Common Oncologic Emergencies

Transcript

1. Common Oncologic Emergencies Robert W Warner MD Heartland Oncology and Hematology
2. House Calls Radio Show Sunday 9:30 am The Chuck & Don Show Tuesday 9:35 am KMA 960 AM kma960.com HeartlandOncology.com On the Radio
3. • Any clinical manifestation related to the treatment or presence of a patient’s cancer • May actually herald a cancer diagnosis • Onset can be insidious or develop rapidly Oncologic Emergencies Defined
4. • Superior Vena Cava Syndrome • Spinal Cord Compression • Neutropenic Fever • Hypercalcemia • Tumor Lysis Syndrome • Acute Leukemia • Extravasation • Dehydration Common Oncologic Emergencies
5. • Superior Vena Cava Syndrome • Spinal Cord Compression • Neutropenic Fever • Hypercalcemia • Tumor Lysis Syndrome • Acute Leukemia • Extravasation • Dehydration Common Oncologic Emergencies
6. • Obstruction of blood flow through the superior vena cava • Cancer of the lung is now the underlying process in approximately 70% of patients with SVCS Superior Vena CavaSyndrome
7. Superior Vena CavaSyndrome Anatomy
8. • Shortness of breath • Facial swelling and head fullness • Cough • Chest pain • Arm swelling • Trouble swallowing Superior Vena CavaSyndrome Symptoms
9. Superior Vena CavaSyndrome
10. • Prominent neck and chest wall veins • Facial and/or arm swelling • Cyanosis • Facial plethora Superior Vena CavaSyndrome Physical Findings
11. • Lung cancer • Lymphoma • Thymoma • Germ cell • Breast Cancer • SVC Thrombosis Superior Vena CavaSyndrome
12. • Chest x-ray • CT chest • Biopsy Bronchoscopic or CT-guided • Mediastinoscopy Superior Vena CavaSyndrome Diagnosis
13. Superior Vena CavaSyndrome
14. • Goals of therapy • Type of cancer • Staging of primary cancer Superior Vena CavaSyndrome Management
15. • Palliation ◦ Radiation therapy ◦ Endovascular stents ◦ Thrombolysis ◦ Angioplasty Superior Vena CavaSyndrome Management
16. • Before antibiotics the most common causes were from complications of untreated infection ◦ Syphilitic thoracic aneurysms ◦ fibrosing mediastinitis • Malignancy is presently the most common cause Superior Vena CavaSyndrome Etiology
17. • Lung cancer is the most common • Lymphoma is second most common • Together represent 94% of cases Superior Vena CavaSyndrome Etiology
18. • Small cell lung cancer ◦ Response rates – radiation 94%, chemo 93% ◦ Usually radiation + chemotherapy ◦ Relief in 7-10 days • Lymphoma ◦ Chemotherapy + radiation ◦ Relief within 2 weeks Superior Vena CavaSyndrome Management
19. • Bed rest with head elevated • Oxygen supplementation • Diuretics • Steroids Superior Vena CavaSyndrome Management
20. • Endovascular placement under fluoroscopy • Patients who have recurrent disease in previously irradiated fields • Tumors refractory chemotherapy • Patient too ill to tolerate radiation or chemotherapy Superior Vena CavaSyndrome Intraluminal Stents
21. • Superior Vena Cava Syndrome • Spinal Cord Compression • Neutropenic Fever • Hypercalcemia • Tumor Lysis Syndrome • Acute Leukemia • Extravasation • Dehydration Common Oncologic Emergencies
22. • The degree of pretreatment neurologic dysfunction is the strongest predictor of treatment outcome • Early intervention = treatment is effective in about 90% of patients Spinal Cord Compression
23. Spinal Cord Compression Anatomy
24. Spinal Cord Compression Anatomy
25. Spinal Cord Compression Anatomy
26. Spinal Cord Compression Anatomy
27. • Lung cancer • Prostate cancer • Breast cancer Spinal Cord Compression
28. • Metastatic tumor from any primary site • Tumors with predilection to metastasize to spinal column • Prostate, breast, and lung carcinoma ◦ 15-20% of cases • Renal cell, non-Hodgkin’s lymphoma, or myeloma ◦ 5-10% of cases Spinal Cord Compression Causes
29. • Compression of epidural venous plexus • Venous stasis • Hypoxia • Vascular permeability • Edema • Impaired cord function • Weakness and sensory impairment Spinal Cord Compression Symptoms
