Oncological Emergencies

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Oncological Emergencies

• Dr. Gary Harding MD, FRCPC
• Medical Oncology Fellow CancerCare Manitoba

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CASE 1
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Mr. SV

• ID 65 year old male with PMHx of CAD and
  emphysema
• EC present to clinic with one week history of
  increasing SOB
• HPI 3 month history of weight loss, decreased
  appetite, a change in his chronic cough, and
  intermittent hemoptysis

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On Physical Examination

• Inspection

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Respiratory Examination

• Stridor
• Dullness to percussion on right lower lung fields
• Increased tactile fremitus to right lower lung
  fields
• Decreased A/E to right lower lung fields

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Chest X-Ray
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right pleural effusion
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Thoracentesis

• Exudate
• Gram stain
• Negative
• AFB stain
• Negative
• Cytology
• non-small cell lung cancer
• Large cell type

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T1-weighted axial MRI demonstrating paratracheal
soft tissue mass that invades into the SVC
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Superior Vena Cava Syndrome
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Definition

• Obstruction of blood flow in the superior vena
  cava results in signs and symptoms of SVC syndrome

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Etiology

• Caused by either invasion or external compression
  of the SVC by contiguous pathologic process
• Right lung pathology, lymph nodes, other
  mediastinal structures, or thrombosis

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Etiology

• Before antibiotics the most common causes were
  from complications of untreated infection
• Syphilitic thoracic aneurysms
• fibrosing mediastinitis
• Malignancy is presently the most common cause

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Symptoms and Signs

• As the obstruction develops venous collaterals
  are formed
• Symptom onset depends on speed of SVC obstruction
  onset
• Malignant disease can arise in weeks to months
• Not enough time to develop collaterals
• Fibrosing mediastinitis can take years to have
  symptoms

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Symptoms and Signs

• Central venous pressures remain high even in
  collaterals
• High pressures cause the characteristic clinical
  picture
• Shortness of breath is the most common symptom1

1. Parish, JM, Marschke, RF Jr, Dines, DE, Lee,
RE. Etiologic considerations in superior vena
cava syndrome. Mayo Clin Proc 1981 56407.
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Signs and Symptoms

• Facial swelling or head fullness
• exacerbated by bending forward or lying down
• Cough
• Arm edema
• Cyanosis

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Facial swelling associated with SVC Syndrome in a
patient with malignancy
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Physical Findings

• Venous distension
• neck
• chest wall
• Pembertons Sign
• Facial Edema

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Patient who presented with progressively
enlarging veins over the anterior chest wall. A
diagnosis of a right-sided superior sulcus
(Pancoast) tumor compressing the SVC was made.
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Etiology Malignancy

• Lung cancer is the most common2
• Lymphoma is second most common
• together represent 94 of cases

2. Escalante, CP. Causes and management of
superior vena cava syndrome. Oncology (Huntingt)
1993 761.
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NSCLC

• 2-4 of bronchogenic cancer patients develop SVC
  syndrome3
• extrinsic compression or direct invasion
• primary tumor or by enlarging mediastinal nodes

3. Armstrong, BA, Perez, CA, Simpson, JR,
Hederman, MA. Role of irradiation in the
management of superior vena cava syndrome. Int J
Radiat Oncol Biol Phys 1987 13531.
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Small Cell Lung Cancer

• Greatest risk
• 20 will develop SVC obstruction3
• more common because SCLC tends to occur centrally
  in contrast to other types

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Lymphoma

• 2-4 of patients
• predominantly non-Hodgkins lymphoma4
• Hodgkins rarely causes SVC syndrome

4. Perez-Soler, R, McLaughlin, P, Velasquez, WS,
et al. Clinical features and results of
management of superior vena cava syndrome
secondary to lymphoma. J Clin Oncol 1984 2260.
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Lymphoma

• Extrinsic compression caused by enlarging lymph
  nodes
• subtypes of large B cell can be intravascular and
  cause occlusion (angiotropic)
• diffuse large cell and lymphoblastic are most
  commonly associated with SVC syndrome

