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Oncologic Urgencies and Emergencies patients. Following metastasectomy, data would support the use of adjuvant systemic therapy to improve overall outcome. ¢ Melanoma is a highly curable disease when detected and treated early with a wide local excision. ¢ Nodal metastases are uncommon in thin melanomas (Breslow depth less than 0.8 mm) and need not be assessed. ¢ More than one half of patients have melanoma that har- bors a BRAF mutation, which may respond to the BRAF inhibitors combined with MEK inhibitors. e The use of immune checkpoint inhibitors has shown significant improvements in survival for patients with regional nodal and metastatic melanoma. Follow-up All patients should be encouraged to perform skin self- examinations as well as receive regular skin evaluations by a dermatologist for life every 6 months. Patients with early-stage FIGURE 10. Superior vena cava (SVC) syndrome often presents on chest CT melanoma need not undergo routine blood testing or imaging scan with bronchial obstruction due to mediastinal mass (b/ue arrow) and SVC compression (red arrow). studies in the absence of signs or symptoms. thoracentesis (if a pleural effusion is present), or biopsy of a Oncologic Urgencies and peripheral area of lymphadenopathy. Complication rates of these procedures are usually low. Emergencies Cancers that are highly responsive to chemotherapy, such as small cell lung cancer, lymphoma, and germ cell cancers, are Structural Urgencies and treated with initial chemotherapy. Non-small cell lung cancer Emergencies may be treated with initial chemotherapy, radiation therapy, or Superior Vena Cava Syndrome both. Initial surgery may be required in thymoma and meso- Obstruction of the superior vena cava (SVC), or SVC syndrome, thelioma. Although glucocorticoids and loop diuretics are

Oncologic Urgencies and peripheral area of lymphadenopathy. Complication rates of these procedures are usually low. Emergencies Cancers that are highly responsive to chemotherapy, such as small cell lung cancer, lymphoma, and germ cell cancers, are Structural Urgencies and treated with initial chemotherapy. Non-small cell lung cancer Emergencies may be treated with initial chemotherapy, radiation therapy, or Superior Vena Cava Syndrome both. Initial surgery may be required in thymoma and meso- Obstruction of the superior vena cava (SVC), or SVC syndrome, thelioma. Although glucocorticoids and loop diuretics are is usually caused by malignancies with large mediastinal often used, there is no clear evidence of their effectiveness. If masses. Lung cancer accounts for almost 75% of cases of SVC thrombosis is present, anticoagulation should be added. syndrome, with lymphoma and metastatic disease each caus- Treatment of curable malignancies should not be com- ing approximately 10%; rarer tumors, such as germ cell tumor, promised by the presence of SVC syndrome, as prognosis is not thymoma, or mesothelioma, account for the remainder. otherwise altered.

syndrome, with lymphoma and metastatic disease each caus- Treatment of curable malignancies should not be com- ing approximately 10%; rarer tumors, such as germ cell tumor, promised by the presence of SVC syndrome, as prognosis is not thymoma, or mesothelioma, account for the remainder. otherwise altered. Patients typically present with edema of the head, neck, and arms, often with cyanosis, plethora, and distended cuta- ¢ Most patients with superior vena cava syndrome do not neous collateral vessels. They may have headache, cough, require emergency intervention; a tissue diagnosis dyspnea, hoarseness, or syncope. The severity of symptoms should be obtained first with treatment directed by the depends on the degree of narrowing of the SVC and the speed type of cancer. of onset, with slower development allowing venous collaterals to develop. Most patients do not require emergency interven- e Presentation with superior vena cava syndrome does tion, and deaths due to SVC syndrome are rare. A chest CT scan not worsen prognosis in patients who present with oth- with intravenous contrast usually confirms the diagnosis erwise treatable malignancies. (Figure 10). Management is based on the severity of symptoms and the Venous Thromboembolism underlying malignancy. In patients requiring immediate treat- Cancer and cancer treatment are risk factors for venous ment of respiratory distress, an SVC stent can be placed without thromboembolism (deep venous thrombosis and pulmonary tissue diagnosis. For most patients, a tissue diagnosis is obtained, embolism). Symptoms such as calf discomfort, pleuritic chest with treatment directed by the type of cancer. Options for obtain- pain, or shortness of breath should prompt evaluation of deep ing diagnostic tissue include mediastinoscopy, bronchoscopy, venous thrombosis/ pulmonary embolism (see Hematology). 42

