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1. Oncologic EmergenciesOncologic Emergencies
Noel Rowan, MD, FACPNoel Rowan, MD, FACP
Comprehensive Cancer CenterComprehensive Cancer Center
Las Vegas, NevadaLas Vegas, Nevada
cccnevada.comcccnevada.com

2. Oncologic EmergenciesOncologic Emergencies
 CardiovascularCardiovascular
 Pericardial TamponadePericardial Tamponade
 Superior Vena Cava SyndromeSuperior Vena Cava Syndrome
 Central Nervous System EmergenciesCentral Nervous System Emergencies
 Increased Intracranial PressureIncreased Intracranial Pressure
 Spinal Cord CompressionSpinal Cord Compression
 GastrointestinalGastrointestinal
 Bowel ObstructionBowel Obstruction
 Bowel PerforationBowel Perforation
 AscitesAscites
 Esophageal Obstruction and PerforationEsophageal Obstruction and Perforation

3. Oncologic EmergenciesOncologic Emergencies
Hematologic EmergenciesHematologic Emergencies
DICDIC
LeukostasisLeukostasis
ThrombocytopeniaThrombocytopenia
Infectious EmergenciesInfectious Emergencies
Sepsis in the leukopenic patientSepsis in the leukopenic patient
Disseminated Viral InfectionsDisseminated Viral Infections
Fungal and Parasitic DiseasesFungal and Parasitic Diseases

4. Oncologic EmergenciesOncologic Emergencies
Metabolic EmergenciesMetabolic Emergencies
HyperuricemiaHyperuricemia
HypercalcaemiaHypercalcaemia
HypoglycemiaHypoglycemia
Lactic AcidosisLactic Acidosis
Tumor Lysis SyndromeTumor Lysis Syndrome
Orthopedic EmergenciesOrthopedic Emergencies
Pathologic FracturePathologic Fracture

5. Oncologic EmergenciesOncologic Emergencies
 WaldenstromsWaldenstroms
 Hyperviscosity SyndromeHyperviscosity Syndrome
 PlasmaphoresisPlasmaphoresis

9. Oncologic EmergenciesOncologic Emergencies
 Renal EmergenciesRenal Emergencies
 Ureteral Obstruction – Pelvic TumorsUreteral Obstruction – Pelvic Tumors
 Respiratory EmergenciesRespiratory Emergencies
 Airway ObstructionAirway Obstruction
 PneumothoraxPneumothorax
 EffusionEffusion
 Symptomatic EmergenciesSymptomatic Emergencies
 PainPain
 VomitingVomiting
 MucositisMucositis
 DyspneaDyspnea

10. Pericardial TamponadePericardial Tamponade
 MechanismMechanism
 Fluid in pericardial sac due to metastaic tumorFluid in pericardial sac due to metastaic tumor
 Post X-ray treatment – 4000 rPost X-ray treatment – 4000 r
 Decreased CO because of decreased venous returnDecreased CO because of decreased venous return
 SymptomsSymptoms
 DyspneaDyspnea
 ConfusionConfusion
 ComaComa
 Distended neck veinsDistended neck veins
 Pulses ParadoxesPulses Paradoxes
 CHFCHF

11. Pericardial TamponadePericardial Tamponade
DiagnosisDiagnosis
Enlarged heartEnlarged heart
CXR – sac-like heartCXR – sac-like heart
EchoEcho
TreatmentTreatment
PercardiocentesisPercardiocentesis
Catheter SFUCatheter SFU
X-Ray TherapyX-Ray Therapy
Surgery – window vs. pericardiectomySurgery – window vs. pericardiectomy

12. SVC SyndromeSVC Syndrome
 MechanismMechanism
 Masse(s) in chest/mediastinum compress SVCMasse(s) in chest/mediastinum compress SVC
 LymphomaLymphoma
 Hodgkin'sHodgkin's
 LungLung
 BreastBreast
 SymptomsSymptoms
 Facial EdemaFacial Edema
 Periorbital EdemaPeriorbital Edema
 Cyanosis – speed determines collateral pattern onCyanosis – speed determines collateral pattern on
chest wallchest wall

13. SVC SyndromeSVC Syndrome
DiagnosisDiagnosis
Chest X-ray – right sided mediastinal massChest X-ray – right sided mediastinal mass
Radionucleotide SVC gramRadionucleotide SVC gram
Tissue Diagnosis – may have to waitTissue Diagnosis – may have to wait
TherapyTherapy
X-ray therapy – high doseX-ray therapy – high dose
SteroidsSteroids
ChemotherapyChemotherapy

19. Increased IntracranialIncreased Intracranial
PressurePressure
 MechanismMechanism
 Primary Brain TumorPrimary Brain Tumor
 Metasitic TumorMetasitic Tumor
 MeningesMeninges
 DiagnosisDiagnosis
 HeadachesHeadaches
 Personality ChangesPersonality Changes
 LethargyLethargy
 ComaComa
 PapilledemaPapilledema
 Stiff neckStiff neck
 Fixed pupil – tentorial herniationFixed pupil – tentorial herniation
 CT/MRI of BrainCT/MRI of Brain
 LP - cellsLP - cells

20. Increased IntracranialIncreased Intracranial
PressurePressure
TreatmentTreatment
SteroidsSteroids
Crainotomy – primaryCrainotomy – primary
Whole Brain Irradiation – 3000 r – 2 weeksWhole Brain Irradiation – 3000 r – 2 weeks
Meningeal – MTX or ARA C ITMeningeal – MTX or ARA C IT

