Prevalence of cancer: American Prevalence of cancer: American Cancer Society Cancer Society Oncologic Emergencies • 13.7 million Americans are living with cancer or history of the disease • American Cancer Society projects 1.6 million new diagnoses this year Luca Delatore, MD • Cancer is the 2 nd leading cause of death James Emergency Department Medical Director Associate Professor – Clinical in the US (Heart disease #1) Department of Emergency Medicine • Cancer accounts for more than 500,000 The Ohio State University Wexner Medical Center deaths per year Prevalence of cancer Prevalence of cancer Cancer-related ED visits Cancer-related ED visits • Patients with high acuity New therapies have led to longer survival • Admission rate of 60-70% New drugs • Often (~5%) a new diagnosis made in the ED Radiation • Frequently the more acute patients with Bone marrow transplants lower survival rates present to the ED Immunotherapy-most recent and area • Also older patients and those with limited of growth at OSU healthcare access present to the ED 1
Cancer-related ED visits Cancer-related ED visits Why a specific Emergency Why a specific Emergency Department? Department? Resisting labels is critical for appropriate • Provide specialized care in the emergency treatment setting for cancer patients Cancer does not mean terminal • Improve access to unique treatment and research opportunities for patients with Cancer does not assume DNR cancer Treatment is indicated • Establish hospital based guidelines for emergency department care • Pain • Evaluation of patient outcome • Dehydration Admissions • Vomiting Inpatient length of stay • Infection Infection rates • Palliative Patient Satisfaction Classification of Classification of Structural Oncologic Structural Oncologic Oncologic Emergencies Oncologic Emergencies Emergencies Emergencies Can be broken down into 3 main areas Spinal Cord Compression • Structural Malignant pericardial effusion • Metabolic/endocrine Brain metastases • Hematologic Superior Vena Cava Syndrome 2
Spinal Cord Compression- Spinal Cord Compression- Spinal Cord Spinal Cord Exam findings Exam findings Compression Compression • Major emergency requiring radiation treatment • Tenderness to palpation • Most are due to metastatic lesions • Weakness • Most common in the thoracic spine (70%) and • Spasticity lumbrosacral (20%) • Abnormal reflexes • Most common early symptom is pain (95%) • Sensory deficits • Pain is positional and usually worse when supine • Occurs in approximately 5% of all cancer • Good indicator of location of lesion patients • Palpable bladder • Most common in breast, lung and prostate cancer, renal, lymphoma • Decreased rectal tone • Life threatening if above C3 Malignant pericardial Malignant pericardial Spinal Cord Compression Spinal Cord Compression effusion effusion • Early recognition is key. Early MRI imaging • Due to neoplastic infiltration or radiation • Prognosis is closely related to pretreatment level treatment of function • Can lead to cardiac tamponade • Late Signs • Difficult diagnosis to make and often • Autonomic dysfunction misdiagnosed as CHF, PE or anxiety • Urinary retention • Constipation • Beat to beat alteration of the QRS • Transport for rapid evaluation of emergent • Symptoms radiation therapy and steroids Dyspnea • Surgery for tissue diagnosis and stabilization Orthopnea • Treatment delays may result in loss of bowel or Cough bladder function Chest pain Weakness 3
Malignant pericardial Malignant pericardial Malignant pericardial Malignant pericardial effusion effusion effusion effusion • Physical exam findings: Cardiac tamponade “muffled” heart sounds • Initial treatment is temporizing Increased JVP Oxygen, IVF, vasopressors Decreased systolic blood pressure May require pericardiocentesis, pericardial window • Echocardiogram (Most Helpful Tool) 60% of malignant effusions reaccummulate Diastolic collapse of RA and RV Treat underlying malignancy Dilated IVC Brain Metastases Brain Metastases Brain Metastases Brain Metastases • Most common form of malignant CNS involvement • Diagnosis: Find the primary tumor • Common associated cancers: • CT scan of the chest, abdomen, and Lung (most common) pelvis Breast • If negative, then consider mammogram Melanoma or other imaging study Leukemia/lymphoma • In 30% of patients no primary tumor is • Causes symptoms via compression and identified edema Headache Seizures Focal weakness Exam may be normal 4
