October 2020
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Cancer is a chronic disease, but acute emergency complications (e.g. spinal cord compression, superior vena cava syndrome, malignant effusions) or generalized systemic effects (e.g. hypercalcemia, opportunistic infections, disseminated intravascular coagulation, hyperuricemia) may occur as a consequence of the local invasion of cancer.

Essentials of Diagnosis

* Back pain is the most common presenting symptom.

* Prompt diagnosis is essential because once a severe neurologic deficit develops, it is generally irreversible.

* Emergent treatment may prevent or potentially reverse paresis ( a condition typified by a weakness of voluntary movement, or by partial loss of voluntary movement) or by impaired movement and urinary and bowel incontinence.

General Considerations

Cancers that cause spinal cord compression most commonly metastasize to the vertebral bodies, resulting in physical damage to the spinal cord from edema, hemorrhage, and ischemia.

Clinical Findings

Symptoms and Signs

Back pain at the level of the tumor mass occurs in over 80% of cases and may be aggravated by lying down, weight-bearing, sneezing, or coughing; it usually precedes the development of neurologic symptoms or signs.

The initial findings of impending cord compression may be quite subtle, and there should be a high index of suspicion when back pain or weakness of the lower extremities develops in cancer patients.

Imaging

MRI is usually the initial imaging procedure of choice in a cancer patient with new-onset back pain.

When there are neurologic findings suggesting spinal cord compression, an emergent MRI should be obtained; the MRI should include a survey of the entire spine in order to define all areas of tumor involvement for treatment planning purposes.

Treatment

Patients found to have epidural impingement of the spinal cord should be given corticosteroids immediately.

Patients without a known diagnosis of cancer should have emergent surgery to relieve the impingement and obtain a pathologic specimen. Patients with a single area of compression due to solid tumors are best treated with surgical decompression followed by radiation therapy.

Malignant Effusions

Essentials of Diagnosis
* Occur in pleural, pericardial, and peritoneal spaces.
* Caused by direct neoplastic involvement of serous surface or obstruction of lymphatic drainage.
* Half of the undiagnosed effusions in patients not known to have cancer are malignant.

General Considerations

The development of an effusion in the pleural, pericardial, or peritoneal space may be the initial finding in a patient with cancer, or effusion may appear during the course of disease progression.

Signs of pleural effusions include decreased breath sounds, egophony, and percussion dullness.

Laboratory Findings

Malignancy is confirmed as the cause of an effusion when analysis of the fluid specimen shows malignant cells in either the cytology or cell block specimen.

Imaging

The presence of effusions can be confirmed with radiographic studies or ultrasonography.

Differential Diagnosis

The differential diagnosis of a malignant exudative pleural or pericardial effusion includes nonmalignant processes, such as infection, pulmonary embolism, congestive heart failure, and trauma.

Treatment

In some cases, treatment of underlying cancer with chemotherapy can cause regression of the effusions; however, not uncommonly, the presence of an effusion is an end-stage manifestation of the disease.

In this situation, decisions regarding management are in large part dictated by the patient’s symptoms and goals of care.

Pleural Effusion

A pleural effusion that is symptomatic may be managed initially with a large volume thoracentesis. With some patients, the effusion slowly reaccumulates, which allows for periodic thoracentesis when the patient becomes symptomatic.

However, in many patients, the effusion reaccumulates quickly, causing a rapid return of symptoms of shortness of breath.

Pericardial Effusion

Fluid may be removed by needle aspiration or by the placement of a catheter for more thorough drainage. As with pleural effusions, most pericardial effusions will reaccumulate.

 

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