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

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It’s Not A Tumor! Oncologic Emergencies

Diane M. Birnbaumer, M.D., FACEP Professor of Medicine University of California, Los Angeles Senior Clinical Educator Department of Emergency Medicine Harbor-UCLA Medical Center

Oncologic Emergencies

n Increasing incidence of cancer n Improved survival n Patients with malignancies may present to

EDs and general medical offices

n Oncologic emergencies

n Those resulting from the disease itself n Those resulting from cancer therapy

Oncologic Emergencies: General Categories

n Metabolic Emergencies

n Hypercalcemia n Tumor Lysis Syndrome

n Neurologic Emergencies

n Malignant spinal cord compression n Brain metastases and increased ICP

n Infectious Complications

n Neutropenic fever

Oncologic Emergencies: General Categories

n Cardiovascular Emergencies

n Malignant pericardial effusion n Superior vena cava syndrome

n Hematologic Emergencies

n Hyperviscosity due to dysproteinemia n Hyperleukocytosis and leukostasis

2 Oncologic Emergencies Neutropenic Fever

n Fever

n Single oral temperature > 38.3C (101.3F) n Sustained temperature > 38C (100.4F) for

> 1 hour

n Neutropenia

n Absolute neutrophil count < 1,000

n Severe neutropenia

n Absolute neutrophil count < 500

Oncologic Emergencies Neutropenic Fever

n Most commonly seen after chemotherapy

n Also seen in myelogenous cancers

n Risk of infection depends on…

n Depth of neutropenia n Duration of neutropenia n Comorbid conditions (e.g. mucositis)

n Nadir usually 5-10 days after last chemo

dose

n Recovers 5 days after nadir (usually)

Oncologic Emergencies Neutropenic Fever

n Organisms

n Multiple organisms implicated

n Enteric gram negatives n Gram positives

n Frequently no organism recovered

Oncologic Emergencies Neutropenic Fever

n Presentation

n Fever usually only symptom n May range from fever only to severe sepsis n Neutropenia leads to atypical presentation

with common infections

n E.g. pneumonia patients may have no infiltrate;

UTI patients may have no pyruia

3 Oncologic Emergencies Neutropenic Fever

n Presentation

n Careful physical examination crucial

n Particular attention to skin, oral cavity, sites of

indwelling catheters, perianal area

n Rectal examination discouraged

Oncologic Emergencies Neutropenic Fever

n Evaluation

n Blood cultures

n Peripheral vein AND any indwelling catheters n Urine cultures n Sputum cultures n Stool, CSF cultures if indicated

Oncologic Emergencies Neutropenic Fever

n Evaluation

n CXR may be normal

n Consider CT for higher

resolution

Oncologic Emergencies Neutropenic Fever

n Treatment

n All febrile neutropenic patients should receive

antibiotics ASAP

n Afebrile neutropenic patients with high suspicion of

infection also should get rx

n Broad spectrum to start;

narrow later

4 Oncologic Emergencies Neutropenic Fever

n Treatment

n Most patients should be admitted n Highly selected patients MAY be treated as

• utpatients

n Very close follow-up necessary n Must have ready access to health care n Assess personal / social situation

Oncologic Emergencies Neutropenic Fever

n Multinational Association Scoring System

n No or mild symptoms

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n No hypotension

5

n No COPD

4

n Solid tumor or no previous fungal infxn

4

n No dehydration

3

n Moderate symptoms

3

n Outpatient status

3

n Age < 60 years

2 Score • 21 low risk for serious medical complications

Neutropenic Fever Antibiotic Strategies

n Broad empiric coverage + coverage for

any suspected/ known infections

n Gram-negative coverage for all patients n Gram-positive coverage for selected patients

per IDSA recommendations

n Use bactericidal antibiotics administered

through alternate ports to indwelling lines

Neutropenic Fever Treatment

n Clinical Practice Guidelines n Clinical Infectious Diseases CID

2011:52 (15 February)

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IDSA Management Algorithm

Clin Infect Dis 2002; 34: 730-51.

IDSA Recommendations 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.