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Other cancers

• Thymoma
• primary mediastinal germ cell neoplasm
• solid tumors with mediastinal nodal metastases
• breast cancer most common type

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Other causes

• Post radiation local vascular fibrosis can also
  be considered in oncology patients
• Thoracic radiation treatment may predate syndrome
  by many years

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Other causes

• Thrombosis
• Indwelling central venous catheters
• Subcutaneous tunneled catheters have fewer
  thrombotic and infectious complications
• Can also cause pulmonary embolism5

5. Sivaram, CA, Craven, P, Chandrasekaran, K.
Transesophageal echocardiography during removal
of central venous catheter associated with
thrombus in superior vena cava. Am J Card Imaging
1996 10266.
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Diagnosis

• Timely identification of the cause is essential
• Radiographic studies are useful
• Up to 60 of patients with SVC syndrome related
  to neoplasm do not have a known diagnosis of
  cancer6
• Need a tissue biopsy for histologic studies

6. Schraufnagel, DE, Hill, R, Leech, JA, Pare,
JA. Superior vena caval obstruction. Is it a
medical emergency?. Am J Med 1981 701169.
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Radiographic Studies

• Most patients have an abnormal chest x-ray at
  presentation
• Most common findings are
• Mediastinal widening
• Pleural effusion

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CT Chest

• Preferred choice
• IV contrast
• defines the level of obstruction
• Maps out collateral pathways
• Can identify underlying cause of obstruction

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Venography

• Bilateral upper arm venograpy
• superior to CT to define site of obstruction
• Does not define cause unless thrombosis is solely
  responsible

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Helical CT

• With bilateral upper arm IV contrast injection
• Best visualization of level of obstruction and
  cause

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MRI

• Can be useful in patients with IV contrast
  allergies

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T1-weighted axial MRI demonstrating the primary
tumor and the paratracheal soft tissue mass that
invades into the SVC
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Same patients MRI with different technique to
further define the intramural mass
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Histologic Diagnosis

• Essential
• Guides treatment
• Aids in defining prognosis

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Histologic Diagnosis

• Sputum cytology, pleural fluid cytology, biopsy
  of enlarged peripheral nodes
• Bone marrow biopsy for NHL
• Bronchoscopy, mediastinoscopy, or thoracotomy are
  more invasive but sometimes necessary

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Treatment of Oncologic Causes
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Treatment

• Aimed at underlying cause
• Evolution of thought has occurred in recent years

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• Historically SVC syndrome was considered a
  potentially life-threatening emergency
• Standard of care was immediate radiotherapy
• Zap now
• Ask questions later
• The emergent approach is not appropriate for most
  patients

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Newer strategies
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Emergent to Urgent

• Symptomatic obstruction is usually a prolonged
  process
• Most patients are not in immediate danger at
  presentation
• Most have time for a full diagnostic work up

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Emergent to Urgent

• Prebiopsy radiation can obscure the diagnosis
• Current strategies aim at accurate diagnosis of
  underlying etiology before therapy

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Exception to new rule

• Stridor
• Central airway obstruction or laryngeal edema
• True medical emergency
• Immediate action needed
• Possible intubation and ICU admission
• Immediate therapy to target obstruction needed

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Prognosis

• ?Linked to tumor histology and stage at
  presentation

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Treatment Sensitive Tumors

• NHLs, germ cells, and limited-stage small cell
  lung cancers usually respond to chemotherapy and
  or radiation
• Can achieve long term remission with tumor
  specific directed therapy
• Symptomatic improvement usually takes 1-2 weeks
  after start of therapy

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Note Corticosteroids

• Controversial issue with regards to treatment
  benefit at presentation

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Non-small cell lung cancer

• SVC obstruction is a strong predictor of poor
  prognosis
• Median survival around 5 months7
• Choice of therapy considers likelihood of
  response to each modality

7. Martins, SJ, Pereira, JR. Clinical factors and
prognosis in non-small cell lung cancer. Am J
Clin Oncol 1999 22453.
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Non-small cell lung cancer

