Imaging of urgencies and emergencies in the lung cancer patient
Lung cancer patients often experience potentially life-threatening medical urgencies and emergencies, which may be a direct or indirect result of the underlying malignancy. This pictorial review addresses the most common thoracic, neurological and musculoskeletal medical emergencies in lung cancer patients, including superior vena cava syndrome, pulmonary embolism, spontaneous pneumothorax, cardiac tamponade, massive haemoptysis, central airway obstruction, oesophagorespiratory fistula, malignant spinal cord compression, carcinomatous meningitis, cerebral herniation and pathological fracture. Emphasis is placed on imaging findings, the role of different imaging techniques and a brief discussion of epidemiology, pathophysiology and therapeutic options. Since early diagnosis is important for adequate patient management and prognosis, radiologists have a crucial role in recognising and communicating these urgencies and emergencies.
• Multiplanar multidetector computed tomography is the imaging examination of choice for thoracic urgencies and emergencies.
• Magnetic resonance imaging is the imaging modality of choice for investigating central nervous system emergencies.
• Urgencies and emergencies can be the initial manifestation of lung cancer.
• Radiologists have a crucial role in recognising and in communicating these urgencies/emergencies.
KeywordsLung cancer Emergencies Radiography Computed tomography Magnetic resonance imaging
Superior vena cava syndrome
Small cell lung cancer
Superior vena cava
Computed tomography pulmonary angiography
Malignant spinal cord compression
Lung cancer is very common, accounting for 17% and 9% of all cancers in men and women, respectively . Furthermore, lung cancer is the biggest cancer killer, representing 19% of all cancer-related deaths. The disease course in lung cancer is generally characterised by high morbidity and complications, some of which are acute and potentially life-threatening. An oncological emergency can be defined as an acute, potentially life-threatening condition in a cancer patient, either as a direct or indirect effect of the underlying malignancy or secondary to its treatment, requiring rapid intervention to avoid death or severe morbidity. Urgencies and emergencies differ in the severity of the consequences of a delay in treatment. Oncological emergencies can occur at any time during the course of a malignancy and can be the initial manifestation in some patients . The causes of oncological urgencies and emergencies are myriad. While metabolic, infectious and haematological emergencies are primarily diagnosed by the clinical presentation and laboratory findings, thoracic, neurological and musculoskeletal emergencies often require imaging studies. The aim of this pictorial review is to identify and discuss these urgencies and emergencies in which radiologists play an important role and can have a significant impact on patient management and prognosis. The contribution of imaging in urgencies and emergencies goes beyond making the initial diagnosis, as imaging can also play a role in the planning of treatment and follow-up after treatment.
Superior vena cava syndrome
Massive pulmonary embolism (PE)
Haemodynamic and respiratory support is the initial treatment of acute massive PE, followed by anticoagulation or, in the case of massive acute PE, fibrinolysis . Treatment for patients with incidental, asymptomatic PE remains the same as for patients with symptomatic PE according to guidelines published by the American College of Chest Physicians .
Small, asymptomatic pneumothorax can be treated conservatively. Larger, symptomatic pneumothorax requires active intervention by needle aspiration or chest drain insertion .
Pericardial effusion in oncology patients may develop by four mechanisms: direct extension or metastatic spread, chemotherapeutic toxicity, radiation toxicity, or as an opportunistic infection . Primary lung cancer is the most common cause, accounting for over one-third of malignant pericardial effusions. Only a small percentage of patients with a malignant pericardial effusion develop cardiac tamponade, which is a medical emergency . Cardiac tamponade results from an accumulation of pericardial fluid leading to an impaired ventricular filling with decreased cardiac output. This can occur with as little as 200 ml of pericardial fluid [17, 19]. Symptoms suggestive of cardiac tamponade are dyspnoea, non-specific chest pain and fatigue.
Since cardiac tamponade carries a high mortality, emergent pericardiocentesis, with or without placement of an indwelling pericardial drain, can be life-saving .
