Pathological Fractures
Along the same lines as SCC, these fractures cause debility and suffering at the end of life. Diagnosis with plain films is usually adequate. Surgical intervention may be indicated, using the same indications as with SCC. Success of surgical interventions is most impacted by the patient’s functional status prior to the fracture.

Superior Vena Cava Syndrome
Superior vena cava syndrome (SVCS) is seen primarily in lung cancer when the mass is in the right upper lobe. This mass, or the associated lymphadenopathy, obstructs the venous return through the superior vena cava into the right atrium. This leads to engorgement of veins in the upper torso, arm, face, brain, and larynx. Clinically, the patient may present with swelling of the face and neck, especially when lying down (due to increased compression of the obstructed vessel). The presentation can be as significant as altered mental status from brain edema or stridor from laryngeal edema compromising the airway.

Definitive diagnosis of SVCS requires a chest CT with contrast. Endovascular stenting is now the treatment of choice. Other options include radiotherapy or chemotherapy, depending on the sensitivity of the tumor.

Treatment of SVCS improves a patient’s quality of life and extends survival as much as six months, depending on the tumor type. Treatment of this syndrome requires a high index of suspicion on the physician’s part because it can significantly alter a patient’s overall prognosis.

Hypercalcemia of Malignancy
Lastly, a relatively common condition that arises in cancer patients is hypercalcemia of malignancy (HCM), with the incidence being as high as one in five patients. This is most commonly seen in breast and lung cancer and multiple myeloma.

Mild cases present with musculoskeletal pain and nonspecific gastrointestinal symptoms. More severe cases present with altered mental status, delirium, or coma. As with other electrolyte disturbances, it’s the rate of change, not necessarily the extent of change, that causes symptoms.

If your patient had a good functional status prior to this complication, treat HCM aggressively with fluids and IV bisphosphonates. These patients are usually profoundly hypovolemic and need aggressive IV hydration.

Bisphosphonates are now standard of care for the treatment of HCM. These agents’ main method of lowering calcium is blocking osteoclastic resorption. These drugs require 48 hours to lower calcium and must be given intravenously. There are two agents available in the United States: pamidronate, 60–90 mg IV over two hours, or zoledronate, 4 mg IV over 15 minutes. Both work well, although zoledronate is somewhat more efficacious—and more expensive.