• Goal usually directed to palliation rather than
  long term remission
• Palliative radiation and chemotherapy can be used

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Intraluminal Stents

• Endovascular placement under fluoroscopy
• Patients who have recurrent disease in previously
  irradiated fields
• Tumors refractory chemotherapy
• Patient too ill to tolerate radiation or
  chemotherapy

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Intraluminal Stents

• Some data suggests benefit from immediate stent
  placement in NSCLC at presentation8
• Tends to provide more rapid relief of symptoms
• Issue of anticoagulation after is not resolved

8. Rowell, NP, Gleeson, FV. Steroids,
radiotherapy, chemotherapy and stents for
superior vena caval obstruction in carcinoma of
the bronchus a systematic review. Clin Oncol (R
Coll Radiol) 2002 14338.
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CASE 2
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Mr. EC

• ID 56 year old man with history of HTN and
  osteoarthrtis
• EC presents to family doctor with one month
  history of back pain that is not responding to
  Tylenol
• Pain beginning to wake him at night
• More pain with recumbancy
• Some shooting pains down right leg
• ROS negative

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On examination

• vitals stable, no fever
• CVS, Respiratory, GI, GU exams reported as normal
• Back exam
• Inspection normal
• Palpation some pain in L1
• ROM normal
• Some pain in right leg with straight leg raising

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Investigation in Clinic

• Lumbar Spine X-ray
• Some age related degeneration

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Diagnosis

• Sciatica vs. Back strain
• Treatment
• NSAIDS
• Few days of bed rest

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The story continues

• Mr. ECs pain does not resolve
• More trials of various forms of pain control fail
• One month later Mr. EC awakens in the morning and
  has difficulty supporting his weight
• Subjective leg muscle weakness
• Goes to HSC Emergency room

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In ER

• Patient has objective leg weakness on physical
  exam
• A very keen medical student does a rectal exam
  and discovers a large nodular prostate
• PSA 45.0
• MRI Spine..

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Spinal Cord Compression
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Malignant Epidural Spinal Cord Compression (ESCC)

• Neoplastic invasion of the space between
  vertebrae and spinal cord (epidural invasion)
• Usually from bone metastases
• Compresses thecal sac of spinal cord
• Frequent complication of malignancy
• Can cause pain
• Can cause irreversible loss of neurologic function

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Definition

• Any radiological indentation of the thecal sac
• Tip of the spinal cord lies at the L1 vertebral
  level
• Lumbosacral nerve roots form the cauda equina

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Epidemiology

• Many cases of unrecognized ESCC
• Difficult to define incidence
• Autopsy review studies suggest around 5 of
  cancer patients die with ESCC9

9. Barron, KD, Hirano, A, Araki, S, Terry, RD.
Experiences with metastatic neoplasms involving
the spinal cord. Neurology 1959 991.
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Causes

• Metastatic tumor from any primary site
• Tumors with predilection to metastasize to spinal
  column
• Prostate, breast, and lung carcinoma
• 15-20 of cases
• Renal cell, non-Hodgkins lymphoma, or myeloma
• 5-10 of cases

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• Vertebral metastases are more common than ESCC
• Prostate cancer 90
• Breast Cancer 74
• Lung Cancer 45
• Lymphoma 29
• Renal cell 29
• GI 25

10. Posner, JB. Neurologic Complications of
Cancer. FA Davis, Philadelphia, 1995
69

• ESCC can be initial presentation of a malignancy
• Around 20 of cases
• In many cases diagnosis is made by biopsy of the
  spinal lesion

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Spinal Location10

• Thoracic spine 60
• Lumbosacral spine 30
• Cervical spine 10
• Specific tumor predilection is difficult to define

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Clinical Features
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• Important to recognize
• Early recognition leads to better outcomes
• Efficacy of treatment depends most on patients
  neurological function at presentation
• Median time from symptoms to diagnosis is around
  2 months11
• More than half of patients who present to
  hospital are non-ambulatory

