Oncologic Emergencies PART – 1
(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)
Question: Thank you Chiragbhai for explaining important points related to BONE SARCOMAS 1. Role of radiologist in diagnosis. 2. Availability of sarcoma surgeons – early involvement of these surgeons improves not overall outcome, especially better chance of limb preserving surgery. Huge value to avoid amputation, especially considering most of these patients are young. 3. Osteosarcoma: Surgery alone cures only about 20%, with addition of chemotherapy cure rate is about 70-80%. 4. High dose methotrexate is not a standard of care for every patient of osteosarcoma. 5. Ewing sarcoma: most patients need all three modalities i.e. surgery, chemotherapy, radiotherapy. 6. Chondrosarcoma: treated primarily by surgery.
We have completed discussion of sarcomas, what next tumor type you would like to discuss?
¬Ans: No tumor type.
Que: What? Are you suggesting we end our series? I am sure we have not completed all cancer types yet. There are so many cancers. Don’t we have like more than 250 types of cancers, as mentioned in your first book “Cancer Mati Shake Che”?
Ans: Don’t worry, we are not stopping discussion. Just that remaining tumor types are not so common, and likely to be not so interesting for our readers. They need to know more about what is more relevant to their day to day practice. We will pick topics in that direction.
Que: Please explain. I am confused.
Ans: Let us see. Any doctor, who is not an oncologist, deals with so many different types of patients. for example, a family doctor, physician, surgeon, orthopedic, gynecologist, pediatrician,…Some of these patients will have cancer, either known case under treatment or not yet diagnosed or some under palliative care. Different issues will be important in these different settings.
Some of these patients will present with symptoms or signs or laboratory abnormalities that require urgent intervention. If not recognized and treated in a timely manner, it may result in loss of life, limb or organ. This category of issues may be seen in patients who are under treatment already, or not yet diagnosed with cancer but these are the presenting symptoms/signs of cancer. We call these as “ONCOLOGIC EMERGENCIES”.
Even if you are not an oncologist, these are the ones you should know well for obvious reasons.
Que: Very interesting. This makes a lot of sense, as an important topic to discuss. Can you give us some examples?
Ans: Many of these are known issues to a practicing doctor. But in view of cancer, they have certain specific points to remember, or certain more urgency, or some are unique to cancer.
- Leukostasis: very high wbc count with or without symptoms e.g. undiagnosed acute myeloid leukemia with wbc 150,000 and mild headache – if untreated, this patient may die within a day. This is not fiction, has happened to patients while waiting over weekend. Or a myeloproliferative neoplasm with platelet count of 25 lac and mild leg swelling on one side – he may have a deep vein thrombosis, and may soon develop a massive pulmonary embolism.
- Febrile neutropenia: someone who is under chemotherapy every 3 weeks in Ahmedabad, but lives 150 km away in your town, has been your patient for 25 years, and comes to you Saturday night for a fever of 101 F, but only mild weakness. This patient may die of sepsis in less than 24 hours, if his wbc count is low and does not receive intravenous antibiotics within few hours. He cannot be treated like a general fever – THIS IS AN EMERGENCY.
- Back pain: a case of prostate cancer, treated two years ago with bilateral orchidectomy, with last PSA 0.2 (done 6 months ago), not on any treatment, doing very well otherwise. Now has significant back pain for 2 days, and possibly some weakness in one leg. Visits an orthopedic surgeon. Prescribed analgesics and advised to return after one week. Develops complete paralysis of both legs over next 3 days. Rushes to his old oncologist – diagnosed spinal cord compression, now with irreversible neurological injury.
- A 64 year old patient with history of 40 pack year of smoking, otherwise healthy and fit until now. Comes to you with significant generalized weakness, constipation, mild headache off and on, increased urinary frequency, weight loss – over just last 7 days. What tests would you order? What oncologic emergencies are likely?
October 13th 2019. Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. firstname.lastname@example.org