1. Oncological Emergencies
Dr. Gary Harding MD, FRCPC
Medical Oncology Fellow CancerCare Manitoba

2. CASE 1…

3. Mr. SV ID: 65 year old male with PMHx of CAD and emphysema
EC: present to clinic with one week history of increasing SOB
HPI: 3 month history of weight loss, decreased appetite, a change in his chronic cough, and intermittent hemoptysis

4. On Physical Examination
Inspection:

5. Respiratory Examination
Stridor
Dullness to percussion on right lower lung fields
Increased tactile fremitus to right lower lung fields
Decreased A/E to right lower lung fields

6. Chest X-Ray…

7. right pleural effusion

8. Thoracentesis Exudate Gram stain AFB stain Cytology Negative
non-small cell lung cancer
Large cell type

9. T1-weighted axial MRI demonstrating paratracheal soft tissue mass that invades into the SVC

10. Superior Vena Cava Syndrome

11. Definition
Obstruction of blood flow in the superior vena cava results in signs and symptoms of SVC syndrome

13. Etiology
Caused by either invasion or external compression of the SVC by contiguous pathologic process
Right lung pathology, lymph nodes, other mediastinal structures, or thrombosis

14. Etiology
Before antibiotics the most common causes were from complications of untreated infection
Syphilitic thoracic aneurysms
fibrosing mediastinitis
Malignancy is presently the most common cause

15. Symptoms and Signs
As the obstruction develops venous collaterals are formed
Symptom onset depends on speed of SVC obstruction onset
Malignant disease can arise in weeks to months
Not enough time to develop collaterals
Fibrosing mediastinitis can take years to have symptoms

16. Symptoms and Signs
Central venous pressures remain high even in collaterals
High pressures cause the characteristic clinical picture
Shortness of breath is the most common symptom1
1. Parish, JM, Marschke, RF Jr, Dines, DE, Lee, RE. Etiologic considerations in superior vena cava syndrome. Mayo Clin Proc 1981; 56:407.

17. Signs and Symptoms Facial swelling or head fullness Cough Arm edema
exacerbated by bending forward or lying down
Cough
Arm edema
Cyanosis

18. Facial swelling associated with SVC Syndrome in a patient with malignancy

19. Physical Findings Venous distension Pemberton’s Sign Facial Edema neck
chest wall
Pemberton’s Sign
Facial Edema

20. Patient who presented with progressively enlarging veins over the anterior chest wall. A diagnosis of a right-sided superior sulcus (Pancoast) tumor compressing the SVC was made.

21. Etiology: Malignancy Lung cancer is the most common2
Lymphoma is second most common
together represent 94% of cases
2. Escalante, CP. Causes and management of superior vena cava syndrome. Oncology (Huntingt) 1993; 7:61.

22. NSCLC 2-4% of bronchogenic cancer patients develop SVC syndrome3
extrinsic compression or direct invasion
primary tumor or by enlarging mediastinal nodes
3. Armstrong, BA, Perez, CA, Simpson, JR, Hederman, MA. Role of irradiation in the management of superior vena cava syndrome. Int J Radiat Oncol Biol Phys 1987; 13:531.

23. Small Cell Lung Cancer Greatest risk 20% will develop SVC obstruction3
more common because SCLC tends to occur centrally in contrast to other types

24. Lymphoma 2-4% of patients predominantly non-Hodgkin’s lymphoma4
Hodgkin’s rarely causes SVC syndrome
4. Perez-Soler, R, McLaughlin, P, Velasquez, WS, et al. Clinical features and results of management of superior vena cava syndrome secondary to lymphoma. J Clin Oncol 1984; 2:260.

25. Lymphoma Extrinsic compression caused by enlarging lymph nodes
subtypes of large B cell can be intravascular and cause occlusion (angiotropic)
diffuse large cell and lymphoblastic are most commonly associated with SVC syndrome

26. Other cancers Thymoma primary mediastinal germ cell neoplasm
solid tumors with mediastinal nodal metastases
breast cancer most common type

27. Other causes
Post radiation local vascular fibrosis can also be considered in oncology patients
Thoracic radiation treatment may predate syndrome by many years

28. Other causes Thrombosis Indwelling central venous catheters
Subcutaneous tunneled catheters have fewer thrombotic and infectious complications
Can also cause pulmonary embolism5
5. Sivaram, CA, Craven, P, Chandrasekaran, K. Transesophageal echocardiography during removal of central venous catheter associated with thrombus in superior vena cava. Am J Card Imaging 1996; 10:266.