30. • Usually first symptom ◦ 80-90% of the time • Usually precedes other neurologic symptoms by seven weeks ◦ Increases in intensity • Severe local back pain • Aggravated by recumbency ◦ Distension of venous plexus • May become radicular Red Flag: Pain Spinal Cord Compression Symptoms
31. • Weakness tends to be symmetrical • Progressive weakness is followed by lost of gait function then paralysis • The severity of weakness is greatest with thoracic metastases Spinal Cord Compression Symptoms
32. • Diagnosis depends on ability to demonstrate a mass compressing the thecal sac • Plain radiographs are not enough • Historically this involved invasive procedures • Advent of MRI has allowed non-invasive diagnosis • Clinical examination is not reliable in determining level of lesion Spinal Cord Compression Diagnosis
33. • Entire imaging of spine is ideal ◦ Focused CT imaging can miss clinically unapparent lesions • Myelography and MRI are better than plain X-Rays, bone scans and CT for diagnosis Spinal Cord Compression Diagnosis
34. • Decadron • Surgery • Radiation therapy • Chemotherapy Spinal Cord Compression Management
35. • Indications for surgery ◦ Failure to respond to radiation ◦ Prior radiation to the site ◦ Unstable spine ◦ Bone fragments causing compression ◦ No diagnosis ◦ Rapid neurologic deterioration Spinal Cord Compression Management
36. Common Oncologic Emergencies • Superior Vena Cava Syndrome • Spinal Cord Compression • Neutropenic Fever • Hypercalcemia • Tumor Lysis Syndrome • Acute Leukemia • Extravasation • Dehydration
37. • Most common complication of chemotherapy • Bacterial infections most common (fungal infections increasing) • Gram - replaced by Gram + organisms (often methicillin resistant) Neutropenic Fever
38. • Single oral temp ≥ 101℉ or temp ≥ 100.4℉ for more than an hour • Neutropenia < 500 neutrophils • At least one-half of neutropenic patients who become febrile have an established or occult infection Neutropenic Fever Symptoms
39. • Symptoms may be minimal or absent • Blood cultures • Stool cultures if with diarrhea • Urine culture • Chest x-ray • Other work up Neutropenic Fever Diagnosis
40. • Broad-spectrum antibiotics • Colony-stimulating factors • Neutropenic precautions ◦ Good Handwashing ◦ Regular oral rinsing and cleaning with sponge ◦ Avoid rectal or vaginal manipulation Neutropenic Fever Management
41. • Seeding of the bloodstream from endogenous flora in the GI tract most common cause • Commonly cultured bacterial pathogens ◦ Gram neg (Pseudomonas, E Coli, Klebsiella etc..) ◦ Gram pos (Coag-neg staph, staph aureus, streptococcus etc…) • Commonly cultured fungal pathogens ◦ Candida species, Aspergillus ◦ usually arise later as a secondary infection in patients with prolonged neutropenia and antibiotic use • Viral pathogens ◦ HSV, VZV Neutropenic Fever
42. Outpatient Inpatient Neutropenic Fever
43. Common Oncologic Emergencies • Superior Vena Cava Syndrome • Spinal Cord Compression • Neutropenic Fever • Hypercalcemia • Tumor Lysis Syndrome • Acute Leukemia • Extravasation • Dehydration
44. • Most commonly seen in multiple myeloma and breast cancer • Other possibility: Hyperparathyroidism • Affected by albumin level ◦ Ionized calcium Hypercalcemia
45. • General: dehydration, weight loss, anorexia, pruritus, polydipsia • Neuromuscular: fatigue, lethargy, muscle weakness, confusion, psychosis, seizure, obtunded, coma • Gastrotestional: nausea, vomiting, constipation, ileus • Genitourinary: polyuria, elevated creatnine • Cardiac: arrythemia, bradcardia Hypercalcemia Symptoms
46. • Mediated by factors released be malignant cells that act to resorb calcium from bone • PTH related-protein Hypercalcemia
47. • Occurs in about 10 to 20% of patients with cancer • Both solid tumors and leukemias • Most common ◦ Breast ◦ Lung ◦ Multiple myeloma Hypercalcemia Epidemiology
48. • Increase urine excretion • Decrease bone resorption • Treat underlying disease • IV Hydration • Diuretics ◦ Furosemide not thiazide • Dialysis with renal failure Hypercalcemia Management
49. • Bisphosphonates ◦ Pamidronate or zolendronate • Calcitonin • Steroids • Oral phosphate • Gallium nitrate • Stop inactivity Hypercalcemia Management