IDSA Recommendations Inpatient Treatment

n Inpatient Care for Children and “High Risk” Adult

Patients

n Monotherapy: Single, broad-spectrum IV agent

n Cefipime (4th generation cephalosporin) n Ceftazidime (3rd generation cephalosporin) n Carbapenem (Imipenem or Meropenem)

n Combination Therapy:

n Aminoglycoside (Gentamicin, Tobramycin, or Amikacin) PLUS n Antipseudomonal beta-lactam (Ticarcillin-clavulanic acid or

Piperacillin-tazobactam), OR

n Antipseudomonal cephalosporin (Cefipime or ceftazidime), OR n Carbapenem (Imipenem or Meropenem)

n None of these have been shown to be clearly superior. Clin Infect Dis 2002; 34: 730-51.

Oncologic Emergencies Spinal Cord Compression

n Relatively common

n 2.5 to 6% of cancer patients n Most common: Breast, lung, prostate

n Confers poor prognosis overall n Urgent need to make diagnosis and treat

n Neuro status at presentation and rapidity of

• nset predict functional outcome

6 Oncologic Emergencies Spinal Cord Compression

n Usually results from extension from spinal

bony metastases

n Less commonly extends through foramina

n Lymphomas, sarcomas n Will not see bony destruction

n Most common in thoracic spine

Oncologic Emergencies Spinal Cord Compression

n Presentation

n 90% have back pain n 80% have preceding diagnosis of malignancy n May have several simultaneous lesions n BACK PAIN + MALIGNANCY = SCC!!

Oncologic Emergencies Spinal Cord Compression

n Presentation

n Symptoms

n Radicular pain n Motor weakness n Gait disturbance n Bowel or bladder dysfunction

n Imperative to try to diagnose before

neurologic dysfunction occurs

Oncologic Emergencies Spinal Cord Compression

n Evaluation

n MRI is imaging study of choice n Consider imaging entire spine (+ /- C spine) n CT myelography second choice n Plain films / nuclear medicine poor choices

n Limited sensitivity and specificity n Plain films may show bony lesions n Negative plain films do NOT rule out SCC

7 Oncologic Emergencies Spinal Cord Compression

n Treatment

n Start as soon as possible; need tissue

diagnosis

n Glucocorticoids

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 Malignant Pericardial Effusion

n Common in advanced cancer n Frequently asymptomatic n Poor prognosis

n Most patients die within one year

Oncologic Emergencies Malignant Pericardial Effusion

n Presentation

n Symptoms depend on rapidity of onset n May see dyspnea, cough, chest pain,

dysphasia, hiccups, hoarseness

n May find tachycardia, distant heart sounds,

JVD, UE and LE edema, pulsus paradoxus

n Tamponade = hypotension/shock with

tachycardia, JVD

Oncologic Emergencies Malignant Pericardial Effusion

n EKG

n Low voltages n Electrical alternans

8 Oncologic Emergencies Malignant Pericardial Effusion Oncologic Emergencies 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 Superior Vena Cava Syndrome

