Oncology 2020.pdf

10/18/2020 Cancer and Oncologic Emergencies John D. Gonzalez DNP, APRN, ACNP-BC 1 1 10/18/2020 Epidemiology Please read the power point presentation by the American Cancer Society about the Current Cancer Facts and Figures The link is provided in Canvas 2 2 10/18/2020 Tumor Classifications Benign Tu...

10/18/2020 Cancer and Oncologic Emergencies John D. Gonzalez DNP, APRN, ACNP-BC 1 1 10/18/2020 Epidemiology Please read the power point presentation by the American Cancer Society about the Current Cancer Facts and Figures The link is provided in Canvas 2 2 10/18/2020 Tumor Classifications Benign Tumors- Nonmalignant new growth Characteristics slow growing well encapsulated- do not invade surrounding tissues well differentiated cells- usually looks like the tissue it arose from and is named after it Lipoma-benign fatty tumor Leiomyoma- (leio=smooth, myo= muscle)- benign tumor of the smooth muscle of the uterus 3 3 10/18/2020 Tumor Classifications Malignant Tumors Rapid growth rate of cells poorly differentiated and disorganized cells invade surrounding tissues and structures are capable of metastasis are named after the cell of origin but in addition to the “oma” they have the root words “carcino” or “sarco” Tumors involving epithelial tissue usually have “carcinoma” plus the organ of origin. Hepatocellular Carcinoma- malignant tumor of the surface epithelial tissue of the liver adeno- refers to the glandular epithelial tissue (deeper epithelial tissue or glands) adenoma-benign tumor of the glandular tissue adenocarcinoma- malignant tumor of the glandular tissue 4 4 10/18/2020 Malignant Tumor Classification cont. Carcinoma in Situ- very early and pre-invasive carcinoma of the glandular or squamous epithelial tissue. It has not broken thru the basement membrane. The basement membrane is a very thin layer of tissue which separates the epithelium (skin, respiratory tract, GI tract, etc.), mesothelium (pleural cavity, peritoneal cavity, pericardial cavity etc.), and the endothelium (blood vessels, lymph vessels) from the underlying connective tissue. Malignant Tumors of Connective Tissue Have the root word “sarcoma” osteosarcoma- malignant tumor of the bone. (osteo=bone) osteoma- benign tumor of the bone Chondrosarcoma- malignant tumor of joint cartilage (chondro= cartilage) 5 5 10/18/2020 Malignant Tumor Classification cont. Malignant Tumors of the Muscle Tissue These tumors are named using the specific muscle type “sarcoma” and “myo” Uterine Leiomyosarcoma- malignancy of the smooth muscle of the uterus Rhabdomyosarcoma- malignancy of the skeletal muscle Malignant Tumors of Nervous Tissue Name is assigned based on the nerve cell type plus “blastoma” Neuroblastoma- malignancy of the nerve cell Neuroma- benign growth of nerve cell 6 6 10/18/2020 Malignant Tumor Classification cont. Exceptions to the Rule Lymphoma- malignancy of the lymphatic system, i.e. Hodgkin Lymphoma Leukemia- (leuk= white)- cancer of the WBCs, or leukocytes. There are several categories myleocytic- excessive production of granulocytes lymphocytic- excessive production of lymphocytes multiple myeloma- excessive production of plasma cells 7 7 10/18/2020 Paraneoplastic Syndromes Are manifestations of cancer which are caused by other factors than direct tumor invasion or compression. Their presence does not necessarily mean metastasis is present. Their presence is a sign of a cancer. They should trigger the nurse practitioner to consider the diagnosis of cancer in someone who is undiagnosed. The broad categories of paraneoplastic syndromes include: endocrine, dermatologic, neurologic, rheumatologic, and hematologic. They each come with their own set of clinical manifestations and are associated with certain type of cancer. I have provided you with a table of paraneoplastic syndromes which includes their clinical manifestations and associated cancers. You are only required to know the ones with an asterisk sign next to it and the others are provided for you as an FYI. 8 8 10/18/2020 Ovarian Cancer Second most common gynecologic malignancy (uterine cancer is most common), the most common cause of death from a gynecologic cancer, and the fifth leading cause of cancer death in women (lung and bronchus, breast, colon, and pancreatic cancer are more common) Epithelial ovarian cancer is the most common type. The incidence increases with age. Risk factors Family history