Thoracic Oncological Emergencies

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Thoracic Oncological Emergencies

• Carrie Featherstone
• Consultant Clinical Oncologist
• Beatson West of Scotland Cancer Centre

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Thoracic Oncological Emergencies

• Airway
• Tracheal occlusion (extrinsic and intrinsic)
• Breathing
• Haemoptysis
• Breathlessness
• Effusions
• Circulation
• SVCO
• Pericardial effusions

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Thoracic Oncological Emergencies

• Acute
• Oxygen
• Airway
• Nebulised Saline/ B-agonists/Adrenaline
• Intravenous steroids
• Diuretics
• BiPAP
• ??Heliox

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Thoracic Oncological Emergencies

• Acute
• Oxygen
• Airway
• Nebulised Saline/ B-agonists/Adrenaline
• Intravenous steroids
• Diuretics
• BiPAP
• ??Heliox
• NOT STANDARD ASTHMA/COPD
• What now and who

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Who now?
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cardiologist
anaesthetist
Cardiothoracic surgeon
radiology
otolaryngology
oncologist
respiratory
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Airway assessment

• Level of obstruction
• Oral cavity
• Above or below vocal cords
• Tracheal
• Degree of Obstruction
• Presumably subtotal
• Hopefully secretions/oedema

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Intrinsic and Extrinsic Compression
Bronchoscopic assessment can be therapeutic and
diagnostic
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Extrinsic compression/Intrinsic obstruction

• Extrinsic
• Head and neck cancer
• Thyroid Cancer
• Lung cancer-Small cell or non-small cell
• Lymphoma
• Thymoma (myasthenia)

• Intrinsic
• Tracheal
• adenoid cystic
• non-small cell lung cancer

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Specific therapies

• Bronchoscopic
• Surgery
• Chemotherapy
• External beam radiotherapy/Brachytherapy

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Specific therapy-endobronchial

• Mechanical debulking
• Laser
• Electrocautery
• Argon
• PDT
• (diagnostic tissue/ebus)
• Mostly fast and effective
• complications

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Specific Therapy-stent
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Specific therapy-Surgery

• Very few but important as maybe curative
• Diagnostic

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Specific therapy-Chemotherapy/radiotherapy

• Lymphoma
• Small cell lung cancer
• Non small cell
• Can be given in ITU
• Can respond quickly but dependent on histology
• Different prognosis

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Central airways obstruction
Acute management/diagnosis
Dilation/coring Laser photoresection Electrocauter
y Argon plasma coagulation Photodynamic Brachyther
apy External beam radiotherapy
Dilation Stent Brachytherapy External beam
radiotherapy
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Breathing

• Haemoptysis
• Tranexamic Acid
• Laser
• Radiotherapy
• Effusion
• Aspirate
• Pleurodesis

• Breathlessness
• Oxygen
• Nebs
• Steroids
• Morphine/Oxycodone
• Anaemia
• Radiotherapy/Chemotherapy

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Circulation
Superior vena caval obstruction
Pericardial effusions
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Superior vena caval obstruction

• Compression of the superior vena cava (SVC) by
  either a tumour arising in the right main or
  upper lobe bronchus or mediastinal
  lymphadenopathy (usually right paratracheal or
  precarinal).
• Malignancy is the commonest cause (gt90)
• Other causes include thrombus, iv catheters, ext
  compression (ruptured thoracic aneurysm and
  trauma)

• Dexamethasone
• Anticoagulate
• Stent
• Anticancer therapy

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Results of systematic review

• C/RT (n777)
• mean age 56-66 (29-88)
• QoL none
• RR 60-77
• Rapidity of response
• 7, 10 or 15 days
• Median 14 days
• 75 by 3 weeks

• Stent (n159)
• Mean age 58-72 (37-85)
• Not split by tumour type
• RR 95 (84-100)
• Rapidity of response
• facial oedema 24 hours
• Arm oedema 72 hours

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Results of systematic review

• C/RT
• Relapse
• SCLC(73 of cases)
• recurrence in 16.7
• NSCLC (20 of cases) recurence in 18.5
• Relapse 1-16 months after initial Rx
• Median survival 2-9.5 months

• Stent
• Relapse due to thrombus or tumour ingrowth
• Relapse 10.7
• Relapse median 1-2 months range 3 days to 8
  months
• Median survival 1.5-6.5 months

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Implications for practice

• Need anti-cancer treatment in both SCLC and NSCLC
  to maximise survival, to improve maintain QoL
• SCLC and lymphoma
• stent on relapse
• or if SVCO persists following initial
  treatment)
• NSCLC/other
• stent on initial presentation on
  relapse/persistence

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Pericardial Effusion

• Pericardiocentesis
• Pericardial Window
• Intrapericardial sclerosant/chemo
• Systemic therapy

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cardiologist
anaesthetist
Cardiothoracic surgeon
radiology
otolaryngology
oncologist
respiratory