Oncologic emergencies for the internist - Cleveland Clinic Journal of ...

More documents

Recommendations

Info

ONCOLOGIC EMERGENCIESKRIMSKY AND COLLEAGUESExpertsrecommendpursuing atissue diagnosisin superior venacava syndrome60-mg or a 90-mg dose over at least 2 hours. 18Approximately 60% of patients respond to a60-mg dose and nearly 100% to a 90-mgdose. 19 Pamidronate usually takes approximately12 to 48 hours to produce an initialresponse, and the response is sustained for anaverage of about 2 weeks. 20Calcitonin is frequently used in additionto bisphosphonates because it has a rapidonset of effect: within 2 to 4 hours of administration.21 Its main drawbacks are hypersensitivityreactions and tachyphylaxis; the latterusually develops within 3 days.Gallium nitrate and plicamycin are usedinfrequently because of their toxicity.Steroids are frequently helpful in theshort term, especially in sensitive tumors suchas lymphoma and myeloma.Dialysis remains an option for those whocannot tolerate a saline load.■ SUPERIOR VENA CAVA SYNDROMESuperior vena cava syndrome is relatively rare,affecting 2.4% to 4.2% of lung cancerpatients, who account for 65% of all cases. 22Small cell lung cancer is the most frequentcause of the syndrome because it has apredilection for the central region of thelungs. 23 Lymphoma accounts for 8% of cases,and breast cancer and other mediastinalmetastatic lesions account for 10%. 22Of note: several nonmalignant diseasessuch as granulomatous and fibrosing mediastinitis,goiters, and aortic aneurysms can alsocause superior vena cava syndrome.Features of superior vena cava syndromeSuperior vena cava syndrome results from anincrease in central venous pressure caused byvena caval obstruction. Typically this producescough, dyspnea, and dysphagia combinedwith swelling and discoloration of theneck, face, or upper extremities. Dependingon the site of the disease, both vocal cordparalysis and Horner syndrome (sinking in ofthe eyeball, ptosis of the upper eyelid, elevationof the lower lid, constriction of the pupil,narrowing of the palpebral fissure, andanhidrosis and flushing of the affected side ofthe face; caused by compression of sympatheticnerves) can occur.Treatment of superior vena cava syndromeInitial treatment consists of elevating thehead of the bed and giving diuretics and corticosteroids.However, corticosteroids are moreuseful when the cause of the obstruction islymphoma rather than lung cancer.Chemotherapy and radiation therapy.Unless tracheal obstruction is present orimpending, superior vena cava syndrome isnot immediately life-threatening, and mostexperts recommend pursuing a tissue diagnosisso that specific treatment can be given for theprimary tumor alongside treatment for thesymptoms. 22Both primary chemotherapy and radiationare important components of therapy. In smallcell lung cancer, Chan et al 24 found no differencein the response rate in patients whoreceived chemotherapy compared with radiationtherapy. The recurrence rate of superiorvena cava syndrome depends on the type oftumor causing the obstruction. In large celllymphoma the high risk of recurrence withchemotherapy resulted in a recommendationto use radiation therapy. 25Intravenous stenting can relieve symptoms,particularly dyspnea, for most patients.Anticoagulation. Thrombus formationoccurs in up to 50% of patients with superiorvena cava syndrome. In a small study,Adelstein et al 26 attempted prophylaxis withfull doses of heparin and warfarin but found itconferred no survival advantage when treatedpatients were compared with 10 historicalcontrols. However, anticoagulation is stillused for symptom relief regardless of effect onsurvival.■ SPINAL CORD COMPRESSIONSpinal cord compression is not immediatelylife-threatening unless it involves level C3 orabove, but it may lead to profound, permanentmorbidity. Paraplegia or loss of sphincter controlor both not only diminishes a patient’squality of life but also predisposes to furthercomplications such as venous thrombosis,decubitus ulcers, and urinary obstruction.Spinal cord compression occurs at sometime in approximately 5% of all cancerpatients, 27 most often in carcinomas of theprostate, lung, and breast.214 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 69 • NUMBER 3 MARCH 2002
