Oncologic Emergencies 1 PDF

(L2) ONCOLOGIC EMERGENCIES 1  LECTURE 02 ONCOLOGIC EMERGENCIES 1 Types of oncologic emergencies ① Pericardial Tamponade 1 Cardiovascular...

(L2) ONCOLOGIC EMERGENCIES 1  LECTURE 02 ONCOLOGIC EMERGENCIES 1 Types of oncologic emergencies ① Pericardial Tamponade 1 Cardiovascular ② Superior Vena Cava Syndrome ① Increased Intracranial Pressure 2 Central Nervous System ② Spinal Cord Compression ① Bowel Obstruction ② Bowel Perforation 3 Gastrointestinal ③ Ascites ④ Esophageal Obstruction and Perforation ① DIC 4 Hematologic ② Leukostasis ③ Thrombocytopenia ① Sepsis in the leukopenic patient 5 Infectious ② Disseminated Viral Infections ③ Fungal and Parasitic Diseases ① Hyperuricemia ② Hypercalcaemia 6 Metabolic ③ Hypoglycemia ④ Lactic Acidosis ⑤ Tumor Lysis Syndrome 7 Orthopedic ① Pathologic Fracture ① Ureteral Obstruction 8 Renal ② Pelvic Tumors ① Airway Obstruction 9 Respiratory ② Pneumothorax ③ Effusion ① Pain ② Vomiting 10 Symptomatic ③ Mucositis ④ Dyspnea Dr.Noaman Page 1  Medicine - Delta Semester (7) Oncologic emergencies 1 hypercalcemia types ① Humoral hypercalcemia of malignancy (paraneoplastic syndrome):  80% of cases.  May or may not have bone metastasis but have tumors that secrete hormones and cytokines that cause calcium resorption form bone and hypercalcemia ② Local Osteolytic Hyperclacemia:  Occurs primarily in patients with extensive osteolytic bone metastasis. Symptoms and signs ① Impaired concentration ② Confusion 1 Central Neurological ③ Apathy ④ Drowsiness or lethargy ① Muscle weakness Peripheral 2 ② Hypotonia Neuromuscular ③ Decreased or absent deep-tendon reflexes ① Increased gastric acid secretion 3 Gastrointestional ② Nausea, vomiting, and anorexia ③ Constipation ① Polyuria ② Polydipsia ③ Dehydration 4 Renal 1. Thirst 2. Dry mucosa 3. Decreased or absent sweating 4. Concentrated urine Dr.Noaman Page 2  Medicine - Delta Semester (7) Oncologic emergencies 1 ① Slow cardiac conduction: 1. Prolonged P-R interval 2. Widened QRS 3. Shortened QT, ST intervals 5 Cardiovascular ② Bradycardia ③ Brady-arrhythmias can progress to: 1. Bundle branch block 2. Atrioventricular block with complete heart block treatment 1 Goal of therapy ① Correct dehydration ② Increase renal excretion of calcium with vigorous saline diuresis ③ Inhibit calcium resorption from the bone with antiresorptive agents ④ Treat the underlying malignancy 2 Pharmacological Intervention ① Bisphophonates:  Etidronate, zolendraonate, pamidronate  Prevents precipitation of calcium phosphate ② Zolendronate:  Usually the drug of choice but pamidronate may also be used (both are intravenous)  Serum creatinine must be closely monitored when using zolendronate ③ Calcitonin:  May be combined with one of the above if the serum creatinine is > 1.3mg/dl ④ Corticosteroid:  May be added to enhance and prolong the effects of the calcitionin Dr.Noaman Page 3  Medicine - Delta Semester (7) Oncologic emergencies 1 Hyperviscosity Syndrome DEFINITION AND ETIOLOGY  Elevated blood viscosity is the result of pathological increase in: ① Serum proteins ② Red blood cells (RBC) ③ White blood cells (WBC) ④ Platelets  Waldenstrom macroglobulinemia (WM) SYMPTOMS  Most common symptom is triad of: ① Neurological deficits ② Visual changes ③ Mucosal bleeding. MANAGEMENT ① Supportive care:  Intravenous fluid  Plasmapheresis ② Treatment of the underlying hematological condition Leukostasis  Definition: WBC sludging in microcirculation  