Presence of the BRCA1 and BRCA 2 mutations. Persons with BRCA 1 mutation develop ovarian cancer on average 10 years earlier than those with BRCA2 mutation. The absolute risk of developing ovarian cancer over a lifetime associated with a BRCA 1 mutation is 35-45% and for BRCA 2 mutation is 15-25%. Early menarche or late menopause- it is thought that the increased number of ovulations leads to a pattern of ovarian injury and repair which contributes to the development of the cancer. The opposite is true. Infertility and Nulliparity Hereditary nonpolyposis colorectal cancer Endometriosis Risk is decreased by pregnancy, use of contraceptives, and breast feeding > 1year, tubal ligation, hysterectomy, salpingo-oophorectomy. 9 9 10/18/2020 Ovarian Cancer Most are diagnosed around age 65 There are no effective screening tools to help with early diagnosis. Clinical Presentation Disease that is localized to the ovary rarely has symptoms. Adnexal mass may be indicative of ovarian cancer. Advanced disease – manifestations are vague Abdominal fullness or bloating Pelvic heaviness, pelvic pain Painful intercourse Vaginal bleeding or discharge Lack of appetite, nausea, vomiting, constipation Other symptoms include: urinary frequency or urgency, difficulty eating or feeling full fast. Patients can present acutely with ascites, pleural effusions or bowel obstructions. They rarely have paraneoplastic syndromes but if they include: cerebellar degeneration, polyneuritis, dermatomyositis, hemolytic anemia, IDC, acanthosis, or nephrotic syndrome. Overall the symptoms associated with ovarian cancer are nonspecific and may be caused by gastrointestinal, urologic or other conditions. Symptoms that warrant further evaluation for ovarian cancer are those that are of new onset, coexist with other symptoms, occur nearly daily and are more severe than expected. 10 10 10/18/2020 Ovarian Cancer Diagnostic evaluation Pelvic examination Transvaginal US CA125 marker – elevated in 80% of women A definitive diagnosis can only be made via surgical exploration. This is done if there is enough data to suspect ovarian cancer. The patient should have a preoperative evaluation prior to surgery. Referral/Treatment GYN Surgical Oncology Goal of surgery is to achieve optimal surgical cytoreduction, which is defined as having no remaining tumor nodule 1cm or larger after surgery. Advanced cancers will need surgical debulking Will need chemotherapy 11 11 10/18/2020 Ovarian Cancer Screening and prevention There are no good reliable screening tests which can be used. The USPSTF recommends against screening. The society of gynecologic oncology recommends against screening low risk females. Those women who are BRCA1 and BRCA2 positive should have a prophylactic bilateral salpingo-oophorectomy at age 35 or after completion of childbearing. This reduces the risk by 90%, although these women remain at risk for primary peritoneal carcinoma. 12 12 10/18/2020 Uterine Cancer Is the most common gynecologic malignancy in developed countries. Adenocarcinoma of the endometrium is the most common type. Average age at diagnosis is 61. Risk factors include: unopposed estrogen, tamoxifen therapy, obesity, diabetes mellitus, advanced age, polycystic ovarian disease, nulliparity, late menopause. Lynch syndrome increases the risk of developing this cancer. It is recommended that these women have a total hysterectomy to reduce their risk after they have finished having children. These women should be screen yearly with an endometrial biopsy starting at age 30 or 5-10 years before the earliest age at diagnosis of a lynch syndrome related malignancy in the woman’s family. Other than these women routine screening is not recommended. 13 13 10/18/2020 Uterine Cancer Clinical Features The most common presenting symptom is abnormal vaginal bleeding, mainly in post menopausal women. Any bleeding (spotting or staining or otherwise) in a post menopausal woman should be evaluated for endometrial cancer. Women age 45 to menopause who have bleeding between menses, or heavy bleeding (> 80ml) or prolonged menses (> 7days) should be evaluated for endometrial cancer. Women younger than age 45 with abnormal bleeding which occurs in the setting of unopposed estrogen exposure (obesity, chronic anovulation) or failed medical management of bleeding or in women at high risk of cancer (i.e. has lynch syndrome) should be evaluated for endometrial cancer. Pelvic imaging (CT/MRI/US) which shows a thickened endometrial lining is concerning for endometrial cancer and should be evaluated even if this is an incidental finding. 