29. Diagnosis Timely identification of the cause is essential
Radiographic studies are useful
Up to 60% of patients with SVC syndrome related to neoplasm do not have a known diagnosis of cancer6
Need a tissue biopsy for histologic studies
6. Schraufnagel, DE, Hill, R, Leech, JA, Pare, JA. Superior vena caval obstruction. Is it a medical emergency?. Am J Med 1981; 70:1169.

30. Radiographic Studies
Most patients have an abnormal chest x-ray at presentation
Most common findings are
Mediastinal widening
Pleural effusion

31. CT Chest Preferred choice IV contrast defines the level of obstruction
Maps out collateral pathways
Can identify underlying cause of obstruction

32. Venography Bilateral upper arm venograpy
superior to CT to define site of obstruction
Does not define cause unless thrombosis is solely responsible

33. Helical CT With bilateral upper arm IV contrast injection
Best visualization of level of obstruction and cause

34. MRI
Can be useful in patients with IV contrast allergies

35. T1-weighted axial MRI demonstrating the primary tumor and the paratracheal soft tissue mass that invades into the SVC

36. Same patient’s MRI with different technique to further define the intramural mass

37. Histologic Diagnosis Essential Guides treatment
Aids in defining prognosis

38. Histologic Diagnosis
Sputum cytology, pleural fluid cytology, biopsy of enlarged peripheral nodes
Bone marrow biopsy for NHL
Bronchoscopy, mediastinoscopy, or thoracotomy are more invasive but sometimes necessary

39. Treatment of Oncologic Causes

40. Treatment Aimed at underlying cause
Evolution of thought has occurred in recent years

41. Historically SVC syndrome was considered a potentially life-threatening emergency
Standard of care was immediate radiotherapy
Zap now
Ask questions later
The emergent approach is not appropriate for most patients

42. Newer strategies

43. Emergent to Urgent
Symptomatic obstruction is usually a prolonged process
Most patients are not in immediate danger at presentation
Most have time for a full diagnostic work up

44. Emergent to Urgent Prebiopsy radiation can obscure the diagnosis
Current strategies aim at accurate diagnosis of underlying etiology before therapy

45. Exception to new rule Stridor True medical emergency
Central airway obstruction or laryngeal edema
True medical emergency
Immediate action needed
Possible intubation and ICU admission
Immediate therapy to target obstruction needed

46. Linked to tumor histology and stage at presentation
Prognosis…
Linked to tumor histology and stage at presentation

47. Treatment Sensitive Tumors
NHLs, germ cells, and limited-stage small cell lung cancers usually respond to chemotherapy and or radiation
Can achieve long term remission with tumor specific directed therapy
Symptomatic improvement usually takes 1-2 weeks after start of therapy

48. Note: Corticosteroids
Controversial issue with regards to treatment benefit at presentation

49. Non-small cell lung cancer
SVC obstruction is a strong predictor of poor prognosis
Median survival around 5 months7
Choice of therapy considers likelihood of response to each modality
7. Martins, SJ, Pereira, JR. Clinical factors and prognosis in non-small cell lung cancer. Am J Clin Oncol 1999; 22:453.

50. Non-small cell lung cancer
Goal usually directed to palliation rather than long term remission
Palliative radiation and chemotherapy can be used

51. Intraluminal Stents Endovascular placement under fluoroscopy
Patients who have recurrent disease in previously irradiated fields
Tumors refractory chemotherapy
Patient too ill to tolerate radiation or chemotherapy

52. Intraluminal Stents
Some data suggests benefit from immediate stent placement in NSCLC at presentation8
Tends to provide more rapid relief of symptoms
Issue of anticoagulation after is not resolved
8. Rowell, NP, Gleeson, FV. Steroids, radiotherapy, chemotherapy and stents for superior vena caval obstruction in carcinoma of the bronchus: a systematic review. Clin Oncol (R Coll Radiol) 2002; 14:338.

