1. Introduction

Cancer patients frequently visit emergency department (ED) in the late stages of disease. It acts as a critical portal to address acute illness issues. Approximately two-thirds of ED visits by patients with cancer end in hospital admission [1, 2]. ED care is focused on symptom control and management of the adverse effects of cancer treatment. Retrospective studies have described patient characteristics presenting to the ED and common complaints included pain, respiratory and gastrointestinal symptoms [1, 3-7]. A retrospective study done at an oncology centre in Ethiopia stated that most common malignancy in female was gynaecological (47%) followed by breast (26%). Carcinoma cervix was the most common among all gynaecological malignancies to present in ED (8). It is important to assess treatment outcome of cancer patients treated in ED. In this study we aim to analyse the presentation, diagnosis and treatment outcome of gynaecological cancer patients visiting the ED.

2. Material and Methods

We conducted a cross sectional study in the Emergency Department of All India Institute of Medical Sciences New Delhi from January 1, 2018 to December 31, 2018. Study was conducted as per principles of Declaration of Helsinki. This hospital provides a tertiary level referral treatment and it is opened for 24 hours for emergency services. The study cohort comprised of all Gynaecological cancer patients which included cervical, ovarian, uterine and gestational trophoblastic malignancies. All participants provided written informed consent. In the ED, inpatient medical record of all patients was evaluated. Exclusion criteria included pregnancy and not willing to participate. Study variables included age, type of cancer, stage, presenting symptoms and diagnosis, emergency treatment received, further plan of care and outcome. Data was analyzed using SPSS software (version 18.0, SPSS, inc, Chicago, IL) and included descriptive statistics such as mean, percentage, proportion and frequency. Fifty patients were included in the analysis.

3. Results

Median age of fifty patients was 45.5 years (range 18-68). Distribution of patients as per type of malignancy is shown in Figure 1.

Figure 1: Distribution of fifty patients as per type of malignancy.

Carcinoma cervix was the most common (28 cases, 56%) followed by carcinoma ovary (14 cases, 28%), carcinoma endometrium (3 cases, 6%), gestational trophoblastic neoplasia (3 cases, 6%), molar pregnancy (1 case, 2%) and leiomyosarcoma (1 case, 2%). Among the twenty eight patients of carcinoma cervix, eighteen (64%) were treatment naive and ten (36%) were recurrent cases. Among fourteen cases of carcinoma ovary, five (36%) were treatment naive, four (28%) were recurrent and five (36%) were germ cell tumors. Of three cases of carcinoma endometrium, two (67%) were recurrent cases. Figure 2 shows the overall distribution of primary or recurrent cases.

Figure 2: Distribution of fifty cases as treatment naive (primary) or recurrent.

Stage distribution of carcinoma cervix cases was sixteen (57%) stage III B, six (21%) stage IVA and six (21%) stage IVB. Among carcinoma ovary cases, two (14%) were stage I, seven (50%) stage III C, two (14%) stage IVA and three (21%) stage IV B. Two (67%) carcinoma endometrium cases were stage I and one (33%) was stage II. Among gestational trophoblastic neoplasia one case each was in stage II, III and IV respectively. Leiomyosarcoma case was in stage IVB. Overall stage distribution is shown in Figure 3.

Figure 3: Stage distribution of fourty nine patients (excluding Hyaditiform mole).

Presenting complaints of cases are depicted in Table 1.

ED= Emergency department

Table 1: Presenting symptoms of fifty cases of Gynaecological cancer in ED.

Pain was the predominant complain followed by no urine output, bleeding per vaginum, shortness of breath, not passes flatus or stool, abdominal distension, nausea and vomiting, lower limb swelling, altered sensorium, dizziness and blood in urine. One case each had urinary leak from vagina, blood in sputum, jaundice, headache, fever, seizures and feeling of insects (maggots) crawling in the perineum.

Diagnosis was made by the emergency team which are enlisted in Table 2.

ED= Emergency department, PCN= Per cutaneous nephrostomy

Table 2: Diagnosis of fifty patients with Gynaecological cancer in ED.

