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

* Complication of metastatic solid tumor lymphoma or multiple myeloma.

* Back pain is 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 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.

Persistent compression can result in irreversible changes to the myelin sheaths resulting in permanent neurologic impairment.

Prompt diagnosis and therapeutic intervention are essential since the probability of reversing neurologic symptoms largely depends on the duration of symptoms.

Patients who are treated promptly after symptoms appear may have a partial or complete return of function and, depending on tumor sensitivity to specific treatment, may respond favorably to subsequent anticancer therapy.

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.

Since involvement is usually epidural, a mixture of the nerve root and spinal cord symptoms often develops. Progressive weakness and sensory changes commonly occur. Bowel and bladder symptoms progressing to incontinence are late findings.

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.

Bone radiographs, if done, may show evidence of vertebral body or pedicle destruction by cancer. However, bone radiographs are neither sensitive nor specific and therefore are not helpful in diagnosis or treatment planning.

If the back pain symptoms are nonspecific, bone scan imaging may be useful as a screening procedure.

Treatment

Patients found to have epidural impingement of the spinal cord should be given corticosteroids immediately. The initial dose is 10–100 mg intravenously followed by 4–6 mg every 6 hours intravenously or orally.

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.

A randomized trial comparing surgery followed by radiation therapy with radiation therapy alone showed better outcomes (i.e., improved ability to ambulate and improved bladder and bowel functions) in persons who had surgery followed by radiation therapy.

If multiple vertebral body levels are involved with cancer, radiation therapy is the preferred treatment option. Corticosteroids are generally tapered toward the end of 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.

Direct involvement of the serous surface with the tumor is the most frequent initiating cause of the accumulation of fluid.

The most common malignancies causing pleural and pericardial effusions are lung and breast cancers; the most common malignancies associated with malignant ascites are ovarian, colorectal, stomach, and pancreatic cancers.

Patients with pleural and pericardial effusions complain of shortness of breath and orthopnea. Patients with ascites complain of abdominal distention and discomfort.

Cardiac tamponade causing pressure equalization in the chambers impairing both filling and cardiac output can be a life-threatening event.

Signs of tamponade include tachycardia, pulsus paradoxus (a pulse that weakens abnormally during inspiration and is symptomatic of various abnormalities (as pericarditis), and hypotension.

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. Malignant effusions are rarely transudative(a filtrate of blood and accumulates in tissues outside the blood vessels and causes edema (swelling).

The differential diagnosis of malignant ascites includes similar benign processes, such as congestive heart failure and infections; cirrhosis and pancreatic disease also cause ascites.

Bloody effusions are usually due to cancer, but a bloody pleural effusion can also be due to pulmonary embolism or trauma.

Chylous pleural or ascitic fluid is generally associated with obstruction of lymphatic drainage as might occur in lymphomas.

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.

For those patients, several options exist for management. Chest tube drainage followed by pleurodesis is the preferred option for patients with a reasonable life expectancy. The procedure involves the placement of a chest tube that is connected to closed water-seal drainage.

After lung expansion is confirmed on a chest radiograph, a sclerosing agent (such as talc slurry or doxycycline) is injected into the catheter.

Patients should be premedicated with analgesics and placed in a variety of positions in order to distribute the drug through the pleural spaces.

Pleurodesis will not be successful if the lung cannot be reexpanded; these patients may be treated with the placement of a shunt or an indwelling catheter.

Placement of an indwelling catheter that can be drained by a family member or a visiting nurse may also be preferable for patients with short life expectancies or for those who do not respond to pleurodesis.

Pericardial Effusion

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

Management options for recurrent, symptomatic effusions include catheter drainage followed by sclerosis with such agents as doxycycline or bleomycin or by pericardiectomy.

Malignant Ascites

Patients with malignant ascites not responsive to chemotherapy are generally treated with repeated large volume paracenteses.

As the frequency of drainage to maintain comfort can compromise the patient’s quality of life, other alternatives include placement of a catheter or port so that the patient, family member, or visiting nurse can drain fluid as needed at home.

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