53. CASE 2…

54. Mr. EC ID: 56 year old man with history of HTN and osteoarthrtis
EC: presents to family doctor with one month history of back pain that is not responding to Tylenol
Pain beginning to wake him at night
More pain with recumbancy
Some shooting pains down right leg
ROS: negative

55. On examination vitals stable, no fever
CVS, Respiratory, GI, GU exams reported as normal
Back exam
Inspection: normal
Palpation: some pain in L1
ROM: normal
Some pain in right leg with straight leg raising

56. Investigation in Clinic
Lumbar Spine X-ray
Some age related degeneration

57. Diagnosis Sciatica vs. Back strain Treatment: NSAIDS
Few days of bed rest

58. The story continues… Mr. EC’s pain does not resolve
More trials of various forms of pain control fail
One month later Mr. EC awakens in the morning and has difficulty supporting his weight
Subjective leg muscle weakness
Goes to HSC Emergency room

59. In ER Patient has objective leg weakness on physical exam
A very keen medical student does a rectal exam and discovers a large nodular prostate
PSA: 45.0
MRI Spine…..

61. Spinal Cord Compression

62. Malignant Epidural Spinal Cord Compression (ESCC)
Neoplastic invasion of the space between vertebrae and spinal cord (epidural invasion)
Usually from bone metastases
Compresses thecal sac of spinal cord
Frequent complication of malignancy
Can cause pain
Can cause irreversible loss of neurologic function

65. Definition Any radiological indentation of the thecal sac
Tip of the spinal cord lies at the L1 vertebral level
Lumbosacral nerve roots form the cauda equina

66. Epidemiology Many cases of unrecognized ESCC
Difficult to define incidence
Autopsy review studies suggest around 5% of cancer patients die with ESCC9
9. Barron, KD, Hirano, A, Araki, S, Terry, RD. Experiences with metastatic neoplasms involving the spinal cord. Neurology 1959; 9:91.

67. Causes Metastatic tumor from any primary site
Tumors with predilection to metastasize to spinal column
Prostate, breast, and lung carcinoma
15-20% of cases
Renal cell, non-Hodgkin’s lymphoma, or myeloma
5-10% of cases

68. Vertebral metastases are more common than ESCC Prostate cancer: 90%
Breast Cancer: 74%
Lung Cancer: 45%
Lymphoma: 29%
Renal cell: 29%
GI: 25%
10. Posner, JB. Neurologic Complications of Cancer. FA Davis, Philadelphia, 1995

69. ESCC can be initial presentation of a malignancy
Around 20% of cases
In many cases diagnosis is made by biopsy of the spinal lesion

70. Spinal Location10 Thoracic spine: 60% Lumbosacral spine: 30%
Cervical spine: 10%
Specific tumor predilection is difficult to define

71. Clinical Features

72. Important to recognize Early recognition leads to better outcomes
Efficacy of treatment depends most on patient’s neurological function at presentation
Median time from symptoms to diagnosis is around 2 months11
More than half of patients who present to hospital are non-ambulatory
11. Husband, DJ. Malignant spinal cord compression: Prospective study of delays in referral and treatment. BMJ 1998; 317:18.

73. RED FLAGS…..

74. First Red Flag: Pain Usually first symptom12
80-90% of the time
Usually precedes other neurologic symptoms by seven weeks
Increases in intensity
Severe local back pain
Aggravated by recumbency
Distension of venous plexus
May become radicular
12. Bach, F, Larsen, BH, Rohde, K, et al. Metastatic spinal cord compression. Occurrence, symptoms, clinical presentations and prognosis in 398 patients with spinal cord compression. Acta Neurochir (Wien) 1990; 107:37.

75. Second Red Flag: Motor Weakness: 60-85%13 At or above conus medularis
Extensors of the upper extremities
Above the thoracic spine
Weakness from corticospinal dysfunction
Affects flexors in the lower extremities
Patients may be hyperreflexic below the lesion and have extensor plantars
13. Greenberg, HS, Kim, JH, Posner, JB. Epidural spinal cord compression from metastatic tumor: Results with a new treatment protocol. Ann Neurol 1980; 8:361.

76. Weakness tends to be symmetrical
Progressive weakness is followed by lost of gait function then paralysis
The severity of weakness is greatest with thoracic metastases

77. Third Red Flag: Sensory
Less common than motor findings
Still present in majority of cases
Ascending numbness and parathesias

78. Fourth Red Flag: Bladder and Bowel Function
Loss is late finding
Autonomic neuropathy presents usually as urinary retension
Rarely sole finding

79. Radiologic Investigation

80. Diagnosis depends on ability to demonstrate a mass compressing the thecal sac
Plain radiographs are not enough
Historically this involved invasive procedures
Advent of MRI has allowed non-invasive diagnosis
Clinical examination is not reliable in determining level of lesion