14 14 10/18/2020 Uterine Cancer Evaluation Pelvic examination Women of child bearing age should have a pregnancy test Pelvic sonogram is the first line diagnostic and if the endometrial lining is < 4mm in a post menopausal woman a endometrial biopsy is not required. However for ongoing bleeding a biopsy should be performed even if the endometrial lining is < 4mm. Endometrial biopsy Treatment In the early stages is a hysterectomy is the treatment of choice and adjunctive chemotherapy is not required. Chemo and radiation may be require in advanced stages. 15 15 10/18/2020 Multiple Myeloma Is a hematologic malignancy characterized by the malignant transformation and proliferation of plasma cells in the bone marrow. Often these malignant plasma cells migrate to the bones and cause osteolytic lesions, osteopenia and pathologic fractures. Multiple myeloma accounts for 1% of all cancers and more than 17% of hematologic malignancies. It occurs 2-3 times more often in African Americans than in Caucasians. The risk is lower in Asians from Japan and in Mexicans. It does occur more frequently in men than women. This disease typically occurs in persons older than 50 but in rare instances may occur in persons who are younger. Median age of diagnosis is 65-74. An increased body mass index has been associated with an increase risk of multiple myeloma, as has exposure to agent orange. An increase risk has been noted in persons who have a first degree relative who has been diagnosed with this disorder. 16 16 10/18/2020 Multiple Myeloma Clinical Manifestations: The manifestations result from an infiltration of the malignant cancer cells into the bones or other organs. Multiple myeloma should be suspected when the individual presents with any of the following: Bone pain with lytic lesions seen on routine imaging. Vertebrae are the most common bone sites affected by the disease. Other bone affected include skull, ribs, femur, and pelvis. An increase in total serum protein concentrations The present of a monoclonal protein in the urine or serum Hypercalcemia Acute kidney injury Additional symptoms include: normocytic anemia, paresthesias, hepatomegaly, splenomegaly, lymphadenopathy, fever, weight loss, fatigue, and weakness. 17 17 10/18/2020 Multiple Myeloma Individuals with suspected multiple myeloma should be evaluated quickly. A delay in making the diagnosis has been associated with negative outcomes. Evaluation Chemistry Obtain a urinalysis. In MM there will be large, waxy, laminated casts. The urine dipstick is usually negative for protein. CBC with peripheral smear. The smear will show leukopenia, thrombocytopenia and rouleaux formation. This is when the RBCs look like a stack of coins. Serum free monoclonal light chain analysis. Will be positive in 20% of person with MM. SPEP and UPEP via 24 hour urine, both of which can detect the presence of the monoclonal protein (M protein), which is characteristic of MM. This is a protein which is produced and released by the malignant cells in 97% of patients. Bone marrow biopsy is a key part of the diagnostic evaluation. The presence of clonal bone marrow plasma cells >/= 10% is a major criterion for the diagnosis of MM. CT/MRI/Pet scans have demonstrated to be more sensitive than plain radiographs. MRI is the most sensitive for determining bone involvement. PET scan/CT are more sensitive at detecting extramedullary involvement. CT is often used even though it is less sensitive because it quicker and costs less than an MRI. 18 18 10/18/2020 Multiple Myeloma Diagnostic Criteria Clonal bone marrow plasma cells ≥ 10% or a biopsy proven bony or soft tissue plasmacytoma plus one of the following Presence of related organ or tissue impairment Presence of a biomarker associated with near inevitable progression to end organ damage. Treatment Initially all persons are treated with induction therapy (chemotherapy). Those eligible for a bone marrow transplant will receive one. If they are not they will continue with chemotherapy. 