Massive haemoptysis is defined as expectoration of 100 ml of blood in a single episode or more than 600 ml of blood over a 24-h period. Massive haemoptysis is a life-threatening medical emergency, which is fatal in about one-third of cases. Bronchogenic carcinoma is the most common cause of massive haemoptysis in patients over 40 years old with an overall rate of haemoptysis of 10-20%, although only fatal in 3% . In case of severe haemoptysis, the bleeding usually stems from bronchial (90%) and pulmonary (5%) arteries [24, 25].
In emergency, arterial endovascular embolisation is the procedure of choice while surgery may be performed in select cases when the patient is stabilised. Performing a multidetector CT angiography before endovascular treatment is useful to provide a detailed depiction of the origin and course of bronchial and non-bronchial systemic arteries responsible for haemoptysis and determine the optimal endovascular approach .
Central airway obstruction
Central airway obstruction can be caused by a myriad of malignancies but is most commonly caused by lung cancer extending directly into the airway lumen. Up to 30% of lung cancer patients will have tumour obstruction of the central airways at some point in the course of their disease . Central airway obstruction usually manifests with symptoms of respiratory distress, including stridor and dyspnoea, haemoptysis, cough and fever due to post-obstructive pneumonitis .
In case of severe airway obstruction, urgent therapeutic bronchoscopy with placement of airway stents is the treatment of choice . To help determine the appropriate size of the stent, it is important to report the length of obstruction, the maximum degree of obstruction and the luminal diameter of the normal airways .
An oesophagorespiratory fistula (ERF) is a rare, life-threatening complication of lung cancer affecting less than 1% of patients [30, 31]. The trachea is most commonly involved but oesophagobronchial and oesophagopulmonary fistula can also develop occasionally. An ERF, in the setting of lung cancer, may develop either through direct erosion of tumour through adjacent structures into the oesophagus or, uncommonly, after initial treatment, in particular in patients treated with angiogenesis inhibitors and chemoradiation . ERF typically presents with coughing, dyspnoea secondary to aspiration pneumonitis, recurrent pulmonary infections and poor nutrition.
Palliative stenting of the oesophagus and/or trachea is the treatment of choice .
Malignant spinal cord compression
Malignant spinal cord compression (MSCC) is a common complication and has a negative effect on quality of life and survival. Because of rapid progression of neurological dysfunction, it is considered a medical emergency . Between 2.5 and 5% of patients with terminal cancer will have MSCC, with lung cancer accounting for 15–20% of cases .
Treatment options are corticosteroids, surgery and radiotherapy in different combinations .
Carcinomatous meningitis occurs in approximately 5% of lung cancer patients, usually late in the course of the disease [36, 37]. Carcinomatous meningitis carries a poor prognosis with a high morbidity and survival ranging from weeks if untreated and up to 8 months with timely treatment . Haematogenous dissemination is the most common mechanism of leptomeningeal tumour spread, but direct tumour extension from bone and brain lesions, and perivascular or perineural spread may also occur . Symptoms of carcinomatous meningitis are myriad and include symptoms of cranial neuropathy, symptoms indicative of cerebral hemisphere involvement and symptoms of spinal cord or nerve root involvement .
Treatment options include intravenous administration of mannitol or dexamethasone, which have a transient effect, or emergent neurosurgery as a more definite treatment modality .
Surgery is the treatment of choice, typically requiring plates or intramedullary rods with the addition of bone cement or joint arthroplasty when the fracture occurs near a joint .
Due to often late-stage diagnosis with widespread metastatic disease and aggressive nature, oncological urgencies and emergencies are relatively frequent in the lung cancer patient. Whereas plain radiography often remains the first-line imaging modality that may point to possible abnormalities, multidetector CT with multiplanar imaging is the imaging modality of choice for urgencies and emergencies in the chest. In the central nervous system, this role is for MRI. Radiologists have a central and crucial role in the early recognition of these entities, as well as communication with thoracic oncologists, allowing appropriate management and minimising the risk of associated morbidity and mortality.
Statement of authorship
This manuscript represents original work. Neither this manuscript nor one with substantially similar content has been published or is being considered for publication elsewhere. All authors contributed to this manuscript, read the manuscript and approved the final version of the submitted manuscript.
Compliance with ethical standards
Conflicts of interest
All the authors declare that they have no conflict of interest.
The material in the manuscript has been acquired according to modern ethical standards.
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