ONCOLOGIC EMERGENCIESKRIMSKY AND COLLEAGUESMRI withoutcontrast is thebest test forspinal cordcompressionFeatures of spinal cord compressionPain is the primary symptom and iseventually reported in 96% of patients withspinal cord compression. 28 The pain may beacute or may gradually increase over weeks.Although the pain is similar to that of discdisease, one potential difference is that thepain of spinal cord compression can beincreased in the supine position anddecreased when upright.Other signs and symptoms are weakness,sensory deficits, and autonomic dysfunction.Diagnosis of spinal cord compressionIt is often difficult to decide whether a patientwith back pain should be thoroughly evaluatedto exclude spinal cord compression, but apatient with known or suspected metastaticdisease (especially tumor types with a tropismfor bone) presenting with a new pain patternor a neurologic deficit deserves meticulousevaluation.Magnetic resonance imaging (MRI)without contrast is the best and most costeffectivetest. 29Several nonmalignant conditions, suchas osteoporotic compression fractures andspinal abscesses, may also cause spinal cordcompression and must be diagnosed accurately,as their treatment and prognosis aremarkedly different.Treatment of spinal cord compressionNeurologic compromise can be rapid; therefore,treatment must begin quickly after diagnosis.Corticosteroids are a critical part of theinitial management because they decreaseedema that may compress vasculature or thenerves directly and lead to permanent injury.Although dosages are debated, the minimumis dexamethasone 10 mg (or an equivalent) byintravenous bolus followed by 4 mg intravenouslyevery 6 hours.Radiation therapy. Carcinomas of theprostate, lung, and breast are more predictablyresponsive to radiotherapy than are othertypes of tumors. However, a patient presentingwith any type of malignant spinal cord compressionshould also seen urgently by a radiationoncologist.Chemotherapy may be an option forextremely chemosensitive tumors such aspediatric neuroblastomas.Surgery is the remaining option if a tissuediagnosis is needed, the area has previouslyreceived maximal irradiation, spinal stabilizationis needed, or other treatments are notworking.■ STROKES AND SEIZURESStrokes and seizures are common in cancerpatients. Strokes occur in 7% of all cancerpatients 30 and are equally split between hemorrhagicand thrombotic subtypes. Seizuresoccur in 2.7% of patients with cerebral metastasesand in 1.8% of cancer patients withoutbrain metastases. 31Initial treatment of strokes and seizures incancer patients is the same as in patients withoutcancer. After initial stabilization, specifictreatment of the tumor such as radiotherapyor steroids should be started. In addition,patients with thrombotic strokes might beconsidered candidates for antiplatelet, anticoagulation,or thrombolytic therapy.Patients with cerebral metastasis withouta history of seizure should be advised not todrive or engage in activities in which an unexpectedseizure could harm them or others.Randomized studies have shown no benefitfrom prophylactic anticonvulsants, 32 withpossible exceptions for melanoma brainmetastases or leptomeningeal metastases.■ TREATMENT-RELATED EMERGENCIESExtravasation of chemotherapeutic drugsExtravasation—leakage of chemotherapeuticdrugs into the skin— results in pain, redness,swelling, and even necrosis. Its reported incidenceranges from 0.1% to 6.5% ofchemotherapy infusions. 33 Although thesereactions are usually seen in an oncologic setting,they are increasingly being seen in theprimary care physician’s office as morepatients undergo home infusion therapy.Occasionally, symptoms may develophours or days after the initial insult. The delaycan be caused by endocytolysis, in which asmall amount of drug kills and lyses cells atthe injection site and then moves on repeat-216 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 69 • NUMBER 3 MARCH 2002
Page 1 and 2: CANCER DIAGNOSIS AND MANAGEMENTWILL
Page 3: Not available for online publicatio
Page 7 and 8: ONCOLOGIC EMERGENCIESKRIMSKY AND CO

Oncologic emergencies for the internist - Cleveland Clinic Journal of ...

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?