19 19 10/18/2020 Testicular Cancer This is the most common type of cancer in men age 15-35, however it only represents 1% of cancers in men. The survival/ cure rates are relatively high even when the disease is diagnosed in an advanced stage. It is 90% or higher. Risk factors include: Occurs most commonly between ages 15-35 Family history of testicular cancer Undescended testicle Inguinal hernia Infertility 20 20 10/18/2020 Testicular Cancer Disease presentation Presents as a painless, hard, heavy, firm testicular mass. May become painful if the tumor begins to hemorrhage inside of itself The tumor does not transilluminate May present with signs of metastasis Neck mass- supraclavicular lymph node mets Back pain secondary to mets to the retroperitoneum Anorexia, nausea, vomiting or GI hemorrhage- mets to the retroduodenal area. Cough or Dyspnea- mets to the lung Bone pain- skeletal mets Lower extremity swelling- iliac or caval venous obstruction or thrombosis Gynecomastia may occur but is not that common Physical exam Testicular exam – any firm, hard or fixed area is suspicious Check the abdomen and chest for any signs of metastasis Check for gynecomastia Check for supraclavicular lymphadenopathy which may indicate intrathoracic malignancy. 21 21 10/18/2020 Testicular Cancer Evaluation of a testicular mass A scrotal US It can see intra-testicular lesions as small as 1-2mm. It can distinguish between extra-testicular masses and intra-testicular masses. Intra-testicular masses are most commonly malignant. A cyst or fluid filled mass is not likely to be cancerous. Seminomas- are well defined, hypoechoic lesions with cystic areas Nonseminomatous germ cell tumors- are inhomogeneous with calcifications, have cystic areas, and indistinct margins. If a diagnosis of Testicular is made, then a CT of the Abdomen and pelvis, and CXR should be completed to evaluate for metastasis. HCG, AFP and LDH tumor markers should be done as part of the evaluation of a testicular mass, especially if you suspect cancer. If HCG > 10,000 or the person has multiple lung lesions a CT of the head needs to be completed because they are at a high risk for brain mets. 22 22 10/18/2020 Testicular Cancer Treatment is dependent upon the histologic subtype. Usually involves chemotherapy, sometimes surgery. Prior to doing radiographic evaluation and treatment for a male patient with testicular cancer the patient should be offered cryopreservation of sperm and one should discuss saving his sperm prior to radiation exposure if the patient wishes to preserve fertility. Complications Bone mets is common but not as common as from prostate cancer. Spinal cord compression, SVC Syndrome 23 23 10/18/2020 Testicular Cancer Screening and Prevention Testicular Self Examination USPSTF- recommends against testicular examination by the clinician or the patient. American Cancer Society- does not have a recommendation on regular self-examination but recommends that men with a family history, a history of undescended testicle, or previous testicular cancer consider doing self-examinations. American Academy of Physicians and the American Academy of Pediatrics do not recommend screening for testicular cancer in asymptomatic males. Routine Screening It is not recommended. There is no data on the effectiveness (sensitivity or specificity) of testicular self-examination. Biomarkers such as HCG or AFP. They are tumor markers and are elevated in 80-85% of testicular cancers, but they do not have sufficient sensitivity or specificity to be used as a screening tool. 24 24 10/18/2020 Testicular Cancer Clinical Pearl A testicular mass in a male patient age 60 and over should be considered testicular lymphoma until proven otherwise. This is the most common cause of testicular masses in this age group. 25 25 10/18/2020 TNM Staging This system is used to classify the size of the tumor, the degree of local invasion and the extent of distant metastasis. Diagnostic tests such as CT scan, MRI, bone scans assist with staging. Review the following website. The link is provided in blackboard http://www.cancer.gov/about-cancer/diagnosis-staging/staging/staging-fact-sheet#q3 What are the common elements of staging systems? What is the TNM System? Are all cancers staged with TNM Classifications? 