11. Husband, DJ. Malignant spinal cord
compression Prospective study of delays in
referral and treatment. BMJ 1998 31718.
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RED FLAGS..
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First Red Flag Pain

• Usually first symptom12
• 80-90 of the time
• Usually precedes other neurologic symptoms by
  seven weeks
• Increases in intensity
• Severe local back pain
• Aggravated by recumbency
• Distension of venous plexus
• May become radicular

12. Bach, F, Larsen, BH, Rohde, K, et al.
Metastatic spinal cord compression. Occurrence,
symptoms, clinical presentations and prognosis in
398 patients with spinal cord compression. Acta
Neurochir (Wien) 1990 10737.
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Second Red Flag Motor

• Weakness 60-8513
• At or above conus medularis
• Extensors of the upper extremities
• Above the thoracic spine
• Weakness from corticospinal dysfunction
• Affects flexors in the lower extremities
• Patients may be hyperreflexic below the lesion
  and have extensor plantars

13. Greenberg, HS, Kim, JH, Posner, JB. Epidural
spinal cord compression from metastatic tumor
Results with a new treatment protocol. Ann Neurol
1980 8361.
76

• Weakness tends to be symmetrical
• Progressive weakness is followed by lost of gait
  function then paralysis
• The severity of weakness is greatest with
  thoracic metastases

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Third Red Flag Sensory

• Less common than motor findings
• Still present in majority of cases
• Ascending numbness and parathesias

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Fourth Red Flag Bladder and Bowel Function

• Loss is late finding
• Autonomic neuropathy presents usually as urinary
  retension
• Rarely sole finding

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Radiologic Investigation
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• Diagnosis depends on ability to demonstrate a
  mass compressing the thecal sac
• Plain radiographs are not enough
• Historically this involved invasive procedures
• Advent of MRI has allowed non-invasive diagnosis
• Clinical examination is not reliable in
  determining level of lesion

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• Entire imaging of spine is ideal
• Focused CT imaging can miss clinically unapparent
  lesions
• Myelography and MRI are better than plain X-Rays,
  bone scans and CT for diagnosis

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Plain Spine Radiographs

• Easiest and cheapest
• Need large bony destruction or vertebral collapse
  to be diagnostic
• High false negative rate
• Not recommended to confirm diagnosis

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MRI vs. CT Myelography
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• Both image thecal sac and display indentation and
  encircling
• CT myelography involves a lumbar puncture
• Contraindicated in brain metastases,
  thrombocytopenia, or coagulopathy
• Can diagnose leptomeningeal metastases
• Available in Winnipeg in middle of the night

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MRI

• Images whole spine
• High detail
• Spares lumbar puncture
• Patients in pain must lie still

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• Roughly equivalent in terms of sensitivity and
  specificity
• Presently no large comparative studies b/c MRI in
  the US has become so readily available
• MRI standard of care in centers that have access

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Bone Scan

• More sensitive than plain radiograph
• Visualizes entire skeleton
• Can miss neoplasms that do not have increased
  blood flow

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CT Scan alone

• Does not visualize spinal cord and epidural space
  clearly

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Intramedullary Metastases

• Less common
• Often present with hemicord symptoms
• Unilateral weakness below lesion
• Contralateral diminution of pain and temperature
  sensation
• Can progress to bilateral dysfunction

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Radiation Myelopathy

• Can mimic ESCC
• MR imaging can make distinction

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MRI of epidural spinal cord compression in a
women with past history of breast cancer.
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Treatment
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Treatment delays.

• 2 month median delay in treatment from onset of
  back pain11
• 14 day delay in treatment from onset of
  neurological symptoms11

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Why the delay?