Carcinoma cervix cases had obstructive uropathy, anaemia, electrolyte imbalance, metabolic acidosis, lung metastases, hematuria, deep vein thrombosis, sepsis, septic shock, vesicovaginal fistula, sciatic nerve involvement, bone metastases, displaced PCN and/or maggots in perineum. Carcinoma ovary cases presented with ascites, pleural effusion, lung collapse, tumor rupture and hemoperitoneum and/or adnexal torsion. Carcinoma endometrium cases had pneumonia or intestinal obstruction. Gestational trophoblastic neoplasia cases had anaemia, lung and/or brain metastases. Leiomyosarcoma patient had lung metastases and collapse.

Management in emergency comprised of hyperkalaemia correction, hypokalemia correction, hemodialysis, bilateral per cutaneous nephrostomy (PCN), antifibrinolytics, blood transfusion, pain management, intravenous antibiotics, nagogastric tube insertion, nil per oral and intravenous fluids, emergency laparotomy (intestinal resection and anastomosis in one case), therapeutic ascitic tapping, drainage of pleural effusion, intercostal chest tube insertion, anticoagulation, seizure control by phenytoin, urinary bladder irrigation, ionotropes, hemostatic radiotherapy, vaginal packing, PCN repositioning, intubation, cardiopulmonary resuscitation, local debridement and turpentine oil. These findings are depicted in Table 3.

ED= Emergency department, PCN= Per cutaneous nephrostomy

Table 3: Management of fifty patients of Gynaecological cancer in ED.

Median length of hospital stay was 48 hours (6-96 hours). Patients were discharged after planning a definitive therapy i.e. chemotherapy (30%), palliation of symptoms (42%), chemoradiation (10%), radiotherapy (12%) and surgical evacuation in the case of hyaditiform mole. Six patients underwent emergency laparotomy, with adnexal torsion, tumor rupture with hemoperitoneum and intestinal obstruction identified in two cases each. Of fifty patients two (4%) expired during the stay. Treatment outcome at the time of discharge is depicted in Figure 4.

Figure 4: Treatment outcome of fifty patients at the time of discharge.

One case was a sixty five year old with stage IIIB carcinoma cervix who presented with altered sensorium and anuria. She had metabolic acidosis and obstructive uropathy with serum urea and creatinine level of 120 and 17 mg/dl respectively. She was administered cardiopulmonary resuscitation for fourty five minutes but could not be revived. Another mortality was that of a fifty six year old with stage IV B leiomyosarcoma uterus, post surgery and post chemotherapy and radiotherapy. She had shortness of breath with lung metastases and collapse. She was intubated and started on supportive care but she expired after 22 hours of stay.

4. Discussion

Around 3% of all ED population of patients are with a diagnosis of cancer [9]. They present in an acute state with high symptom burden, and frequent need for admission. In the study by Rivera DR et al, 4.2% of all cases were cancer patients [3]. There are no prior reports exclusive to gynaecological cancer patients. An Australian report by Livingston PM et al showed Gynecologic cancer on fifth place (2.5% of all cases) whereas in another report by Sisay F et al., gynecological cancers comprised 11.7% of all oncological cases and was the third most common [10, 11].

Carcinoma cervix was the most frequent malignancy (56%) to present in ED and in an advanced stage. This is similar to another study by Wondimagegnehu T et al done in Ethiopa in which carcinoma cervix was the most common among all gynaecological malignancies to present in ED [8].One third of the cases were recurrent tumor in present study. Pain, anuria and bleeding per vaginum were the predominant symptoms and patients had obstructive uropathy, anaemia, electrolyte imbalance, metabolic acidosis, lung metastases, hematuria, deep vein thrombosis, sepsis, septic shock, vesicovaginal fistula, sciatic nerve involvement, bone metastases, displaced PCN and/or maggots in perineum. Carcinoma ovary cases presented with ascites, pleural effusion, lung collapse, tumor rupture and hemoperitoneum and/or adnexal torsion. Carcinoma endometrium cases had pneumonia or intestinal obstruction. Gestational trophoblastic neoplasia cases had anaemia, lung and/or brain metastases. Leiomyosarcoma patient had lung metastases and collapse.