26 26 10/18/2020 Patterns of Metastasis Metastasis occurs as direct invasion, hematogenous spread or via the lymphatic system Sites of Metastasis Bladder- bone, liver lung Breast- bone, brain, liver, lung Colorectal –liver, lung, peritoneum Kidney- adrenal gland, bone, brain, liver, lung Lung- adrenal gland, brain, liver, bone Melanoma- bone, brain, liver, lung, skin, muscle Ovary- liver, lung, peritoneum Pancreas- liver, lung, peritoneum Prostate- adrenal gland, bone (commonly to vertebrae), liver, lung Stomach- liver, lung, peritoneum Testicular- lungs, liver, brain Thyroid- bone, liver, lung Uterus- bone, liver, lung, peritoneum, vagina 27 27 10/18/2020 Tumor Markers Substances produced by the cancer cells that are found on tumor plasma membranes or in the blood, spinal fluid or urine. Are used to help diagnose, detect, or manage some cancers. A decrease may mean the cancer is responding to treatment and a resurgence of the marker may mean recurrence of the cancer. No change in the marker may mean the cancer is not responding to treatment. They are not good screening tools and should not be used as such. 28 28 10/18/2020 Tumor Marker Indicator Lab Value Alpha-fetoprotein Hepatocellular Carcinoma Testicular Cancer Normal range 1-15ng/ml Carcinoembryonic Antigen (CEA) Colorectal Cancer Levels > 50ng/ml consistent with cancer Beta Human Chorionic Gonadotropin (bHCG) Choriocarcinoma, teratomas, seminomas Normal range < 5mlU/ml Prostate Specific Antigen Prostate cancer Levels > 4.0ng/ml consistent with malignancy CA-125 Ovarian cancer Normal < 35U/ml CA19-9 Pancreatic cancer, gall bladder cancer and bile duct cancer Normal < 37.0U/ml CA15-3 Breast cancer Normal < 30U/ml CA27-29 Breast cancer Normal < 38U/ml 29 29 10/18/2020 Metastatic Work up Metastatic evaluation involves the search for a site of distant metastasis when the primary site of cancer is known. The evaluation will typically call for a CT of the head, CT of chest or CXR, CT of the abdomen and pelvis and/or a bone scan. Allow the clinical scenario to help guide the evaluation. Normal calcium, normal alkaline phosphatase, and no bone pain you do not need a bone scan at this point Most commonly you will need to scan the head, chest, abdomen and pelvis. Typically, a CXR is enough for screening but if a mass is identified a CT will need to be completed. Generally, you will use contrast. Contrast is contraindicated with elevated creatinine. Hemorrhagic brain tumors should be ruled out prior to initiating anticoagulation for DVT prevention or treatment. 30 30 10/18/2020 Diagnosis of Unknown Primary Cancer of unknown primary is defined by a pathologically confirmed site of mets when the primary site of cancer is not known. Adenocarcinomas are the most common type of cancer of unknown primary site. They most often arise from tumors of the lungs, pancreas, hepatobiliary tree, and the kidney. Other cancer types responsible for cancer of unknown primary include squamous cell, neuroendocrine both of which are rare and poorly differentiated. Diagnostic evaluation H&P including rectal exams, pelvic exams, breast and testicular exams. Identify possible risk factors Labs: CBC, CMP, UA, urine cytology Tissue biopsy of the site of metastasis (core or excisional biopsy) CT of thorax, abdomen, pelvis Positron emission tomography (PET scans) Reveal highly metabolically active tissues Can be used with CT scans Their use us debatable. Endoscopic evaluations Colon, EDG, bronchoscopy, laryngoscopy In women the evaluation should include a mammography and pelvic examination. Goal of evaluation is to identify the most appropriate treatment 31 31 10/18/2020 Oncological Emergencies and Complications 32 32 10/18/2020 Neutropenia Results from chemotherapy adverse reactions or from aplastic anemia or leukemia, or radiation therapy Defined as a ANC < 1500/mcl Absolute neutrophil count (ANC) This definition will vary but this is what we will use for our purposes. Is used to determine immune status ANC = WBC x (% neutrophils + %bands) x 1000 Count is used to determine when to order granulocyte stimulating factor (neupogen) which is typically not ordered unless the count is < 500. The risk of infection increases if the neutropenia lasts > 7days and/or with a count < 500. Risk of infection by gram positive and negative bacteria and fungi. The risk increases for bacteremia when the ANC is < 500. < 500 significant risk of infection (severe neutropenia) 7 days Low risk patients are those with ANC < 500 for ≤ 7 days With a Multinational Association for Supportive Care in Cancer Score of < 21 With a Multinational Association for Supportive Care in Cancer Score ≥ 21. Diagnosis H&P with good ROS CXR, UA, Urine culture, Blood cultures CBC, CMP, Procalcitonin if available