• Patient factors
• General practitioner factors
• Hospital factors
• EDUCATION

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Treatment Objectives

• Pain control
• Avoidance of complications
• Preserve or improve neurological function

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Pain management

• Corticosteroids
• Decrease edema
• Opiates
• Needed to decrease pain for comfort and
  examination purposes

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Bed Rest

• No
• No
• No
• No

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Anticoagulation

• Cancer is a hypercoaguable state
• High burden of tumor in metastatic disease
• Possible value in prophylaxis against venous
  thromboembolism
• If patient not mobile subcutaneous heparin or
  compression devices is indicated

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Prevention of Constipation

• Factors
• Autonomic dysfunction
• Limited mobility
• Opiate analgesic
• Risk of perforation
• Masked by corticosteroids
• Bowel regimen needed

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Corticosteroids
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• Part of standard regimen
• Limited data on benefit vs. side effects
• Many studies suggesting lower doses can be
  effective
• No randomized trials

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Corticosteroid Recommendations

• High dose dexamethasone and half dose every three
  days
• Pain with minimal neurological dysfunction can
  have lower dose
• Small asymptomatic lesions can forgo steroids

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Radiation Therapy
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• Definitive choice
• Portal 8 cm wide
• Centered on spine
• Extends one to two vertebral bodies above and
  below the epidural metastasis

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• Relieves pain in most cases
• Post-neurological function usually determines
  response
• Response most associated with tumor type and
  radiosensitivity eg. lymphoma
• Dosing 20 to 40 Gy in 5 to 20 fractions
• Popular
• 30 Gy in 10 fractions

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Surgery

• Changing role
• Historically posterior vertebral decompression
  was done
• No survival benefit with or without radiation15

15. Findlay, GF. Adverse effects of the
management of malignant spinal cord compression.
J Neurol Neurosurg Psychiatry 1984 47761.
107

• Better techniques today allow aggressive approach
• Gross spinal tumor resection with vertebral
  reconstruction now possible
• Experienced surgeon required

108

• Recent controlled trial comparing aggressive
  surgery followed by radiation vs. radiation
  alone16
• Improvement in surgeryrads
• Days remained ambulatory (126 vs. 35)
• Percent that regained ambulation after therapy
  (56 vs. 19)
• Days remained continent (142 vs. 12)
• Less steroid dose, less narcotics
• Trend to increase survival

16. Patchell, R, Tibbs, PA, Regine, WF, et al. A
randomized trial of direct decompressive surgical
resection in the treatment of spinal cord
compression caused by metastasis (abstract). proc
Am Soc Clin Oncol 2003 221.
109
Chemotherapy

• Can be successful in chemosensitive tumors
• Hodgkins lymphoma
• Non-Hodgkins lymphoma
• Neuroblastoma
• Germ cell
• Breast cancer (hormonal manipulation)
• Prostate cancer (hormonal manipulation)

110
Bisphosphonates

• Recommended
• Decrease pathologic fractures in bony disease
• Multiple myeloma
• Breast cancer

111
Prognosis

• Median survival with ESCC is 6 months14
• Ambulatory patients with radiosensitive tumors
  have the best prognosis

14. Sorensen, PS, Borgesen, SE, Rohde, K, et al.
Metastatic epidural spinal cord compression.
Results of treatment and survival. Cancer 1990
651502.
112
Treatment Delay

• Education
• EXPERIENCE
• Education
• EXPERIENCE

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Case 3 Mrs. HC

• ID 75 year old female living alone with no
  significant past medical history
• EC brought to ER by paramedics after neighbor
  called b/c she was found in her apartment
  unresponsive
• No collateral history

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Examination

• Fluctuating level of consciousness
• Vitals normal, no fever
• Dehydrated
• Coarse upper airway sounds
• No other pertinent findings

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Investigations

• CBC normal
• Mildly elevated BUN and Cr
• Normal LFTs
• Standard electrolytes normal

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• Concern of pneumonia
• Chest x-ray ordered

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Multiple Pulmonary Metastasis
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• Calcium checked
• 4.5

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Hypercalcemia
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Symptoms

• Usually nonspecific
• Many times patients present with very high
  calcium level
• Most research done in hyperparathyroidism

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Gastrointestinal

• Constipation is most common15
• Exacerbated or confused with narcotic effects
• Related to autonomic dysfunction
• Anorexia
• Vague abdominal pain
• Rarely can lead to pancreatitis