21. Spinal Cord CompressionSpinal Cord Compression
MechanismMechanism
Lymphoma – mediastinal or retroperitonealLymphoma – mediastinal or retroperitoneal
nodes or mets from vertebral bodiesnodes or mets from vertebral bodies
SymptomsSymptoms
Back Pain – syndrome insidiousBack Pain – syndrome insidious
Paraplegia – bowel and bladder dysfunctionParaplegia – bowel and bladder dysfunction
12 – 24 hr progression12 – 24 hr progression
Permanent when completedPermanent when completed

22. Spinal Cord CompressionSpinal Cord Compression
DiagnosisDiagnosis
Myleogram or MRIMyleogram or MRI
TreatmentTreatment
SteroidsSteroids
Decompression LaminectomyDecompression Laminectomy
ChemotherapyChemotherapy
X- ray therapyX- ray therapy

24. HyperuricemiaHyperuricemia
MechanismMechanism
Following initial therapy of sensitive tumors –Following initial therapy of sensitive tumors –
gout – renal tubular damage and acute renalgout – renal tubular damage and acute renal
failurefailure
DiagnosisDiagnosis
Monitor serum uric acid levelsMonitor serum uric acid levels
Uric acid precipitate stones radiolucentUric acid precipitate stones radiolucent

25. HyperuricemiaHyperuricemia
TherapyTherapy
DiuresisDiuresis
AlkalizationAlkalization
DialysisDialysis
Prophylaxis -- Allopurinol 600 mg daily 2 daysProphylaxis -- Allopurinol 600 mg daily 2 days
before treatment and continue for 2 weeksbefore treatment and continue for 2 weeks
after treatmentafter treatment

26. HypercalcaemiaHypercalcaemia
 MechanismMechanism
 Mets to bone, breast, lung, renalMets to bone, breast, lung, renal
 MyelomaMyeloma
 Ectopic parathyroid hormone productionEctopic parathyroid hormone production
 SymptomsSymptoms
 NauseaNausea
 VomitingVomiting
 ConstipationConstipation
 Urinary frequencyUrinary frequency
 LethargyLethargy
 ConfusionConfusion
 ComaComa
 DeathDeath

27. HypercalcaemiaHypercalcaemia
DiagnosisDiagnosis
Serum Calcium level - correct for albuminSerum Calcium level - correct for albumin
TherapyTherapy
Hydration - salineHydration - saline
Diuresis - LasixDiuresis - Lasix
MithramycinMithramycin
SteroidsSteroids

30. Tumor Lysis SyndromeTumor Lysis Syndrome
MechanismMechanism
Rapid necrosis of tumor cellsRapid necrosis of tumor cells
Release of massive intracellular material intoRelease of massive intracellular material into
the circulation -- metabolic loadthe circulation -- metabolic load
AscitiesAscities
Renal impairmentRenal impairment
ArrhythmiasArrhythmias

31. Tumor Lysis SyndromeTumor Lysis Syndrome
DiagnosisDiagnosis
Potassium increasedPotassium increased
Phosphate increasedPhosphate increased
Calcium decreasedCalcium decreased
Uric Acid increasedUric Acid increased
AcidosisAcidosis
AzotemiaAzotemia

32. Tumor Lysis SyndromeTumor Lysis Syndrome
TreatmentTreatment
Correct acidosis, potassium, uric acidCorrect acidosis, potassium, uric acid
DiuresisDiuresis
Dialysis if neededDialysis if needed
Prompt treatment can prevent deathPrompt treatment can prevent death

33. Mucositis/EsophagitisMucositis/Esophagitis
MechanismMechanism
Radiation therapyRadiation therapy
ChemotherapyChemotherapy
Antitumor antibioticsAntitumor antibiotics
AntimetabolicsAntimetabolics
SymptomsSymptoms
PainPain
VomitingVomiting

34. Mucositis/EsophagitisMucositis/Esophagitis
TreatmentTreatment
HydrationHydration
Mycostatin/Magic MouthwashMycostatin/Magic Mouthwash
Kepivance (palifermin) 60 mcg/kg/d for 3 daysKepivance (palifermin) 60 mcg/kg/d for 3 days
before and after chemobefore and after chemo
Gelclair (coating agent)Gelclair (coating agent)
Recombinant Keratiocyte Growth FactorRecombinant Keratiocyte Growth Factor

35. AntibioticsAntibiotics
AntiviralsAntivirals
OtherOther
Morphine PatchMorphine Patch
TPN/nutritional supportTPN/nutritional support
Mucositis/EsophagitisMucositis/Esophagitis

36. Avastin (Bevacizumab)Avastin (Bevacizumab)
Erbitux (Cetuximab)Erbitux (Cetuximab)
Tarceva (Erlotinib)Tarceva (Erlotinib)
Iressa (Gefitinib)Iressa (Gefitinib)
Gleevec (Imatinib)Gleevec (Imatinib)
Rituxan (Retuximab)Rituxan (Retuximab)
Others…..Others…..
New DrugsNew Drugs
New ComplicationsNew Complications

37.  AvastinAvastin
 Abdominal PerforationAbdominal Perforation
 Wound dehiscence after surgeryWound dehiscence after surgery
 Stroke riskStroke risk
 ErbituxErbitux
 Acneform Rash 90%! (10% severe)Acneform Rash 90%! (10% severe)
 Rituxan (Anti CD-20 antibody)Rituxan (Anti CD-20 antibody)
 Anaphylactic reactionAnaphylactic reaction
 TarcevaTarceva
 Acneform Rash, pulmonary toxicityAcneform Rash, pulmonary toxicity
 IressaIressa
 Rash, pulmonary toxicityRash, pulmonary toxicity
New DrugsNew Drugs
New ComplicationsNew Complications

38. Acniform RashAcniform Rash
New DrugsNew Drugs
New ComplicationsNew Complications