
--- excreted in urine
Prolonge contact or increase concess
Bladder imitation and hemorrhage
Syndrome gross hematuria, frequent dysuria, burning, urgency, incontinence

Management: preventive
Increase rate of urine flow by hydration
Mesna-detoxifies the metabolites
2-mercaptoethansulfonate
Irrigate bladder with 0.37-0.74%
Formalin solution x10mins.
Prostaglandins
Cystectomy, litigation of hypoglycemic, urinary distention