15. Heath, H 3d. Clinical spectrum of primary
hyperparathyroidism Evolution with changes in
medical practice and technology. J Bone Miner Res
1991 6(Suppl 2)S63.
122
Renal Dysfunction

• Nephrolithiasis
• More common in hyperparathyroidism
• Nephrogenic diabetes insipidus
• Defect in concentrating ability
• Polyuria and polydipsia
• Chronic renal failure
• Longstanding high calcium
• Calcifcation, degeneration, and necrosis of
  tubules

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Neuropsychiatirc

• Anxiety
• Depression
• Cognitive dysfunction
• Delerium
• Psychosis
• Hallucinations
• Somnolence
• Coma

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Cardiovascular

• Short QT interval
• Supraventricualr arrhythmias
• Ventricular arrhythmias

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Physical Findings

• Usually not specific
• Dehydration secondary to diuresis caused by the
  hypercalcemia
• Corneal deposition of calcium
• band keratopathy on slit lamp exam

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Epidemiology

• Occurs in about 10 to 20 of patients with cancer
• Both solid tumors and leukemias
• Most common
• Breast
• Lung
• Multiple myeloma

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Pathogenesis
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Three mechanisms

• Osteolytic metastases with local cytokine release
• Tumor secretion of parathyroid hormone-related
  protein (PTHrP)
• Tumor production of calcitriol

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Osteolytic Metastases
130

• Breast cancer
• Non-small cell lung cancer
• Cytokines released
• Tumor necrosis factor
• Interleukin-1
• Stimulate osteoclast precursor differentiation
  into mature osteoclasts
• Leading to more bone breakdown and release of
  calcium

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PTH-Related Protein

• Most common in patients with non-metastatic
  tumors
• Called humoral hypercalcemia of malignancy
• Secretion of PTH itself is a rare event
• PTHrP binds to same receptor as PTH and
  stimulates adeynylate cyclase activity
• Increased bone resorption
• Increases kidney calcium reabsorption and
  phosphate excretion

132
Calcitriol

• Hodgkins disease (mechanism in majority)
• Non-Hodgkins (mechanism in 1/3)
• Usually responds to glucocorticoid therapy

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Diagnosis
134

• Clinical symptomology with
• History of cancer
• Risk factors for cancer
• Suppressed PTH
• Some centers can test for PTHrP to confirm Dx of
  humoral hypercalcemia
• High PTHrP may predict response to pamidronate16
• Less of a response

16. Gurney, H, Grill, V, Martin, TJ. Parathyroid
hormonerelated protein and response to
pamidronate in tumourinduced hypercalcemia.
Lancet 1993 3411611.
135

• Malignancy must be ruled out in patients that
  present with a very high calcium and no other
  obvious cause

136
Treatment
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Aims

• Lower serum calcium concentration
• Treat complications if present
• Treat underlying disease

138
Volume

• Large volume of normal Saline administration
• Expands intravascular volume
• Increases calcium excretion
• Inhibition of proximal tubule and loop
  reabosrption
• Reduces passive reabsorption of calicum
• Follow fluid status b/c of danger of fluid
  overload

139
Inhibition of Bone Resorption

• Three therapies
• Calcitonin
• Bisphosphonates
• Gallium nitrate
• Historical therapy
• Antitumor antibiotic plicamycin (mithramycin)
• Multiple serious side effects
• No longer manufactured

140
Calcitonin

• Salmon calcitonin
• Increases renal excretion of calcium
• Decreases bone reabsorption by interfering with
  osteoclast maturation
• Weak agent
• Works the fastest

141
Bisphosphonates

• Adsorb to the surface of bone hyroxyapatite
• Interfere with osteoclast activity
• Cytotoxic to osteoclasts
• Inhibit calcium release from bone
• Three commonly used
• Pamidronate
• Zoledronic acid
• Etidronate (1st generation, weaker)

142
Bisphosphonates

• More potent than calcitonin
• Maxium effect occurs in 2 to 4 days
• Trend to use of IV zoledronic acid in the acute
  situation
• Both are can be renal toxic
• More potent than pamidronate
• Administered over a shorter period of time (15
  minutes vs. 2 hours)