Superior Vena Cava Superior Vena Cava Brain Metastases Brain Metastases Syndrome Syndrome • Alleviate Symptoms – ie palliation • Obstruction of the SVC which carries blood • Radiation is the primary treatment for brain back into the heart metastases • Approximately 90% caused by cancer • If single brain lesion, then surgery may be • Lung cancer is the most common (65%) reasonable with or without radiation • Clinical features: • Corticosteroids Edema of the face and arms • Especially if signs of edema Swollen collateral veins on the chest • Chemotherapy Shortness of breath Coughing • Anti-seizure medications – tend to improve Difficulty swallowing quality of life Headache Superior Vena Cava Superior Vena Cava Superior Vena Cava Superior Vena Cava Syndrome Syndrome Syndrome Syndrome • Lung cancer patients account for 65% of all • Supportive care and transport SVCS cases • Elevate the head of the bed and provide oxygen • 3 – 15% of patients with Lung CA if hypoxic • Four times more likely in right vs left sided • Immediate radiation therapy consultation tumors • Consider anticoagulation (50% will have clot • Lymphoma - 8% present) • Usually in the anterior mediastinum • Radiation is the definitive treatment • Breast and other mediastinal tumors 10% • Surgery and chemotherapy in selected cases • Non-malignant conditions account for • Intravenous stents, balloon angioplasty and remainder surgical bypass are becoming more common 5
Overview Overview Oncologic Emergencies • General Considerations • Hypercalcemia of malignancy • Tumor Lysis Syndrome • Septic Shock Joseph Flynn, DO, MPH, FACP Associate Professor – Clinical Division of Hematology & Oncology The Ohio State University Wexner Medical Center Case # 1 Case # 1 General Considerations General Considerations • A 60 y/o white female is brought to the ER • Oncologic Emergencies Have Increased by her family for new onset worsening • Rapid Recognition Required confusion • The patient notes only vague abdominal • Aggressive Treatment is Indicated pain and constipation • If due to underlying cancer, then treat • PE: • HR 115, BP 88/40, RR 10, T 100.2 the cancer • Elderly appearing female • Palliation in Advanced Malignancies • Dry mucous membranes • Tachycardia, no murmurs • Must Consider Doing Nothing • Lungs are clear • Abdomen w/ decreased bowel sounds 6
Laboratory Laboratory Hypercalcemia of Malignancy Hypercalcemia of Malignancy • Most Common Metabolic Emergency in Cancer • Occurs in about 10%-20% of Cancer Patients • Most Often Seen with Lung, Breast Hematologic Malignancies B LT with a Kosher Pickle and Mayonaisse B LT with a Kosher Pickle and Mayonaisse Hypercalcemia Hypercalcemia Cancers that go to bone Cancers that go to bone Etiology Etiology • Breast • Direct Tumor Invasion into Bony • Syndrome Mediated by Production Structures of PTHrP • Lung / Lymphoma • Parathyroid hormone-related • Individual tumor cells peptide which binds to secrete a variety of parathyroid hormone mediators that up- • Thyroid receptors, mobilizing calcium regulate local from bones, and increasing osteoclastic activity, renal reabsorption of calcium. • Kidney causing calcium to be • This Activates Osteoclast released into the serum. Activity • Prostate * Immobility May Contribute • Level of Boney Metastasis Does Not Necessarily to Hypercalcemia Correlate with Level of • Myeloma Calcium 7
Hypercalcemia Hypercalcemia Hypercalcemia Hypercalcemia Acute Symptoms Acute Symptoms Acute Symptoms Acute Symptoms • Early • Late • Late • Early • Nausea • Oliguria • Oliguria • Nausea • Vomiting • Renal failure • Renal failure • Vomiting • Constipation • Stupor, coma • Stupor, coma • Constipation • Muscle Weakness • Ileus • Ileus • Muscle Weakness • Heart block • Heart block • Mental Status • Mental Status Changes Changes • Acute Renal • Acute Renal Insufficiency Insufficiency Hypercalcemia Hypercalcemia Hypercalcemia Hypercalcemia Diagnosis Diagnosis Symptoms Symptoms CNS Cardia GI Renal Weakness Bradycardia Nausea / Vomiting Polyuria • History and Physical Hypotonia Decreased QT Constipation Calcinosis • Serum calcium (>11 mg/dL) • Phosphorus is low or normal Proximal Prolonged PR Ileus Myopathy Interval Mental Status Widened T Pancreatitis Changes wave Seizure /Coma Arrhythmias Dyspepsia Adapted from Escalante et al, Cancer Management, May 2014 8
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