Assess central access for infection 34 34 10/18/2020 Neutropenic Fever Management Initiate empiric antibiotic therapy for high risk patients Make sure to provide broad coverage. Gram positive organisms are the most common cause but you should provide broad coverage. The most common gram positive bacteria is staphylococcus. Gram negative bacteria may cause infection as well and are more virulent and association with sepsis. Antibiotics should be initiated after blood cultures have been obtained and within 60 minutes of presentation of symptoms. Initiating antibiotic therapy promptly is needed to prevent the progression to sepsis and death. Fungal pathogens are more common in high risk patients with prolonged, persistent neutropenic fevers. Candida spp and Aspergillus spp are the most invasive fungal infections during neutropenia. Initiate empiric antifungal if still febrile at 4 days, if a new fever develops after it got better, or new pulmonary infiltrates appear during therapy Lipid formulation of amphotericin B, caspofungin, voriconazole, itraconazole 35 35 10/18/2020 Neutropenic Fever Management Bacterial coverage Antipseudomonal beta lactam Cefepime, meropenem, imipenem-cilastatin, piperacillin-tazobactam May add other agents (aminoglycoside, fluoroquinolone or vancomycin) if the patient presents with complications such as hypotension, mental status changes, focal findings such as pneumonia or cellulitis or if antimicrobial resistance is suspected or proven Low risk patients may be treated outpatient with oral cipro in combination with a beta lactam agent such as Augmentin. Antibiotics should be continued until the ANC is greater than or equal to 500 cells/microL 36 36 10/18/2020 Tumor Lysis Syndrome Results from the rapid breakdown of cells and usually occurs as result of cancer treatment. The cell lysis (cancer) releases large amounts of nucleic acid, phosphorus and potassium into the blood. The catabolism of nucleic acids leads to hyperuricemia and increased renal excretion of uric acid. This can trigger renal vasoconstriction, decreased renal blood flow, and inflammation. All of which lead to AKI. Hyperphosphatemia leads to calcium phosphate deposition in the renal tubules and can also cause AKI. Mostly seen with lymphomas, acute lymphoblastic leukemia, chronic leukemia. Not as common with solid tumors. Clinical manifestations are largely related to the electrolyte imbalances. Clinical Risk factors for Tumor lysis syndrome Pretreatment hyperuricemia (uric acid > 7.5 mg/dL) Preexisting nephropathy or exposure to nephrotoxins Oliguria or acidic urine Dehydration, volume depletion, inadequate hydration during chemotherapy. 37 37 10/18/2020 Tumor Lysis Syndrome Clinical manifestations include lab abnormalities (hyperkalemia, hyperphosphatemia, hypocalcemia), nausea, vomiting, diarrhea, anorexia, lethargy, hematuria, heart failure, cardiac dysrhythmias, seizures, muscle cramps, tetany, syncope, AKI, and sudden death. 38 38 10/18/2020 Tumor Lysis Syndrome Laboratory Diagnostic criteria (2 of the following within 3 days before or 7 days after chemotherapy) Uric acid ≥ 8 mg/dl or 25% increase above baseline Potassium ≥ 6 mEq/L or 25% increase above baseline Phosphorus ≥ 6.5 mg/dl or 25% increase above baseline Calcium ≤ 7mg/dl or 25% decrease from baseline 39 39 10/18/2020 Tumor Lysis Syndrome Management Monitor electrolyte imbalances and treat accordingly Monitor electrolytes every 4-6 hours Rasburicase (Elitek) IV should be ordered if it was not given as prophylaxis. This is a urate oxidase agent which converts uric acids into an inactive metabolite. Given for 1-7 days depending on the patient’s response. Box warnings: RBC hemolysis. Contraindicated in persons with G6PD deficiency. Fatal hypersensitivities have been reported Development of methemoglobinemia Do not use this medication when using sodium bicarbonate. IV Hydration is the main treatment, up to 3000ml/m2/day Use loop diuretics in patients with low urine output < 2ml/kg/h Cardiac monitoring Use phosphate binders & dialysis if not working Do not treat hypocalcemia until the hyperphosphatemia is treated, to avoid calcium/phosphorus precipitation Standard hyperkalemia treatments Bicarb for metabolic acidosis Prevention Use allopurinol for persons at intermediate risk of TLS. Use rasburicase for those at high risk of TLS. IV hydration, aggressive hydration is the cornerstone of preventing