Oncological Emergencies & Cancer Related Complications

SUPERIOR VENA CAVA OBSTRUCTION

Clinical Description

Extrinsic or Intrinsic blockage of the Superior Vena Cava resulting in upper body swelling, upper airway compromise, CNS signs, venous distension and collaterals in the neck and chest. Caused by benign (e.g. TB, thrombus) and malignant causes. It becomes an emergency once tracheal compression and airway compromise established. Malignant causes include primary lung or mediastinal tumors e.g. Lung cancer, Lymphoma, Thymoma/Thymic carcinoma, metastatic disease to mediastinum e.g. breast cancer and germ cell tumors.

INVESTIGATIONS

History and physical examination
CXR: Apical/Mediastinal widening (unilateral: on the right and or bilateral)
Contrasted CT Neck and Chest
Biopsy: Bronchoscopy or CT guided if no obvious masses externally

Treatment

Grade 3 and 4 (severe to life threatening symptoms): refer to surgery for SVC stenting + anticoagulation
Surgery for chemotherapy or radiotherapy resistant tumours e.g. thymomas
Chemotherapy +/- steroids after biopsy for chemo sensitive malignancies: Small cell lung cancer, Lymphoma, Germ Cell Tumours
Radiotherapy: Chemotherapy resistant tumours or where surgery not possible

SPINAL CORD COMPRESSION (SCC)

Clinical Description

This is the initial presentation of cancer in 20-30% of SCC. Common cancers to present with SCC are lung, Cancer of unknown primary, Breast, Prostate, NHL, Multiple myeloma. Mostly in the thoracic spine (60-80%), Lumbar spine (15 – 30%), Cervical spine (4-13%).

Clinical Features

SIGNS AND SYMPTOMS

Back pain (95%)
Weakness (60-80%)
Sensory deficits (40-90%)
Autonomic dysfunction (50%)
Ataxia (5%)

INVESTIGATIONS

High index of suspicion in cancer patient with new back pain or change in character of preexisting back pain

Immediate imaging and consultation with oncologist and a neurosurgeon
Careful documentation of neurology
NOMS criteria to decide treatment
MRI- whole spine (contrast-enhanced) is the gold standard
CT scan is useful in assessing the degree of bone destruction, and differentiating bone vs. tumor

Treatment

Supportive

Pain is mostly resistant to standard analgesics, therefore opioids are indicated
Steroids lessen pain, reduce vasogenic cord oedema and avoid radiation induced spinal oedema
High dose if establishes paraparesis or paraplegia vs. low dose steroids if pain with minimal fallout

Dexamethasone 40-96 mg loading dose then 16-24 mg over next 3 days. Decrease dose and increase time (taper) discontinue after 10days.

Radiotherapy

Preferred treatment for metastatic SCC
First-line therapy if surgery is contraindicated
Radiosensitive tumors are lymphoma, multiple myeloma, breast, prostate and lung

Surgery

Spinal instability, paraplegia at diagnosis
No tissue diagnosis hence decompression & biopsy
Retropulsion of bones within the vertebral canal
Radio-resistant tumors
Deterioration during RT
Prior radiation in the same areas

Chemotherapy

Chemo-sensitive tumors e.g., Lymphoma

UNCONTROLLED TUMOUR HAEMORRHAGE

Clinical Description

Occurs following tumour erosion into a blood vessel or any trauma to tumours in any part of the body

Clinical Features

SIGNS AND SYMPTOMS

Presence of known malignancy
History of bleeding or persistent obvious bleeding
Symptomatic anaemia
Hypovolaemic Shock

Treatment

Volume support

Secure IV access
IV Fluids (isotonic vs. colloids vs. blood products) depending on presentation

Control bleeding

IV Tranexamic acid 500 – 1000 mg 8 hourly
Adrenaline pack or simple pressure pack; including vaginal pack for cervical cancer
Suture or cauterize an obviously bleeding blood vessel
For internal tumours: consider surgical referral or interventional radiology referral for vessel embolization
Definitive or Palliative treatment: Chemotherapy, Radiotherapy, Targeted therapy according to tumor histology and stage of disease