The presentation was made at Oncology Nursing Conference held at All India Institute of Medical Sciences (AIIMS), New Delhi in March 2016.

1. STRUCTURAL ONCOLOGICAL
EMERGENCIES
02.03.2016
Dr Alok Gupta
Assistant Professor
Medical Oncology
AIIMS, New Delhi

5. 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
Analgesics.
– Pain beginning to wake him at night
– More pain with recumbancy
– Some shooting pains down right leg

6. On examination
• vitals stable, no fever
• CVS, Respiratory, GI, GU exams reported as
normal
• Back exam
– Inspection: normal
– Palpation: some pain in L1
– Movement: normal
– Some pain in right leg with straight leg raising

7. Investigation in Clinic
• Lumbar Spine X-ray
– Some age related degeneration

8. Diagnosis
• Sciatica vs. Back strain
• Treatment:
– NSAIDS
– Few days of bed rest

9. The story continues…
• Mr. EC’s 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 Emergency room

11. Spinal Cord Compression

14. 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-Hodgkin’s lymphoma, or
myeloma
– 5-10% of cases

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

16. Spinal Location
• Thoracic spine: 60%
• Lumbosacral spine: 30%
• Cervical spine: 10%
• Specific tumor predilection is difficult to
define

17. First Red Flag: Pain
• Usually first symptom12
– 80-90% of the time
• Usually precedes other neurologic symptoms
by 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; 107:37.

18. Second Red Flag: Motor
• Weakness: 60-85%13
• 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; 8:361.

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

20. Third Red Flag: Sensory
• Less common than motor findings
• Still present in majority of cases
• Ascending numbness and paresthesias

21. Fourth Red Flag: Bladder and Bowel
Function
• Late finding
• Autonomic neuropathy presents usually as
urinary retension
– Rarely sole finding

22. Treatment Objectives
• Pain control
• Avoidance of complications
• Preserve or improve neurological function

23. Pain management
• Corticosteroids
– Decrease edema
• Opiates
– Needed to decrease pain for comfort and
examination purposes

24. Treatment of underlying malignancy

25. Chemotherapy
• Can be successful in chemosensitive tumors
– Hodgkin’s lymphoma
– Non-Hodgkin’s lymphoma
– Neuroblastoma
– Germ cell
– Breast cancer (hormonal manipulation)
– Prostate cancer (hormonal manipulation)

26. Bisphosphonates
• Recommended
• Decrease pathologic fractures in bony disease
– Multiple myeloma
– Breast cancer

27. • 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
Radiation

28. Surgery
• Changing role
• Historically posterior vertebral decompression
was done
• Better techniques today allow aggressive
approach
• Gross spinal tumor resection with vertebral
reconstruction now possible
15. Findlay, GF. Adverse effects of the management of malignant spinal cord
compression. J Neurol Neurosurg Psychiatry 1984; 47:761.

31. Mr. SV
• ID: 65 year old male with Hx 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

32. On Physical Examination
• Inspection:

33. 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

34. Chest X-Ray…

35. right pleural effusion

36. T1-weighted axial MRI demonstrating paratracheal soft
tissue mass that invades into the SVC

37. Superior Vena Cava Syndrome

39. Signs and Symptoms
• Facial swelling or head fullness
– exacerbated by bending forward or lying down
• Cough
• Arm edema
• Cyanosis

40. 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; 7:61.

44. Thank You