TLS. Should be given to patients who are at intermediate or high risk of developing TLS. 40 40 10/18/2020 Superior Vena Cava Syndrome Results when tumor expansion results in obstruction of the superior vena cava and prevents the return of blood to the heart from the head, neck and upper extremities. Most commonly seen with lung cancer. May occur with lymphoma and primary mediastinal tumors. Clinical presentation Neck and facial swelling, venous distention of the neck and chest wall veins. Headache, dyspnea, dysphagia, hoarseness, cough Becomes emergent when there are issues with dyspnea CXR-mediastinal widening and pleural effusion 41 41 10/18/2020 Superior Vena Cava Syndrome Diagnosis Clinical exam Diagnostic imaging In persons with life threatening symptoms, the preferred evaluation is catheter-based venography as it provides the most expedient method for diagnosis and an opportunity for treatment. In persons with mild to moderate symptoms a duplex ultrasound is used to rule out a thrombosis in the subclavian, axillary and brachiocephalic veins. It is the initial test that should be done for anyone with an indwelling device or a malignancy at low risk for SVC. CT of chest with contrast can be used in persons with mild to moderate symptoms with a malignancy that is known to be associated with SVC. The presence of collateral vessels on CT is a strong indicator of SVC syndrome. A biopsy should be obtained if the patient does not have a known cancer diagnosis. 42 42 10/18/2020 Superior Vena Cava Syndrome Management Ensuring the airway is your first priority. Persons with airway compromise (stridor) require immediate, emergent treatment with endovenous recannulization with SVC stent. Radiation is no longer recommended as emergent treatment. Without this symptom, you have time to evaluate the patient and it is not considered emergent. The obstruction tends to occur over weeks and the most important thing in a stable patient is to get a histologic diagnosis. If there is no respiratory compromise it is not an emergency Stent placement is an option for a person requiring urgent intervention. Stent placement is associated with relief in 95-100% of patients. Chemotherapy or radiation. Oncology must manage the chemotherapy and radiation oncology must manage the radiation. 43 43 10/18/2020 Hyperleukocytosis Defined as the presence of a WBC > 50,000 to 100,000 This results in a leukostasis, impaired microcirculation and tissue hypoxia. High mortality Most commonly associated with acute myelogenous leukemia and chronic myeloid leukemia. It may occur in ALL, but is not very common. Clinical presentation Headache, blurry vision, confusion, ischemic stroke with hemorrhage conversion, heart failure, NSTEMI, acute kidney injury, DIC Dyspnea and hypoxia CNS symptoms may indicate intracranial hemorrhage. They are at an increased risk of intracranial hemorrhage, until at least one week post resolution of the crisis. Many patients will experience a spontaneous tumor lysis syndrome 44 44 10/18/2020 Hyperleukocytosis Management Consult Hematology/Oncology Patient should receive emergent chemotherapy. Treatment to prevent tumor lysis syndrome should be given. Hydroxyurea may be given for treatment if the patient is unable to start emergent chemotherapy. Remember to give treatment to prevent TLS. Emergent initiation of chemotherapy if diagnosis is known Leukapheresis –controversial but used as a temporary measure. Should be used in persons who cannot receive emergent chemotherapy. Correct coagulopathies, do not give any RBC transfusions. This will trigger symptomatic leukostasis. Give platelet transfusion to keep the count at 20,000 to 30,000 microL. 45 45 10/18/2020 Chemotherapy Complications /Adverse Effects Chemotherapeutic drugs have many toxicities and affect many body systems. Below is a list, which is by no means comprehensive, of the many side effects which may result from cancer chemotherapy. Pancytopenia (neutropenia, anemia, thrombocytopenia), Cardiomyopathy/ heart failure Liver toxicity, Pulmonary edema Respiratory failure, Nausea and vomiting Stomatitis, diarrhea, Nephropathy, Neuropathy Alopecia, Hepatotoxicity Hearing loss, Myocardial ischemia DVT /PE, Leukemia Hemorrhagic cystitis 46 46 10/18/2020 Chemotherapy Complications /Adverse Effects Certification is now asking questions about specific side effects of specific chemotherapeutic agents. Please