Oncologic Emergencies 2 PDF

(L3) ONCOLOGIC EMERGENCIES 2  LECTURE 03 ONCOLOGIC EMERGENCIES 2 Disseminated Intravascular Coagulation Definition and incidence  An acquired syndrome characterized by the intravas...

(L3) ONCOLOGIC EMERGENCIES 2  LECTURE 03 ONCOLOGIC EMERGENCIES 2 Disseminated Intravascular Coagulation Definition and incidence  An acquired syndrome characterized by the intravascular activation of coagulation with loss of localization arising from different causes.  It can originate from and cause damage to the microvasculature, which if sufficiently severe, can produce organ dysfunction.  DIC is estimated to be present in as many as 1% of hospitalized patients.  DIC is not itself a specific illness; rather, it is a complication or an effect of the progression of other illnesses. characters  Disseminated intravascular coagulation (DIC) is characterized by: Systemic activation of blood coagulation ↓ Generation and deposition of fibrin ↓ Microvascular thrombi in various organs ↓ Multiple organ dysfunction syndrome (MODS).  Consumption of clotting factors and platelets in DIC can result in life-threatening hemorrhage.  Hence, a patient with DIC can present with a simultaneously occurring thrombotic and bleeding problem, which obviously complicates the proper treatment. Dr.Noaman Page 1  Medicine - Delta Semester (7) Oncologic emergencies 2 Clinical picture Features Affected Patients % Bleeding 64% Renal dysfunction 25% Hepatic dysfunction 19% Respiratory dysfunction 16% Shock 14% Central nervous system dysfunction 2% Risk factors ① Infection or sepsis (most common)  May be bacterial, fungal, and viral.  Sepsis from gram-negative bacteria is the most common. ② Intravascular hemorrhage (blood transfusion reaction) ③ Acute leukemia and adenocarcinomas (lung, breast, stomach, and prostate) ④ Liver disease that results in liver failure ⑤ Prosthetic devices (shunts) ⑥ Heat stroke and hyperthermia ⑦ Retained dead fetus syndrome Dr.Noaman Page 2  Medicine - Delta Semester (7) Oncologic emergencies 2 Risk factors Type Cause Bacterial Viral ① HIV ① Gram-negative sepsis ② Cytomegalovirus [CMV] ② Gram-positive infections 1 Infectious ③ Varicella-zoster virus [VZV] ③ Rickettsial ④ Hepatitis virus Fungal Parasitic  Histoplasma  Malaria ① Hematologic (eg, acute myelocytic leukemia) 2 Malignancy ② Metastatic (eg, mucin-secreting adenocarcinoma) ① Amniotic fluid embolism ② Abruptio placentae ③ Acute peripartum hemorrhage ④ Preeclampsia/eclampsia/hemolysis 3 Obstetric ⑤ Elevated liver enzymes, and low platelet ⑥ count (HELLP) syndrome ⑦ Retained stillbirth ⑧ Septic abortion and intrauterine infection ⑨ Acute fatty liver of pregnancy ① Burns 4 Trauma ② Motor vehicle accidents ③ Snake envenomation 5 Transfusion ① Hemolytic reactions ① Liver disease/acute hepatic failure ② Prosthetic devices 6 Others ③ Shunts (Denver or LeVeen) ④ Ventricular assist devices Dr.Noaman Page 3  Medicine - Delta Semester (7) Oncologic emergencies 2 treatment ① Patients with DIC should be treated at hospitals with appropriate critical care and subspecialty expertise ② Platelets, FFP (Fresh Frozen Plasma) ③ Antithrombin III concentrate  To neutralize excess thrombin and slow DIC ④ Controversial heparin therapy as continuous infusion or SC  Heparin contraindicated if intracranial bleeding, open wounds or recent surgery ⑤ E-aminocaproic acid (an antifibrinolytic agent)  Controversial to maintain platelet and fibrinogen levels ⑥ Effective control is measured by normal coagulation screen and platelet count Dr.Noaman Page 4  Medicine - Delta Semester (7) Oncologic emergencies 2 Malignant Pleural Effusion Common causes ① Implantation on the pleural surface leading to increased permeability ② Obstruction of lymphatic flow by tumor preventing fluid reabsorption ③ Tumor obstruction of primary vessels leading to increased capillary hydrostatic pressure. ④ Necrotic tumor cells shed into the pleural space increasing colloid osmotic pressure ⑤ Thoracic duct perforation Clinical picture ① Dyspnea ⑤ Tachypnea ② Orthopnea ⑥ Dullness to percussion ③ Dry, non-productive cough ⑦ Restricted chest wall expansion ④ Chest pain, heaviness ⑧ Impaired transmission in breath sounds treatment ① Small asymptomatic effusions may be left alone  Remember: most recur anyway ② Chemotherapy for a particular tumor  Response to treatment often see a reduction or resolution of the effusion ③ If the tumor is chemo-resistant or refractory to systemic treatment: 1. Pleurodesis may be performed. 