81. Entire imaging of spine is ideal
Focused CT imaging can miss clinically unapparent lesions
Myelography and MRI are better than plain X-Rays, bone scans and CT for diagnosis

82. Plain Spine Radiographs
Easiest and cheapest
Need large bony destruction or vertebral collapse to be diagnostic
High false negative rate
Not recommended to confirm diagnosis

83. MRI vs. CT Myelography

84. Both image thecal sac and display indentation and encircling
CT myelography involves a lumbar puncture
Contraindicated in brain metastases, thrombocytopenia, or coagulopathy
Can diagnose leptomeningeal metastases
Available in Winnipeg in middle of the night

85. MRI Images whole spine High detail Spares lumbar puncture
Patients in pain must lie still

86. Roughly equivalent in terms of sensitivity and specificity
Presently no large comparative studies b/c MRI in the US has become so readily available
MRI standard of care in centers that have access

87. Bone Scan More sensitive than plain radiograph
Visualizes entire skeleton
Can miss neoplasms that do not have increased blood flow

88. CT Scan alone
Does not visualize spinal cord and epidural space clearly

89. Intramedullary Metastases
Less common
Often present with hemicord symptoms
Unilateral weakness below lesion
Contralateral diminution of pain and temperature sensation
Can progress to bilateral dysfunction

90. Radiation Myelopathy
Can mimic ESCC
MR imaging can make distinction

91. MRI of epidural spinal cord compression in a women with past history of breast cancer.

92. Treatment

93. Treatment delays…….
2 month median delay in treatment from onset of back pain11
14 day delay in treatment from onset of neurological symptoms11

94. Why the delay? EDUCATION Patient factors General practitioner factors
Hospital factors
EDUCATION

95. Treatment Objectives Pain control Avoidance of complications
Preserve or improve neurological function

96. Pain management Corticosteroids Opiates Decrease edema
Needed to decrease pain for comfort and examination purposes

97. Bed Rest No

98. Anticoagulation Cancer is a hypercoaguable state
High burden of tumor in metastatic disease
Possible value in prophylaxis against venous thromboembolism
If patient not mobile subcutaneous heparin or compression devices is indicated

99. Prevention of Constipation
Factors
Autonomic dysfunction
Limited mobility
Opiate analgesic
Risk of perforation
Masked by corticosteroids
Bowel regimen needed

100. Corticosteroids

101. Part of standard regimen Limited data on benefit vs. side effects
Many studies suggesting lower doses can be effective
No randomized trials

102. Corticosteroid Recommendations
High dose dexamethasone and half dose every three days
Pain with minimal neurological dysfunction can have lower dose
Small asymptomatic lesions can forgo steroids

103. Radiation Therapy

104. Definitive choice
Portal 8 cm wide
Centered on spine
Extends one to two vertebral bodies above and below the epidural metastasis

105. Relieves pain in most cases
Post-neurological function usually determines response
Response most associated with tumor type and radiosensitivity; eg. lymphoma
Dosing 20 to 40 Gy in 5 to 20 fractions
Popular
30 Gy in 10 fractions

106. Surgery
Changing role
Historically posterior vertebral decompression was done
No survival benefit with or without radiation15
15. Findlay, GF. Adverse effects of the management of malignant spinal cord compression. J Neurol Neurosurg Psychiatry 1984; 47:761.

107. Better techniques today allow aggressive approach
Gross spinal tumor resection with vertebral reconstruction now possible
Experienced surgeon required

108. Improvement in surgery+rads
Recent controlled trial comparing aggressive surgery followed by radiation vs. radiation alone16
Improvement in surgery+rads
Days remained ambulatory (126 vs. 35)
Percent that regained ambulation after therapy (56% vs. 19%)
Days remained continent (142 vs. 12)
Less steroid dose, less narcotics
Trend to increase survival
16. Patchell, R, Tibbs, PA, Regine, WF, et al. A randomized trial of direct decompressive surgical resection in the treatment of spinal cord compression caused by metastasis (abstract). proc Am Soc Clin Oncol 2003; 22:1.

109. Chemotherapy Can be successful in chemosensitive tumors
Hodgkin’s lymphoma
Non-Hodgkin’s lymphoma
Neuroblastoma
Germ cell
Breast cancer (hormonal manipulation)
Prostate cancer (hormonal manipulation)

110. Bisphosphonates Recommended
Decrease pathologic fractures in bony disease
Multiple myeloma
Breast cancer

111. Prognosis Median survival with ESCC is 6 months14
Ambulatory patients with radiosensitive tumors have the best prognosis
14. Sorensen, PS, Borgesen, SE, Rohde, K, et al. Metastatic epidural spinal cord compression. Results of treatment and survival. Cancer 1990; 65:1502.