Etiology: Usually acute leukemia  Clinical picture: Respiratory, neurological, or renal systems  Treatment: ① Leukapheresis ② Hydroxyurea ③ Chemotherapy Dr.Noaman Page 4  Medicine - Delta Semester (7) Oncologic emergencies 1 Pulmonary Embolism Clinical picture  The diagnosis of PE remains one of the most difficult to diagnose since it has a similar presentation as other cardiac and pulmonary disorders. ① Dyspnea (most common) (50%) ⑦ Arterial saturation of less than 92% on ② Tachypnea (> 20/min) (50%) room air ③ Pleuritic chest pain or ⑧ Low-grade temperature ④ Non-retrosternal chest pain ⑨ Tachycardia (>100/min) ⑤ Hemoptysis ⑩ Chest radiograph ⑥ Pleural rub Diagnostic workup  Assess for clinical probability (risk factors and presence of symptoms of DVT) ① D-dimer:  Will be elevated in 90% of patients ② Pulmonary angiogram:  Highly sensitive and specific for the diagnosis of emboli for the proximal pulmonary arteries  More distal emboli cannot be reliably detected ③ Magnetic resonance pulmonary angiography ④ ECG changes: (S1Q3T3” pattern) Dr.Noaman Page 5  Medicine - Delta Semester (7) Oncologic emergencies 1 MANAGEMENT ① Rapid institution of fractionated heparin or LMWH  If a high suspicion that therapy should be started even before results are back  Maintain a PTT of 1.5 to 2 times the control value  Monitor platelet counts ② Oral warfarin  It is started concurrently, and fractionated heparin is continued for 3 to 5 days until warfarin reaches a therapeutic level ③ Warfarin is continued for 3-6 months  The ideal duration of therapy is unknown but 6 months of therapy appears to decrease the risk of recurrent PE compared to 6 weeks.  If high risk for recurrent PE then they may receive long-term or life-long therapy Dr.Noaman Page 6  Medicine - Delta Semester (7) Oncologic emergencies 1 NEUTROPENIC FEVER definition  Neutropenia:  ANC 7 days ② Hemodynamic instability ③ Oral or Gl mucositis interfering with swallowing or causing diarrhea High ④ Neurologic/MS changes - new onset Risk ⑤ Intravascular catheter infection ⑥ New pulmonary infiltrate, hypoxemia or underlying chronic lung disease ⑦ Hepatic or renal insufficiency ⑧ MASCC < 21 ① Neutropenia anticipated ≤ 7 days ② No active medical co-morbidity ③ Adequate hepatic and renal function ④ Multinational Assoc for Supportive Care in Cancer Risk-Index Score (MASCC) ≥ 21 of 26. Low Burden of febrile neutropenia 0,3,5 Risk No hypotension 5 No COPD 4 Solid or Heme w/o fungus 4 No IVF 3 Outpatient 3 Age < 60 2 Dr.Noaman Page 7  Medicine - Delta Semester (7) Oncologic emergencies 1 Risk factors ① Degree of neutropenia ② Rapid decline in ANC ③ Prolonged duration neutropenia (> 7 to 10 days) ④ Cancer not in remission ⑤ Comorbid illness ⑥ Peripheral lines and central venous catheters ⑦ Use of monoclonal antibodies Common Types of Infections 1 Bacterial Infections Gram-negative bacteria Gram-positive bacteria  Primary causes of infection in granulocytopenic patients ① Staphylococcus aureus ① Esherichia coli ② Staphylococcus epidermidis ② Klebsiella pneumoniae ③ Pseudomonas aeruginosa 2 Fungal Infections  Fungal infections are an increasingly important cause of infections for cancer patients.  