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INTRODUCTION

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. 184) and/or increased intracranial pressure; and intestinal, urinary, or biliary obstruction. The last three conditions are discussed in Chap. 71 in HPIM-20.

SUPERIOR VENA CAVA SYNDROME

Obstruction of the superior vena cava reduces venous return from the head, neck, and upper extremities (Fig. 27-1). About 85% of cases are due to lung cancer; lymphoma and thrombosis of central venous catheters are other 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.

FIGURE 27-1

Superior vena cava syndrome (SVCS). A. Chest radiographs of a 59-year-old man with recurrent SVCS caused by non-small-cell lung cancer showing right paratracheal mass with right pleural effusion. B. Computed tomography of same pt demonstrating obstruction of the superior vena cava with thrombosis (arrow) by the lung cancer (square) and collaterals (arrowheads). C. Balloon angioplasty (arrowhead) with stent (arrow) in same pt.

TREATMENT

TREATMENT Superior Vena Cava Syndrome

Radiation therapy is the treatment of choice for non-small-cell lung cancer and other solid tumors; chemotherapy is effective in small-cell lung cancer, lymphoma, and germ cell tumors. Symptoms recur in 10–30% of pts and can be palliated by venous stenting. Clotted central catheters producing this syndrome should be removed and anticoagulation therapy initiated.

PERICARDIAL EFFUSION/TAMPONADE

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

TREATMENT Pericardial Effusion/Tamponade

Drainage of fluid from the pericardial sac may be lifesaving ...

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