50. • Osteonecrosis of the jaw • Recent case reports of jaw bone necrosis in patients on pamidronate • EDUCATION needed Hypercalcemia Newly discovered side effect…
51. Common Oncologic Emergencies • Superior Vena Cava Syndrome • Spinal Cord Compression • Neutropenic Fever • Hypercalcemia • Tumor Lysis Syndrome • Acute Leukemia • Extravasation • Dehydration
52. • Rapid release of intracellular contents into the blood stream and increased to life- threatening concentrations • High uric acid • High potassium • High phosphate • Low calcium Tumor Lysis Syndrome
53. • Muscle cramps • Renal failure • Cardiac arrythmia Tumor Lysis Syndrome Signs
54. • Large tumor burden • High proliferative fraction • Very sensitive to chemotherapy • High-grade lymphoma, leukemia with high counts, rarely solid tumors Tumor Lysis Syndrome
55. • Prevention is essential • IV Hydration • Sodium bicarbonate – urine pH ≥ 7.0 • Allopurinol • Check labs every few hours • Early dialysis Tumor Lysis Syndrome Management
56. • Monitor ◦ Vital signs ◦ Oxygenation ◦ Uric acid, phosphate, potassium, calcium, creatnine, LDH ◦ Urine output Tumor Lysis Syndrome Management
57. Common Oncologic Emergencies • Superior Vena Cava Syndrome • Spinal Cord Compression • Neutropenic Fever • Hypercalcemia • Tumor Lysis Syndrome • Acute Leukemia • Extravasation • Dehydration
58. Acute Leukemia
59. • Clonal neoplastic growth of immature cells of the hematopoietic system • Accumulate and replace normal cells • 20% or more leukemic blasts in the bone marrow Acute Leukemia
60. • Red cells – Anemia • Platelets – Hemorrhage • White cells – Infection • Leukemic infiltration • Tumor Lysis Syndrome • Disseminated intravascular coagulation Acute Leukemia
61. Acute Leukemia Infection Type Number % Gram negative bacilli 617 51 Gram positive 52 4 Anaerobes 19 2 Fungal 68 6 Multiple 116 9 Viral 9 0.7 Pneumocytosis and toxoplasma 3 0.3 Unidentified 325 27
62. • Peripheral smear • Bone marrow smear • CBC, CMP, LDH, DIC panel Acute Leukemia Diagnosis
63. • Goal is eradication of leukemic clone and restoration of normal blood cells • Complete remission is less than 5% blasts in the bone marrow • Induction chemotherapy ◦ Idarubicin or mitoxantrone ◦ Arabinoside C Acute Leukemia Management
64. • Infection ◦ Antibiotics ◦ Growth Factors ◦ Infection prophylaxis, isolation ◦ Oral hygiene ◦ Avoid rectal or vaginal manipulation • Hemorrhage ◦ Immediate access to blood products • Tumor Lysis Syndrome • DIC Acute Leukemia Management
65. • Peripheral blood myeloblasts ≥ 100,000/ uL represent a medical emergency requiring prompt reduction in the blast level to prevent leukostasis ◦ Leukopheresis ◦ Hydroxyurea ◦ Immediate chemotherapy Acute Leukemia
66. Common Oncologic Emergencies • Superior Vena Cava Syndrome • Spinal Cord Compression • Neutropenic Fever • Hypercalcemia • Tumor Lysis Syndrome • Acute Leukemia • Extravasation • Dehydration
67. Extravasations
68. • Leakage of chemotherapy agents into skin • “Home infusion therapy” has increased incidence • Most common with vesicants (doxorubicin, vincristine) Extravasations
69. • Pain, erythema at site • Swelling • Hours to days after chemotherapy • Necrosis Extravasations Signs and Symptoms
70. • Stop infusion, avoid compression • Heat, ice, or antidotes depending on the agent used • If patient presents soon after injection with erythema, refer to the oncologist or plastic surgery Extravasations Treatment
71. Common Oncologic Emergencies • Superior Vena Cava Syndrome • Spinal Cord Compression • Neutropenic Fever • Hypercalcemia • Tumor Lysis Syndrome • Acute Leukemia • Extravasation • Dehydration
72. Dehydration
73. • Often missed • Associated with delirium in 30% of CA patients • Causes include emesis, diarrhea, mucositis • 50% of colon CA patients • Infusional 5FU is big offending agent Dehydration
74. • Acutely: IV fluid resuscitation • Chronic: Anti-emetics, anti-diarrheals • Consider change of treatment (with oncology input) Dehydration Treatment
75. Common Oncologic Emergencies Robert W Warner MD Heartland Oncology and Hematology