112. Treatment Delay
Education
EXPERIENCE

113. Case 3: Mrs. HC
ID: 75 year old female living alone with no significant past medical history
EC: brought to ER by paramedics after neighbor called b/c she was found in her apartment unresponsive
No collateral history

114. Examination Fluctuating level of consciousness Vitals normal, no fever
Dehydrated
Coarse upper airway sounds
No other pertinent findings

115. Investigations CBC normal Mildly elevated BUN and Cr Normal LFTs
Standard electrolytes normal

116. Concern of pneumonia
Chest x-ray ordered……

117. Multiple Pulmonary Metastasis

118. Calcium checked
4.5

119. Hypercalcemia

120. Symptoms Usually nonspecific
Many times patients present with very high calcium level
Most research done in hyperparathyroidism

121. Gastrointestinal Constipation is most common15 Anorexia
Exacerbated or confused with narcotic effects
Related to autonomic dysfunction
Anorexia
Vague abdominal pain
Rarely can lead to pancreatitis
15. Heath, H 3d. Clinical spectrum of primary hyperparathyroidism: Evolution with changes in medical practice and technology. J Bone Miner Res 1991; 6(Suppl 2):S63.

122. Renal Dysfunction Nephrolithiasis Nephrogenic diabetes insipidus
More common in hyperparathyroidism
Nephrogenic diabetes insipidus
Defect in concentrating ability
Polyuria and polydipsia
Chronic renal failure
Longstanding high calcium
Calcifcation, degeneration, and necrosis of tubules

123. Neuropsychiatirc Anxiety Depression Cognitive dysfunction Delerium
Psychosis
Hallucinations
Somnolence
Coma

124. Cardiovascular Short QT interval Supraventricualr arrhythmias
Ventricular arrhythmias

125. Physical Findings Usually not specific
Dehydration secondary to diuresis caused by the hypercalcemia
Corneal deposition of calcium
“band keratopathy” on slit lamp exam

126. Epidemiology Occurs in about 10 to 20% of patients with cancer
Both solid tumors and leukemias
Most common
Breast
Lung
Multiple myeloma

127. Pathogenesis

128. Three mechanisms Osteolytic metastases with local cytokine release
Tumor secretion of parathyroid hormone-related protein (PTHrP)
Tumor production of calcitriol

129. Osteolytic Metastases

130. Non-small cell lung cancer Cytokines released
Breast cancer
Non-small cell lung cancer
Cytokines released
Tumor necrosis factor
Interleukin-1
Stimulate osteoclast precursor differentiation into mature osteoclasts
Leading to more bone breakdown and release of calcium

131. PTH-Related Protein Most common in patients with non-metastatic tumors
Called humoral hypercalcemia of malignancy
Secretion of PTH itself is a rare event
PTHrP binds to same receptor as PTH and stimulates adeynylate cyclase activity
Increased bone resorption
Increases kidney calcium reabsorption and phosphate excretion

132. Calcitriol Hodgkin’s disease (mechanism in majority)
Non-Hodgkin’s (mechanism in 1/3)
Usually responds to glucocorticoid therapy

133. Diagnosis

134. Clinical symptomology with
History of cancer
Risk factors for cancer
Suppressed PTH
Some centers can test for PTHrP to confirm Dx of humoral hypercalcemia
High PTHrP may predict response to pamidronate16
Less of a response
16. Gurney, H, Grill, V, Martin, TJ. Parathyroid hormonerelated protein and response to pamidronate in tumourinduced hypercalcemia. Lancet 1993; 341:1611.