143
Prophylactic Bisphosphonates

• Pamidronate use in patients with known lytic
  lesions17
• Less episodes of hypercalcemia
• Less pathologic fractures
• Less pain
• Less spinal cord compression
• Less need for radiation or surgery

17. Hortobagyi, GN, Theriault, RL, Porter, L, et
al for the Protocol 19 Aredia Breast Cancer Study
Group. Efficacy of pamidronate in reducing
skeletal complications in patients with breast
cancer and lytic bone metastases. N Engl J Med
1996 3351785.
144
Newly discovered side effect

• Osteonecrosis of the jaw
• Recent case reports of jaw bone necrosis in
  patients on pamidronate
• EDUCATION needed

145
Gallium Nitrate

• Effective
• More potential for nephrotoxicity
• Rarely used

146
Dialysis

• Last resort
• Dialysis fluid with little or no calcium is
  effective
• Useful when patients cant tolerate large volume
  resuscitation
• If calcium needs to be correct emergently

147
Recommendations in symptomatic situation

• Volume expansion
• Salmon calcitonin
• IV zoledronic acid or pamidronate
• Close follow up of calcium level and symptoms

148
Transitions in Treatment
149
Chemotherapy

• Two roles
• Direct treatment of cancer
• Palliation of symptoms

150
Palliative Chemotherapy

• Goal is not cure
• Goals
• Control of tumor
• Preservation of function
• Help tumor symptoms
• Pain
• Dsypnea
• Pruritis
• Poor appetite
• Weight loss

151
Fine Balance

• Chemotherapy can be very toxic
• Ratio benefit vs. toxicity
• Host factors and tumor factors
• Delicate balance in palliative situation
• Want medications that affect tumor but do not
  heavily affect host

152
Psychology of Cancer

• Psychological evolution during cancer treatment
• Many people have fought very hard with their
  disease
• Chemotherapy for relief not cure can be
  difficult concept for patients
• ART of medicine

153
Evolution

• Chemotherapeutic protocols that have less side
  effects
• molecular targeted therapies
• Attack tumor specifically
• Less effect on host

154

• Breast cancer
• Colon Cancer
• Prostate cancer
• Lung cancer

155
Breast Cancer

• Aromatase inhibitors for ER positive tumors
• Anastrozole, Letrozole, Exemestane
• Trastuzumab (Herceptin)
• Humanized monoclonal antibody targeting Her-2/neu
  protein on breast cancer cells
• Inhibits growth factor signal transduction
• Tolerated quite well

156
Colon Cancer

• Capecitabine (Xeloda)
• Oral drug that is transformed into 5-FU with
  three enzymatic reactions
• Final enzyme is at higher levels in tumor cells
• Contributes to drugs less toxic side effect
  profile
• Less stomatitis, less myelosupression

157
Targeted GI Therapies

• Bevacizumab
• Monoclonal antibody to vascular endotheial growth
  factor receptor
• Some cardiac toxicity
• Cetuximab
• Monoclonal antibody to human epidermal growth
  factor receptor
• Skin toxicity

158
Prostate Cancer

• LHRH analogues
• Leuprolide (Lupron)
• Goserelin (Zoladex)
• Stop testosterone production with limited side
  effects

159
Lung Cancer

• In stage IV disease patients who receive
  Cisplatin based doublet chemotherapy live longer
  and feel better than best supportive care
• Hard to balance side effects

160
Gefitinib (Iressa)

• Targets epidermal growth factor receptor
  (tyrosine kinase small molecule inhibitor)
• May have a role in the palliation of advanced non
  small cell lung cancer patients

161
Palliative Care Debate

• Do not accept any patient on active therapy
• This needs to be further elucidated
• Patients being palliated with chemotherapy or
  targeted therapies still have other palliative
  care issues and needs
• Should a patient still on Xeloda for breast or
  colon cancer not be admitted to St. Boniface 8A?

162
Thank you
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Any questions?