Its Not A Tumor! n Increasing incidence of cancer Oncologic - PDF document

Oncologic Emergencies It’s Not A Tumor! n Increasing incidence of cancer Oncologic Emergencies n Improved survival n Patients with malignancies may present to Diane M. Birnbaumer, M.D., FACEP EDs and general medical offices Professor of Medicine n Oncologic emergencies University of California, Los Angeles Senior Clinical Educator n Those resulting from the disease itself Department of Emergency Medicine n Those resulting from cancer therapy Harbor-UCLA Medical Center Oncologic Emergencies: Oncologic Emergencies: General Categories General Categories n Cardiovascular Emergencies n Metabolic Emergencies n Malignant pericardial effusion n Hypercalcemia n Superior vena cava syndrome n Tumor Lysis Syndrome n Hematologic Emergencies n Neurologic Emergencies n Hyperviscosity due to dysproteinemia n Malignant spinal cord compression n Hyperleukocytosis and leukostasis n Brain metastases and increased ICP n Infectious Complications n Neutropenic fever 1

Oncologic Emergencies Oncologic Emergencies Neutropenic Fever Neutropenic Fever n Most commonly seen after chemotherapy n Fever n Also seen in myelogenous cancers n Single oral temperature > 38.3C (101.3F) n Risk of infection depends on… n Sustained temperature > 38C (100.4F) for > 1 hour n Depth of neutropenia n Duration of neutropenia n Neutropenia n Comorbid conditions (e.g. mucositis) n Absolute neutrophil count < 1,000 n Nadir usually 5-10 days after last chemo n Severe neutropenia dose n Absolute neutrophil count < 500 n Recovers 5 days after nadir (usually) Oncologic Emergencies Oncologic Emergencies Neutropenic Fever Neutropenic Fever n Organisms n Presentation n Multiple organisms implicated n Fever usually only symptom n Enteric gram negatives n May range from fever only to severe sepsis n Gram positives n Neutropenia leads to atypical presentation n Frequently no organism recovered with common infections n E.g. pneumonia patients may have no infiltrate; UTI patients may have no pyruia 2

Oncologic Emergencies Oncologic Emergencies Neutropenic Fever Neutropenic Fever n Presentation n Evaluation n Careful physical examination crucial n Blood cultures n Particular attention to skin, oral cavity, sites of n Peripheral vein AND any indwelling catheters indwelling catheters, perianal area n Urine cultures n Rectal examination discouraged n Sputum cultures n Stool, CSF cultures if indicated Oncologic Emergencies Oncologic Emergencies Neutropenic Fever Neutropenic Fever n Evaluation n Treatment n CXR may be normal n All febrile neutropenic patients should receive antibiotics ASAP n Consider CT for higher resolution n Afebrile neutropenic patients with high suspicion of infection also should get rx n Broad spectrum to start; narrow later 3

Oncologic Emergencies Oncologic Emergencies Neutropenic Fever Neutropenic Fever n Treatment n Multinational Association Scoring System n No or mild symptoms 5 n Most patients should be admitted n No hypotension 5 n Highly selected patients MAY be treated as n No COPD 4 outpatients n Solid tumor or no previous fungal infxn 4 n Very close follow-up necessary n No dehydration 3 n Must have ready access to health care n Moderate symptoms 3 n Assess personal / social situation n Outpatient status 3 n Age < 60 years 2 Score • 21 low risk for serious medical complications Neutropenic Fever Antibiotic Strategies Neutropenic Fever Treatment n Broad empiric coverage + coverage for n Clinical Practice Guidelines any suspected/ known infections n Clinical Infectious Diseases CID n Gram-negative coverage for all patients 2011:52 (15 February) n Gram-positive coverage for selected patients per IDSA recommendations n Use bactericidal antibiotics administered through alternate ports to indwelling lines 4

IDSA Recommendations IDSA Management Algorithm Outpatient Treatment n Suggested Antibiotic Regimen: n Ciprofloxacin 500mg PO q8 • PLUS n Amoxicillin/Clavulanate 500mg PO q8 • n Penicillin-allergic Patients: n Ciprofloxacin 500mg PO q8 • PLUS n Clindamycin n Note: Outpatient therapy not recommended for the pediatric population. Clin Infect Dis 2002; 34: 730-51. Clin Infect Dis 2002; 34: 730-51. IDSA Recommendations Oncologic Emergencies Inpatient Treatment Spinal Cord Compression n Inpatient Care for Children and “High Risk” Adult n Relatively common Patients n 2.5 to 6% of cancer patients n Monotherapy: Single, broad-spectrum IV agent n Cefipime (4 th generation cephalosporin) n Most common: Breast, lung, prostate n Ceftazidime (3 rd generation cephalosporin) n Carbapenem (Imipenem or Meropenem) n Confers poor prognosis overall n Combination Therapy: n Aminoglycoside (Gentamicin, Tobramycin, or Amikacin) PLUS n Urgent need to make diagnosis and treat n Antipseudomonal beta-lactam (Ticarcillin-clavulanic acid or Piperacillin-tazobactam), OR n Neuro status at presentation and rapidity of n Antipseudomonal cephalosporin (Cefipime or ceftazidime), OR onset predict functional outcome n Carbapenem (Imipenem or Meropenem) n None of these have been shown to be clearly superior. Clin Infect Dis 2002; 34: 730-51. 5