135. Malignancy must be ruled out in patients that present with a very high calcium and no other obvious cause

136. Treatment

137. Aims Lower serum calcium concentration Treat complications if present
Treat underlying disease

138. Volume Large volume of normal Saline administration
Expands intravascular volume
Increases calcium excretion
Inhibition of proximal tubule and loop reabosrption
Reduces passive reabsorption of calicum
Follow fluid status b/c of danger of fluid overload

139. Inhibition of Bone Resorption
Three therapies
Calcitonin
Bisphosphonates
Gallium nitrate
Historical therapy
Antitumor antibiotic plicamycin (mithramycin)
Multiple serious side effects
No longer manufactured

140. Calcitonin Salmon calcitonin Increases renal excretion of calcium
Decreases bone reabsorption by interfering with osteoclast maturation
Weak agent
Works the fastest

141. Bisphosphonates Adsorb to the surface of bone hyroxyapatite
Interfere with osteoclast activity
Cytotoxic to osteoclasts
Inhibit calcium release from bone
Three commonly used
Pamidronate
Zoledronic acid
Etidronate (1st generation, weaker)

142. Bisphosphonates More potent than calcitonin
Maxium effect occurs in 2 to 4 days
Trend to use of IV zoledronic acid in the acute situation
Both are can be renal toxic
More potent than pamidronate
Administered over a shorter period of time (15 minutes vs. 2 hours)

143. Prophylactic Bisphosphonates
Pamidronate use in patients with known lytic lesions17
Less episodes of hypercalcemia
Less pathologic fractures
Less pain
Less spinal cord compression
Less need for radiation or surgery
17. Hortobagyi, GN, Theriault, RL, Porter, L, et al for the Protocol 19 Aredia Breast Cancer Study Group. Efficacy of pamidronate in reducing skeletal complications in patients with breast cancer and lytic bone metastases. N Engl J Med 1996; 335:1785.

144. Newly discovered side effect…
Osteonecrosis of the jaw
Recent case reports of jaw bone necrosis in patients on pamidronate
EDUCATION needed

145. Gallium Nitrate Effective More potential for nephrotoxicity
Rarely used

146. Dialysis
Last resort
Dialysis fluid with little or no calcium is effective
Useful when patients can’t tolerate large volume resuscitation
If calcium needs to be correct emergently

147. Recommendations in symptomatic situation
Volume expansion
Salmon calcitonin
IV zoledronic acid or pamidronate
Close follow up of calcium level and symptoms

148. Transitions in Treatment

149. Chemotherapy Two roles Direct treatment of cancer
Palliation of symptoms

150. Palliative Chemotherapy
Goal is not cure
Goals
Control of tumor
Preservation of function
Help tumor symptoms
Pain
Dsypnea
Pruritis
Poor appetite
Weight loss

151. Fine Balance Chemotherapy can be very toxic
Ratio: benefit vs. toxicity
Host factors and tumor factors
Delicate balance in palliative situation
Want medications that affect tumor but do not heavily affect host

152. Psychology of Cancer Psychological evolution during cancer treatment
Many people have fought very hard with their disease
Chemotherapy for “relief” not “cure” can be difficult concept for patients
ART of medicine

153. Evolution Chemotherapeutic protocols that have less side effects
molecular targeted therapies
Attack tumor specifically
Less effect on host

154. Breast cancer
Colon Cancer
Prostate cancer
Lung cancer

155. Breast Cancer Aromatase inhibitors for ER positive tumors
Anastrozole, Letrozole, Exemestane
Trastuzumab (Herceptin)
Humanized monoclonal antibody targeting Her-2/neu protein on breast cancer cells
Inhibits growth factor signal transduction
Tolerated quite well

156. Colon Cancer Capecitabine (Xeloda)
Oral drug that is transformed into 5-FU with three enzymatic reactions
Final enzyme is at higher levels in tumor cells
Contributes to drug’s less toxic side effect profile
Less stomatitis, less myelosupression

157. Targeted GI Therapies Bevacizumab Cetuximab
Monoclonal antibody to vascular endotheial growth factor receptor
Some cardiac toxicity
Cetuximab
Monoclonal antibody to human epidermal growth factor receptor
Skin toxicity

158. Prostate Cancer LHRH analogues Leuprolide (Lupron) Goserelin (Zoladex)
Stop testosterone production with limited side effects

159. Lung Cancer
In stage IV disease patients who receive Cisplatin based doublet chemotherapy live longer and feel better than best supportive care
Hard to balance side effects

160. Gefitinib (Iressa)
Targets epidermal growth factor receptor (tyrosine kinase small molecule inhibitor)
May have a role in the palliation of advanced non small cell lung cancer patients

161. Palliative Care Debate
Do not accept any patient on “active” therapy
This needs to be further elucidated
Patients being palliated with chemotherapy or targeted therapies still have other palliative care issues and needs
Should a patient still on Xeloda for breast or colon cancer not be admitted to St. Boniface 8A?

162. Thank you

163. Any questions?