The main complain among all patients was pain (28%). This is similar to other studies in oncology patients. 40% in the study by Swenson KK et al. 15.2% in the study by Gianmauray N et al, 22.9% in the study by Ahn S et al. [12-14]. In our study other common complaints were anuria (22%), bleeding per vaginum (22%), shortness of breath (14%), not passed flatus or stool (12%) and abdominal distension (10%). In a study by Christian E et al conducted in Germany, Austria and Switzerland; bleeding, nausea, vomiting and fever were common after pain [15].

Symptomatic treatment was started in all patients and definite management plan was made after consultation with oncology and palliation team. Two patients expired during the course of treatment and both were in terminal stages of their disease. There is a need for improved symptom control before and during the ED visit. Since Pain is the commonest presentation among patients with cancer and appropriately managing pain is a significant contributor to improving quality of life in these patients. Timely specialty consultation and adequate outpatient follow-up for further management is a prerequisite to decrease further ED visits in a decompensated state.

5. Conclusion

Across all malignancies, gynecological cancer contributes a major proportion to ED visits with carcinoma cervix being the commonest. Active intervention is required since the majority present in an acute state and pain being the commonest presenting symptom. Outcomes largely depend on acute management in ED and timely speciality consultation for further symptom palliation and management of primary cause.

Funding

None

Disclosure of Interest

No conflicts of interest to disclose.

References

1. Mayer DK, Travers D, Wyss A, et al. Why do patients with cancer visit emergency departments? results of a 2008 population study in North Carolina. J Clin Oncol 29 (2011): 2683-2688.
2. Vandyk AD, Harrison MB, Macartney G, et al. Emergency department visits for symptoms experienced by oncology patients: a systematic review. Support Care Cancer 20 (2012): 1589-1599.
3. Rivera DR, Gallicchio L, Brown J, et al. Trends in adult cancer-related emergency department utilization: an analysis of data from the Nationwide Emergency Department Sample. JAMA Oncol 3 (2017): e172450.
4. Yang C, Murray WB, Lindstrom DJ, et al. Development and validation of the performance of airway management instrument for paramedics. Ann Emerg Med 62 (2013): S76.
5. Oatley M, Fry M, Mullen L. A cross-sectional study of the clinical characteristics of cancer patients presenting to one tertiary referral emergency department. Int Emerg Nurs 24 (2016): 35-38.
6. Sadik M, Ozlem K, Huseyin M, et al. Attributes of cancer patients admitted to the emergency department in one year.World J Emerg Med 5 (2014): 85-90.
7. Panattoni L, Fedorenko C, Greenwood-Hickman MA, et al. Characterizing potentially preventable cancer and chronic disease-related emergency department use in the year after treatment initiation: a regional study. J Oncol Pract 14 (2018): e176-e185.
8. Wondimagegnehu T, Abera M, Aynalem A. Pattern of Cancer in TASH Oncology Center in Ethiopia from 1998-2010. International Journal of Cancer Research and Molecular Mechanism 1 (2015).
9. Brown J, Grudzen C, Kyriacou DN, et al. The emergency care of patients with cancer: setting the research agenda. Ann Emerg Med 68 (2016): 706-711.
10. Patricia M, Melinda C, Monica S. Clinical and economic Burden of emergency department presentation for neutropenia following out patient’s chemotherapy for cancer in Victoria, Australia. The Oncologist 17 (2010): 998-1004.
11. Sisay F, Kebede S, Abebe A, et al. Treatment outcome of oncologic patients treated in emergency department at black lion specialized hospital, Ethiopia. J Integr Oncol 7 (2018): 213.
12. Swenson KK, Rose MA, Ritz L, et al. Recognition and evaluation of oncology related symptoms in the emergency department. Ann Emerg Med 26 (1995): 12-17.
13. Gianmauro N, Antonella C, Alessandro M, et al. Hospital admission of cancer patients: Avoidable practice or necessary care?. Plos One 10 (2015).
14. Elmar C, Irinaeus A, Normann W, et al. Radiotherapy in oncology emergency final result of pattern of case study In Germany, Australia and Switzerland. Acta Oncol 47 (2008): 81-89.
15. Ahn S, Lee YS, Lim KS, et al. Emergency department cancer unit and management of oncologic emergency: experience in Asian medical center. Support Care Cancer 20 (2012): 2205-2210.