Chapter 11
Oncology: Nursing management in cancer care
277
Table 11-12 Oncological Emergencies: Manifestations and Management
Clinical manifestations and
Emergency
diagnostic findings
Management
Superior vena cava syndrome
(SVCS)
Compression or invasion of
the superior vena cava by
tumour, enlarged lymph nodes,
intraluminal thrombus that
obstructs venous circulation, or
drainage of the head, neck, arms
and thorax. Typically associated
with lung cancer, SVCS can also
occur with breast cancer, Kaposi’s
sarcoma, thymoma, lymphoma
and mediastinal metastases
(Kuzin, 2006). If untreated, SVCS
may lead to cerebral anoxia
(because not enough oxygen
reaches the brain), laryngeal
oedema, bronchial obstruction
and death.
Spinal cord compression
Potentially leading to permanent
neurological impairment and
associated morbidity and
mortality; compression of the cord
and its nerve roots may result from
tumour, lymphomas, intervertebral
collapse or interruption of blood
supply to the nerve tissues
(Kaplan, 2006b).
The prognosis depends on the
severity and rapidity of onset.
About 70% of compressions
occur at the thoracic level,
20% in the lumbosacral level,
and 10% in the cervical region
(Marrs, 2006). Metastasis from
breast, lung, kidney, prostate
cancers, myeloma, lymphoma
to the bone or between the
bone and the epidural space
are associated with spinal cord
compression (Kaplan, 2006b).
Clinical
Gradually or suddenly impaired venous drainage
giving rise to:
• Progressive shortness of breath (dyspnoea),
cough, hoarseness, chest pain and facial
swelling
• Oedema of the neck, arms, hands and thorax
and reported sensation of skin tightness and
difficulty swallowing
• Possibly engorged and distended jugular,
temporal and arm veins
• Dilated thoracic vessels causing prominent
venous patterns on the chest wall
• Increased intracranial pressure, associated
visual disturbances, headache and altered
mental status
Diagnostic
Diagnosis is confirmed by:
• Clinical findings
• Chest x-ray
• Thoracic computed tomography (CT) scan
• Thoracic magnetic resonance imaging (MRI)
Intraluminal thrombosis is identified by venogram.
Clinical
• Local inflammation, oedema, venous stasis and
impaired blood supply to nervous tissues
• Local or radicular back or neck pain along the
dermatomal areas innervated by the affected
nerve root (Marrs, 2006) (e.g. thoracic radicular
pain extends in a band around the chest or
abdomen)
• Pain exacerbated by movement, supine
recumbent position, coughing, sneezing or the
Valsalva manoeuvre
• Neurological dysfunction, and related motor and
sensory deficits (numbness, tingling, feelings of
coldness in the affected area, inability to detect
vibration, loss of positional sense)
• Motor loss ranging from subtle weakness to
flaccid paralysis
• Bladder and/or bowel dysfunction depending
on level of compression (above S2, overflow
incontinence; from S3 to S5, flaccid sphincter
tone and bowel incontinence)
Medical
• Radiation therapy to shrink tumour size and
relieve symptoms
• Chemotherapy for chemosensitive cancers (e.g.
lymphoma, small cell lung cancer) or when the
mediastinum has been irradiated to maximum
tolerance (Kuzin, 2006)
• Anticoagulant or thrombolytic therapy for
intraluminal thrombosis
• Percutaneously placed intravascular stents are
increasingly being used to reopen the occluded SVC
(Kuzin, 2006)
• Surgery (less common), such as vena cava bypass
graft (synthetic or autologous), to redirect blood
flow around the obstruction
• Supportive measures such as oxygen therapy,
corticosteroids and diuretics
Nursing
• Identify patients at risk for SVCS
• Monitor and report clinical manifestations of SVCS
• Monitor cardiopulmonary and neurological status
• Avoid upper extremity venipuncture and blood
pressure measurement
• Facilitate breathing by positioning the patient
properly; this helps to promote comfort and reduce
anxiety produced by difficulty breathing resulting
from progressive oedema
• Promote energy conservation to minimise shortness
of breath
• Monitor the patient’s fluid volume status and
administer fluids cautiously to minimise oedema
• Assess for thoracic radiation-related problems such
as dysphagia (difficulty swallowing) and oesophagitis
• Monitor for chemotherapy-related problems such as
myelosuppression
• Provide postoperative care as appropriate
Medical
• Radiation therapy to reduce tumour size to halt
progression and corticosteroid therapy to decrease
inflammation and swelling at the compression site
• Surgery to debulk tumour and stabilise the spine
if symptoms progress despite radiation therapy
or if vertebral fracture or bone fragments lead to
additional nerve damage; surgery is also an option
when the tumour is not radiosensitive or is located
in an area that was previously irradiated (Kaplan,
2006b)
• Vertebroplasty is used to stabilise vertebrae when
patients have pain without neurological dysfunction;
vertebroplasty involves percutaneous injection of
polymethyl methacrylate (PMMA), a bone cement
filler, into the vertebral body (Kaplan, 2006b)
• Chemotherapy as adjuvant to radiation therapy for
patients with lymphoma or small cell lung cancer
•
Note:
Despite treatment, patients with poor
neurological function before treatment are less likely
to regain complete motor and sensory function;
patients who develop complete paralysis usually do
not regain all neurological function (Kaplan, 2006b)
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