Oncologic Emergencies Oncologic Emergencies Spinal Cord Compression Spinal Cord Compression n Usually results from extension from spinal n Presentation bony metastases n 90% have back pain n Less commonly extends through foramina n 80% have preceding diagnosis of malignancy n Lymphomas, sarcomas n May have several simultaneous lesions n Will not see bony destruction n Most common in thoracic spine n BACK PAIN + MALIGNANCY = SCC!! Oncologic Emergencies Oncologic Emergencies Spinal Cord Compression Spinal Cord Compression n Presentation n Evaluation n Symptoms n MRI is imaging study of choice n Radicular pain n Consider imaging entire spine (+ /- C spine) n Motor weakness n CT myelography second choice n Gait disturbance n Plain films / nuclear medicine poor choices n Bowel or bladder dysfunction n Limited sensitivity and specificity n Imperative to try to diagnose before n Plain films may show bony lesions neurologic dysfunction occurs n Negative plain films do NOT rule out SCC 6

Oncologic Emergencies Oncologic Emergencies Spinal Cord Compression Malignant Pericardial Effusion n Treatment n Common in advanced cancer n Start as soon as possible; need tissue n Frequently asymptomatic diagnosis n Poor prognosis n Glucocorticoids n Most patients die within one year n Dexamethasone 10-16 mg IV, then 4 mg every 6 hours n Radiation n Mainstay of therapy (?) n Surgery may also be indicated (or preferable) Oncologic Emergencies Oncologic Emergencies Malignant Pericardial Effusion Malignant Pericardial Effusion n Presentation n EKG n Low voltages n Symptoms depend on rapidity of onset n May see dyspnea, cough, chest pain, n Electrical alternans dysphasia, hiccups, hoarseness n May find tachycardia, distant heart sounds, JVD, UE and LE edema, pulsus paradoxus n Tamponade = hypotension/shock with tachycardia, JVD 7

Oncologic Emergencies Oncologic Emergencies Malignant Pericardial Effusion Malignant Pericardial Effusion n Evaluation n Echo preferred test n Presence of fluid n “Tamponade physiology” n CT and MRI also useful n Treatment n Pericardiocentesis Oncologic Emergencies Oncologic Emergencies Superior Vena Cava Syndrome Superior Vena Cava Syndrome n Usually caused by compression of SVC n Presentation n Benign and malignant causes n Onset usually insidious; may be rapid n Lung cancer, lymphoma most common n Dyspnea, facial swelling, cough malignancies n Cough may aggravated by leaning forward, n May also be caused by intraluminal stooping thrombus n Exam n Distended neck / chest wall veins n Often due to indwelling catheters n Facial edema n Upper extremity edema 8

Oncologic Emergencies Oncologic Emergencies Superior Vena Cava Syndrome Tumor Lysis Syndrome n Seen in aggressive hematologic n Evaluation malignancies n CT with contrast n High grade lymphoma, acute leukemia n MRI also useful n Seen after treatment of treatment of n Treatment active solid tumors n Unless respiratory compromise, not a true n Massive release of intracellular contents emergency after tumor death n Radiation, stenting, chemo, steroids as n Can cause severe metabolic derangements indicated n May be life threatening Oncologic Emergencies Oncologic Emergencies Tumor Lysis Syndrome Tumor Lysis Syndrome n Presentation n Hyperuricemia n Rare to see; usually prevented during n Crystallize in renal tubules treatment n Can lead to acute renal failure n Suspect in patients with aggressive n Hyperkalemia hematologic malignancies or solid tumors n Especially with recent chemotherapy n Life-threatening arrhythmias n Seizures n Hyperphosphatemia n Arrhythmias n Leads to hypocalcemia, tetany, seizures, n Decreased urine output / volume overload arrhythmias 9

Oncologic Emergencies Oncologic Emergencies Tumor Lysis Syndrome Tumor Lysis Syndrome n Presentation n Treatment n Send uric acid, phosphorus, potassium, LDH, n Prophylaxis best calcium n Allopurinol 2-3 days before chemo n Check EKG as well n Maintain good hydration n Grading systems define degree of illness n If TLS present n Admit ICU / monitor n Maintain hydration n Want urine output 100-200 mL/hr n Take care if renal failure n Treat electrolyte disturbances Oncologic Emergencies: Oncologic Emergencies: Hypercalcemia Hypercalcemia n Occurs in 10-30% of cancer patients n 3 types n Usually seen in patients with known n Humoral hypercalcemia of malignancy n Via PTHrP (parathyroid related hormone) cancer n Most common mechanism (33-88% ) n Carries a poor prognosis n Local bone destruction n Most commonly seen in n Tumor production of vitamin D analogues n Breast cancer n Lung cancer n Multiple myeloma 10