Factors contributing to fungal infections include the following: ① Prolonged granulocytopenia ② Implanted vascular access devices ③ Administration of parenteral nutrition ④ Corticosteroids ⑤ Prolonged antibiotic therapy Dr.Noaman Page 8  Medicine - Delta Semester (7) Oncologic emergencies 1 3 Viral Infections  Most viral infections in cancer patients are caused by: ① Herpes simplex virus (HSV) ③ Cytomegalovirus (CMV) ② Varicella zoster virus (VZV) ④ Hepatitis A or B virus  Various treatments are as follows: HSV and VZV ① Acyclovir ② Valcyclovir ③ Famciclovir HSV and VZV  Vidarabine is effective if used early CMV  Gancliclovir TREATMENT ① Treatment is immediate empiric antibiotic therapy administered intravenously in the hospital setting. ② Other precautions may include: 1. Isolation and protected environment 2. Administration of colony-stimulating factors (neupogen, granulocyte-macrophage colony-stimulating factor) 3. Supportive care to maintain fluid and electrolyte levels may be required ③ Highly specific therapy is initiated once an organism is identified ④ Combination antibiotic therapy usually includes: 1. Beta-lactam antibiotic (antipseudomonal) 2. Aminoglycoside ⑤ Indications for the empiric addition of vancomycin (15 mg/kg IV q12h): 1. Clinically suspected serious catheter-related infections (eg, bacteremia, cellulitis) 2. Known colonization with penicillin- and cephalosporin-resistant pneumococci or methicillin-resistant Staphylococcus aureus (MRSA) 3. Blood culture positive for gram-positive bacteria 4. Hypotension 5. Severe mucositis, if prior fluoroquinolone prophylaxis provided ⑥ Addition of antibiotics (including antifungal):  Depending on clinical response and duration of neutropenia (add antifungal if anticipate or patient has prolonged neutropenia) ⑦ Consider catheter removal Dr.Noaman Page 9  Medicine - Delta Semester (7) Oncologic emergencies 1 Tumor lysis syndrome DEFINITION  Metabolic triad of: ① Hyperuriciemia ② Hyperkalemia ③ Hyperphosphatemia  Can lead to renal failure and hypocalcemia as secondary complications MECHANISM WHO GETS IT ① High tumor cell proliferation rate ② Large tumor burden ③ Tumor chemosensitivity ④ ALL, AML, NHL, Burkitt’s Lymphoma (heme malignancies) ⑤ Small cell >>> Solid Tumors (breast, GI, prostate etc.) Dr.Noaman Page 10  Medicine - Delta Semester (7) Oncologic emergencies 1 CLINICAL PICTURE  Signs and Symptoms are non-specific  Can occur before chemo, but usually within 12 to 72hrs after starting chemo. ① Cardiac arrythmias if hyperkalemia or hypocalcemia ② Tetany if hypocalcemia ③ Renal failure if hyperphosphatemia and hyperuricemia ④ Nausea ⑨ Lethargy ⑤ Vomiting ⑩ Edema ⑥ Diarrhea ⑪ Fluid overload ⑦ Anorexia ⑫ Cramps ⑧ Syncope ⑬ Sudden death TREATMENT “The best management is prevention.” ① FLUIDS and HYDRATION:  Aggressive hydration and diuresis  Improve intravascular volume, renal blood flow, GFR  +/- diuretics (contraindicated in hypovolemia and obstructed uropathy) ② Allopurinol  Inhibits xanthine oxidase  Can cause xanthinuria  Prevents new uric acid formation  Careful Metabolic monitoring ③ Rasburicase  Degrades uric acid to more water soluble form ④ Treatment of hyperkalemia 1. Calcium gluconate 2. Sodium bicarbonate 3. Glucose + insulin 4. Hemodialysis for severe hyperkalemia not responsive to other measures Dr.Noaman Page 11  Medicine - Delta Semester (7) Oncologic emergencies 1 ⑤ Hyperphosphatemia 1. Phosphate binder: aluminium hydroxide 2. Minimize phosphate intake 3. Hemodialysis ⑥ Hypocalcemia 1. Treat only if symptomatic 2. 10% calcium gluconate 3. Use with caution in severe hyperphosphatemia ⑦ Hemodialysis  Indicated in oliguric renal failure not responsive to IVF or patients with volume overload Dr.Noaman Page 12