Emergencies in the cancer pt may be classified into three categories: effects from tumor expansion, metabolic or hormonal effects mediated by tumor products, and treatment complications.
STRUCTURAL/OBSTRUCTIVE ONCOLOGIC EMERGENCIES
The most common problems are superior vena cava syndrome; pericardial effusion/tamponade; spinal cord compression; seizures (Chap. 181) and/or increased intracranial pressure; and intestinal, urinary, or biliary obstruction. The last three conditions are discussed in Chap. 331 in HPIM-19.
SUPERIOR VENA CAVA SYNDROME
Obstruction of the superior vena cava reduces venous return from the head, neck, and upper extremities. About 85% of cases are due to lung cancer; lymphoma and thrombosis of central venous catheters are also causes. Pts often present with facial swelling, dyspnea, and cough. In severe cases, the mediastinal mass lesion may cause tracheal obstruction. Dilated neck veins and increased collateral veins on anterior chest wall are noted on physical examination. Chest x-ray (CXR) documents widening of the superior mediastinum; 25% of pts have a right-sided pleural effusion.
TREATMENT: SUPERIOR VENA CAVA SYNDROME
Radiation therapy is the treatment of choice for non-small-cell lung cancer; addition of chemotherapy to radiation therapy is effective in small-cell lung cancer and lymphoma. Symptoms recur in 10–30% and can be palliated by venous stenting. Clotted central catheters producing this syndrome should be removed and anticoagulation therapy initiated.
Accumulation of fluid in the pericardium impairs filling of the heart and decreases cardiac output. Most commonly seen in pts with lung or breast cancers, leukemias, or lymphomas, pericardial tamponade may also develop as a late complication of mediastinal radiation therapy (constrictive pericarditis). Common symptoms are dyspnea, cough, chest pain, orthopnea, and weakness. Pleural effusion, sinus tachycardia, jugular venous distention, hepatomegaly, and cyanosis are frequent physical findings. Paradoxical pulse, decreased heart sounds, pulsus alternans, and friction rub are less common with malignant than nonmalignant pericardial disease. Echocardiography is diagnostic; pericardiocentesis may show serous or bloody exudate, and cytology usually shows malignant cells.
TREATMENT: PERICARDIAL EFFUSION/TAMPONADE
Drainage of fluid from the pericardial sac may be lifesaving until a definitive surgical procedure (pericardial stripping or window) can be performed.
Primary spinal cord tumors occur rarely, and cord compression is most commonly due to epidural metastases from vertebral bodies involved with tumor, especially from prostate, lung, breast, lymphoma, and myeloma primaries. Pts present with back pain, worse when recumbent, with local tenderness. Loss of bowel and bladder control may occur. On physical examination, pts have a loss of sensation below a horizontal line on the trunk, called a sensory level, which usually corresponds to one or two vertebrae below the site of compression. Weakness and spasticity of the legs and hyperactive reflexes with upgoing toes on Babinski testing are often noted. Spine radiographs may reveal erosion of the pedicles (winking ...