2. Thoracocentesis provides short-term relief of symptoms 3. Thoracostomy tube 4. Pleuroperitoneal shunt 5. External beam XRT Dr.Noaman Page 5  Medicine - Delta Semester (7) Oncologic emergencies 2 SVC Syndrome MECHANISM  Obstruction of blood flow through SVC caused by direct invasion or external compression of the SVC by a pathological process ① Lymphoma ② Hodgkin’s ③ Lung ④ Breast CLINICAL PICTURE ① Facial Edema ② Periorbital Edema ③ Cyanosis: speed determines collateral pattern on chest wall. ④ Congested non pulsating neck veins. ⑤ Pressure symptoms. Dr.Noaman Page 6  Medicine - Delta Semester (7) Oncologic emergencies 2 DIAGNOSIS ① Chest X-ray: right sided mediastinal mass ② Radionucleotide SVC gram ③ Tissue Diagnosis: may have to wait treatment ① X-ray therapy: high dose ② Steroids ③ Chemotherapy Pericardial Tamponade CLINICAL PICTURE ① Dyspnea on exertion ⑩ Hypotension ② Orthopnea ⑪ Neck vein distension ③ Cough ⑫ Pulsus paradoxus ④ Chest pain ⑬ Distant heart sound ⑤ Palpitation ⑭ Pericardial friction rub ⑥ Edema ⑮ Sign of right sided heart failure: ⑦ Syncope 1. Hepatomegaly ⑧ Symptoms of primary cancer 2. Ascites ⑨ Tachycardia 3. Edema DIAGNOSIS  Chest X-ray ① Cardiomegaly, water bottle heart ② Lung parenchyma abnormality ③ Pleural effusion Dr.Noaman Page 7  Medicine - Delta Semester (7) Oncologic emergencies 2 treatment ① Pericardiocentesis ② Pericardiotomy ③ Pleuropericardial window ④ Pericariectomy Increased Intracranial PRESSURE MECHANISM ① Primary Brain Tumor ② Metastatic Tumor ③ Meninges DIAGNOSIS ① Headaches ⑥ Stiff neck ② Personality Changes ⑦ Fixed pupil (tentorial herniation) ③ Lethargy ⑧ CT/MRI of Brain ④ Coma ⑨ Lumber puncture ⑤ Papilledema treatment ① Steroids ② Diuretics:  Osmotic diuretics, (e.g., mannitol, glycerol)  Loop diuretics (e.g., furosemide, ethacrynic acid) ③ Crainotomy: primary ④ Whole Brain Irradiation: 3000 r – 2 weeks ⑤ Intrathical chemotherapy (MTX or ARA C) Dr.Noaman Page 8  Medicine - Delta Semester (7) Oncologic emergencies 2 Spinal Cord Compression overview  1-5% of patients with systemic cancer  MUST BE TREATED IMMEDIATELY  Can lead to irreversible paralysis or loss of bowel and bladder function  Tumor or collapsed fragments in the epidural space pathology Most Common sites Most common malignancies ① Lung ① Thoracic spine (70%) ⑤ Renal ② Breast ② Lumbrosacral (20%) ⑥ Multiple myeloma ③ Unknown primary ③ Cervical (10%) ⑦ Lymphoma ④ Prostate Clinical picture ① Localized pain to the spine  Exacerbated by movement, recumbency, coughing, sneezing, straining  May appear weeks to months before neurological symptoms ② Radicular pain ③ Weakness +/- sensory loss ④ Autonomic dysfunction  Urinary retention  Constipation Dr.Noaman Page 9  Medicine - Delta Semester (7) Oncologic emergencies 2 diagnosis Image the ENTIRE spine ① X-ray  66% will have bony abnormalities  Erosion, loss of pedicles, vertebral body collapse, paraspinous soft tissue mass  Cannot exclude epidural metastasis  Does not exclude cord compression if normal  Follow-up with MRI ② MRI: STANDARD!! ③ CT scan treatment 1 Goal of therapy ① Recovery and maintenance of normal neurological function ② Stabilization of the spine ③ Pain and local tumor control 1 Outcome of therapy ① Degree of neurologic impairment ② Radiosensitivity of tumor 3 Lines of therapy ① Steroids  START DEXAMETHASONE IMMEDIATELY if you suspect cord compression  10 mg IVP followed by 4 mg IV every 6 hours (higher doses be used if patient presents with significant neurological impairment) ② Radiation ③ Surgery  Tissue diagnosis needed  Prior radiation to affected area  Spinal instability  Progression of cord compression despite steroids and radiation Dr.Noaman Page 10