Oncologic Urgencies and Emergencies Central Nervous System Emergencies ambulation compared with radiation alone. See Neurology for Increased Intracranial Pressure further discussion of spinal cord compression. Elevated intracranial pressure can result from primary brain malignancies or from brain metastases, which occur in 10% to e Neoplastic spinal cord compression is initially treated 20% of adult patients with cancer. The most common types of with glucocorticoids; definitive treatment with surgery, primary cancer that cause brain metastases are lung cancer, irradiation, or both depends on whether the patient has breast cancer, and melanoma. Median survival after diagnosis a known cancer diagnosis, the stability of the spine, the of brain metastases varies widely. sensitivity of the cancer to radiation, and the patient’s Symptoms of increased intracranial pressure include overall prognosis. headache, depressed global consciousness, vomiting, and even features of herniation. Emergent CT or MRI imaging will con- e Neurologic status is the most important predictor of firm the diagnosis. Glucocorticoids decrease vasogenic edema outcome for patients with neoplastic spinal cord com- and relieve symptoms in 75% of patients. Patients with severe pression; ambulatory patients tend to remain ambula- symptoms are treated with a loading dose of dexamethasone tory with treatment, but nonambulatory patients of 10 to 20 mg followed by 4 to 6 mg every 6 hours. The most typically do not regain the ability to walk.

and relieve symptoms in 75% of patients. Patients with severe pression; ambulatory patients tend to remain ambula- symptoms are treated with a loading dose of dexamethasone tory with treatment, but nonambulatory patients of 10 to 20 mg followed by 4 to 6 mg every 6 hours. The most typically do not regain the ability to walk. critically ill patients may require osmotic diuresis with man- nitol, head elevation, hyperventilation, and possibly decom- Malignant Pleural and Pericardial Effusions pressive surgery. Antiepileptic drugs should be used in the 25% The types of cancer that most commonly cause malignant of patients who present with seizures. See Neurology for fur- pleural effusions include carcinomas of the breast, lung, ther discussion of antiepileptic drugs. Anticoagulation can be gastrointestinal tract, and ovaries; lymphomas; and meso- safely used when indicated. Lumbar puncture is contraindi- theliomas. Patients present with progressive dyspnea and cated in patients with an increased intracranial pressure may or may not have concomitant chest pain. See Pulmonary because of the risk of herniation. and Critical Care Medicine for further discussion of pleural Spinal Cord Compression effusions. Chest radiography is the initial diagnostic study, Neoplastic epidural spinal cord compression (ESCC) develops often followed by CT, which provides more precise anatomic in approximately 2.5% of patients with metastatic cancer. The detail. Therapeutic thoracentesis is used as the initial treat- most common types of cancer that cause ESCC in adults are ment of symptomatic effusions. Further management lung, breast, and prostate cancer; myeloma; and lymphoma. depends on the rate of reaccumulation, the severity of symp- Approximately 85% of ESCC cases are due to epidural exten- toms, and the patient’s prognosis. Recurrent effusion is sion from vertebral body metastases. Lymphomas are more common, unless the tumor is responsive to systemic therapy. likely to involve a paraspinal mass that extends through the Repeat thoracentesis is appropriate for slowly recurring neural foramina to cause cord compression. Pain, often effusions. For effusions with more rapid reaccumulation, radicular and worse with recumbency, is present in more the best options for management are placement of an than 80% of patients and usually precedes neurologic symp- indwelling pleural catheter with intermittent outpatient toms by several weeks. The absence of neurologic signs drainage or pleurodesis, with similar palliation obtained by should not delay evaluation of such pain. If a sensory level is either method. present, it is typically one to five levels below the actual level Malignancy accounts for 13% to 23% of pericardial effu- of cord compression. Bowel and bladder dysfunction is a late sions and may be the first presentation of the disease. Lung, finding that is present in up to half of patients. MRI of the breast, and esophageal cancers; melanoma; lymphoma; and entire thecal sac is the preferred imaging test when ESCC is leukemia are the most common malignancies that cause peri- suspected. cardial effusions. Cardiac tamponade results when the pericar- The patient’s neurologic status at diagnosis is the most dial fluid pressure impairs filling of one or both ventricles, important predictor of outcome. Of patients who are able to leading to decreased cardiac output. Patients present with walk when starting treatment, 80% remain ambulatory; how- dyspnea, chest discomfort, or fatigue. They usually have ele- ever, less than 20% of nonambulatory patients regain the abil- vated jugular venous distention and may have hypotension and ity to walk. Patients are initially treated with glucocorticoids at peripheral edema. Echocardiography usually establishes the either a moderate or high dose if paraparesis or paraplegia is diagnosis. Symptoms from progressive cardiac tamponade may present. Definitive treatment with surgery, irradiation, or both be inappropriately attributed to nonspecific systemic signs of depends on whether the patient has a known cancer diagno- cancer or heart failure until cardiac filling and cardiac output sis, as well as the stability of the spine, the sensitivity of the is emergently compromised. See Cardiovascular Medicine for cancer to radiation, and the patient’s overall prognosis. For further discussion of cardiac tamponade. patients who are acceptable surgical candidates with an Treatment of symptomatic pericardial effusion involves expected survival of at least 3 months, initial decompressive percutaneous pericardiocentesis or drainage during surgical surgery followed by irradiation increases the likelihood of placement of a pericardial window.