n Usually caused by compression of SVC

n Benign and malignant causes

n Lung cancer, lymphoma most common

malignancies

n May also be caused by intraluminal

thrombus

n Often due to indwelling catheters

Oncologic Emergencies Superior Vena Cava Syndrome

n Presentation

n Onset usually insidious; may be rapid n Dyspnea, facial swelling, cough

n Cough may aggravated by leaning forward,

stooping

n Exam

n Distended neck / chest wall veins n Facial edema n Upper extremity edema

9 Oncologic Emergencies Superior Vena Cava Syndrome

n Evaluation

n CT with contrast n MRI also useful

n Treatment

n Unless respiratory compromise, not a true

emergency

n Radiation, stenting, chemo, steroids as

indicated

Oncologic Emergencies Tumor Lysis Syndrome

n Seen in aggressive hematologic

malignancies

n High grade lymphoma, acute leukemia

n Seen after treatment of treatment of

active solid tumors

n Massive release of intracellular contents

after tumor death

n Can cause severe metabolic derangements n May be life threatening

Oncologic Emergencies Tumor Lysis Syndrome

n Hyperuricemia

n Crystallize in renal tubules n Can lead to acute renal failure

n Hyperkalemia

n Life-threatening arrhythmias

n Hyperphosphatemia

n Leads to hypocalcemia, tetany, seizures,

arrhythmias

Oncologic Emergencies Tumor Lysis Syndrome

n Presentation

n Rare to see; usually prevented during

treatment

n Suspect in patients with aggressive

hematologic malignancies or solid tumors

n Especially with recent chemotherapy

n Seizures n Arrhythmias n Decreased urine output / volume overload

10 Oncologic Emergencies Tumor Lysis Syndrome

n Presentation

n Send uric acid, phosphorus, potassium, LDH,

calcium

n Check EKG as well

n Grading systems define degree of illness

Oncologic Emergencies Tumor Lysis Syndrome

n Treatment

n Prophylaxis best

n Allopurinol 2-3 days before chemo n Maintain good hydration

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: Hypercalcemia

n Occurs in 10-30% of cancer patients n Usually seen in patients with known

cancer

n Carries a poor prognosis n Most commonly seen in

n Breast cancer n Lung cancer n Multiple myeloma

Oncologic Emergencies: Hypercalcemia

n 3 types

n Humoral hypercalcemia of malignancy

n Via PTHrP (parathyroid related hormone) n Most common mechanism (33-88% )

n Local bone destruction n Tumor production of vitamin D analogues

11 Oncologic Emergencies: Hypercalcemia

n Presentation

n Multiple, nonspecific symptoms n Lethargy, confusion n Anorexia, nausea n Constipation n Polyuria, polydipsia

n Some correlation with rapidity of onset

and degree of hypercalcemia

Oncologic Emergencies: Hypercalcemia

n Physical exam usually unhelpful

n May see lethargy n May see dehydration

n Laboratory

n Must correct total serum calcium for albumin

n Measured total Ca + [0.8 x (4.0-albumin)] n Also check creatinine, other electrolytes, alkaline

phosphatase

n Low serum chloride suggestive of hypercalcemia of

malignancy

Oncologic Emergencies: Hypercalcemia

n Treatment

n Consider the big picture;

comfort measures only may be appropriate

n Hydration with normal

saline first step

n Patients often very volume

depleted

n Avoid loop diuretics until

euvolemic

Oncologic Emergencies: Hypercalcemia

n Treatment

n Bisphosphonates

n Pamidronate, zoledronic acid n Doses adjusted based on renal function n Block osteoclastic bone resorption

n SubQ or IM calcitonin (not nasal)

n Quickly lowers serum calcium levels n Short-lived effect

12 Oncologic Emergencies: Hypercalcemia

n Treatment

n Corticosteroids

n Most effective in hematologic malignancies n (Elevated levels of vitamin D) n Dialysis n Patients with renal or heart failure

n Avoid oral phosphate n Effective treatment of underlying cancer may

be useful

Oncologic Emergencies: Hypercalcemia

n Treatment

n Mithramycin

n Multiple side effects limit use

n Gallium nitrate

n Slow infusion rate

n Both have fallen out of favor since

introduction of biphosphonates

Oncologic Emergencies Case Presentation

n Patient received IV NS n Calcium came down to 10.2 with fluids

• nly

n Workup showed multiple bony metastases

throughout

n Follow-up with oncologist; long term care

plan discussed with patient

Oncologic Emergencies Brain Metastases / Increased ICP

n Seen in up to 25% of terminal cancer

patients

n Lung, breast, melanoma most common n Brain edema from tumor expansion causes

increased ICP

13 Oncologic Emergencies Brain Metastases / Increased ICP

n Presentation

n History of cancer in most cases n Symptoms range from focal to generalized n Symptoms often subtle, gradual in onset n Only 50% have headaches n May see seizures, symptoms of increased ICP n Confers very poor prognosis

Oncologic Emergencies Brain Metastases / Increased ICP

n Evaluation

n MRI preferred study n CT may miss posterior fossa lesions

n Treatment

n May want to consider palliative treatment only n Steroids for symptom management n Antiepileptics as needed n Whole brain irradiation may be indicated

A personal note…

n Discussions regarding end of life care

crucial in terminal diseases

n Hospice care, especially home hospice

care, provides comfort and addresses quality of life

n Goal is to help the patients live

comfortably on their own terms and choose how they want to live the rest of their lives

Thank You For Your Attention!!

Any Questions?