critically ill patients may require osmotic diuresis with man- nitol, head elevation, hyperventilation, and possibly decom- Malignant Pleural and Pericardial Effusions pressive surgery. Antiepileptic drugs should be used in the 25% The types of cancer that most commonly cause malignant of patients who present with seizures. See Neurology for fur- pleural effusions include carcinomas of the breast, lung, ther discussion of antiepileptic drugs. Anticoagulation can be gastrointestinal tract, and ovaries; lymphomas; and meso- safely used when indicated. Lumbar puncture is contraindi- theliomas. Patients present with progressive dyspnea and cated in patients with an increased intracranial pressure may or may not have concomitant chest pain. See Pulmonary because of the risk of herniation. and Critical Care Medicine for further discussion of pleural Spinal Cord Compression effusions. Chest radiography is the initial diagnostic study, Neoplastic epidural spinal cord compression (ESCC) develops often followed by CT, which provides more precise anatomic in approximately 2.5% of patients with metastatic cancer. The detail. Therapeutic thoracentesis is used as the initial treat- most common types of cancer that cause ESCC in adults are ment of symptomatic effusions. Further management lung, breast, and prostate cancer; myeloma; and lymphoma. depends on the rate of reaccumulation, the severity of symp- Approximately 85% of ESCC cases are due to epidural exten- toms, and the patient’s prognosis. Recurrent effusion is sion from vertebral body metastases. Lymphomas are more common, unless the tumor is responsive to systemic therapy. likely to involve a paraspinal mass that extends through the Repeat thoracentesis is appropriate for slowly recurring neural foramina to cause cord compression. Pain, often effusions. For effusions with more rapid reaccumulation, radicular and worse with recumbency, is present in more the best options for management are placement of an than 80% of patients and usually precedes neurologic symp- indwelling pleural catheter with intermittent outpatient toms by several weeks. The absence of neurologic signs drainage or pleurodesis, with similar palliation obtained by should not delay evaluation of such pain. If a sensory level is either method. present, it is typically one to five levels below the actual level Malignancy accounts for 13% to 23% of pericardial effu- of cord compression. Bowel and bladder dysfunction is a late sions and may be the first presentation of the disease. Lung, finding that is present in up to half of patients. MRI of the breast, and esophageal cancers; melanoma; lymphoma; and entire thecal sac is the preferred imaging test when ESCC is leukemia are the most common malignancies that cause peri- suspected. cardial effusions. Cardiac tamponade results when the pericar- The patient’s neurologic status at diagnosis is the most dial fluid pressure impairs filling of one or both ventricles, important predictor of outcome. Of patients who are able to leading to decreased cardiac output. Patients present with walk when starting treatment, 80% remain ambulatory; how- dyspnea, chest discomfort, or fatigue. They usually have ele- ever, less than 20% of nonambulatory patients regain the abil- vated jugular venous distention and may have hypotension and ity to walk. Patients are initially treated with glucocorticoids at peripheral edema. Echocardiography usually establishes the either a moderate or high dose if paraparesis or paraplegia is diagnosis. Symptoms from progressive cardiac tamponade may present. Definitive treatment with surgery, irradiation, or both be inappropriately attributed to nonspecific systemic signs of depends on whether the patient has a known cancer diagno- cancer or heart failure until cardiac filling and cardiac output sis, as well as the stability of the spine, the sensitivity of the is emergently compromised. See Cardiovascular Medicine for cancer to radiation, and the patient’s overall prognosis. For further discussion of cardiac tamponade. patients who are acceptable surgical candidates with an Treatment of symptomatic pericardial effusion involves expected survival of at least 3 months, initial decompressive percutaneous pericardiocentesis or drainage during surgical surgery followed by irradiation increases the likelihood of placement of a pericardial window. 43