know these medications and their side effects. Cyclophosphamide (Cytoxan)- alopecia, myelosuppression, hemorrhagic cystitis, cardiotoxicity in high doses Ifosfamide (Ifex)-alopecia, myelosuppression, hemorrhagic cystitis, neurotoxicity Carboplatin (Paraplatin)- myelosuppression, electrolyte imbalances, peripheral neuropathy, nephrotoxicity Cisplatin (Platinol)-myelosuppression, electrolyte imbalances, peripheral neuropathy, nephrotoxicity Methotrexate (MTX)- myelosuppression, nephrotoxicity, hepatoxocitiy, neurotoxicity, photosensitivity, pulmonary toxicity Dacarbazine (DTIC)- photosensitivity, myelosuppression, anorexia, hypotension, flu-like symptoms Cytarabine (Ara-C)-N/V, rash, flu like symptoms,. Myelosuppression, neurotoxicity, ocular toxicity 47 47 10/18/2020 Chemotherapy Complications /Adverse Effects Know these medications too. Fluorouracil (5-FU) – diarrhea, myelosuppression, mucositis, photosensitivity, cardiotoxicity Gemcitabine (Gemzar)- N/V, rash, flu like symptoms, fever, diarrhea, myelosuppression, edema, elevated transaminases Vinblastine (Velban)- constipation, myelosuppression, alopecia, bone pain, malaise, toxic effects on the colon Vincristine (Oncovin)- constipation, toxic effects on the colon, peripheral neuropathy, alopecia Paclitaxel (Taxol) -diarrhea, myelosuppression, peripheral neuropathy, alopecia, edema, mucositis Danuorubicin (Cerubidine)- N/V, diarrhea, red/orange urine, myelosuppression, dose related cardiotoxicity Doxorubicin (Adriamycin) - N/V, diarrhea, red/orange urine, myelosuppression, dose related cardiotoxicity Etoposide (Vepesid)- N/V, diarrhea, fever, hypotension, myelosuppression, alopecia, fatigue You do not order chemotherapy drugs, unless you work for an oncologist and are trained to do this. Important that you assess any cancer patient that you are working with for the type of chemo, assess for side effects and determine where they are in their cycle. 48 48 10/18/2020 Hypercalcemia Hypercalcemia related to malignancy can be very resistant to treatment. Review treatment in your fluid and electrolyte lecture from N5461. 49 49 10/18/2020 Spinal Cord Compression Compression most commonly occurs as a result of mets from lung, breast, prostate cancers. May occur in Non Hodgkin’s lymphoma, multiple myeloma, and renal cancers. Early recognition is important. Restoration of neurologic function is related to the degree of neuro damage. Early recognition can minimize damage. Clinical Presentation New onset of back pain in any cancer patient must be evaluated and considered malignant spinal cord compression. Most commonly affects the thoracic spine. Pain usually precedes the onset of any neurologic symptoms by seven weeks. Pain tends to be worse at night and over time will become radicular in nature. Pain present only on movement is indicative of spine instability. Neuro symptoms will be dependent upon the level of the spinal cord affected. Urinary retention may occur. Bowel and bladder dysfunction are late findings. 50 50 10/18/2020 Spinal Cord Compression MRI of the entire spine is the diagnostic test of choice. Should be performed with and without contrast. Consultations required by oncology, neurosurgery, radiation oncology Treatment Dexamethasone 10mg IV bolus then 16 mg total daily dosing in divided doses. Ongoing doses may be given IV or PO. Pain control VTE prophylaxis- using LMWH or heparin Surgery may be needed. It is generally indicated for instability. Radiation may be able to avoid the need for surgery. This means you will need to consult neurosurgery and radiation oncology. 51 51 10/18/2020 Other complications Increased Intracranial Pressure Observe for neurologic symptoms Treated with dexamethasone SIADH- review in endocrine lecture DIC – review in disorders of hemostasis Septic shock- will be reviewed in the sepsis lecture 52 52 10/18/2020 Geriatric Considerations The overall incidence of cancers as a whole tends to increase with age. So we tend to see many elderly patients with a cancer diagnosis. The treatment for many cancers is very potent and has many toxicities and in the elderly patient they are likely to be more sensitive to the toxicities. Additionally, given that this patient population tends to have higher morbidity than their young counter parts treatment can potentially be even more challenging. One must consider the renal function, hepatic function, the patient nutritional status, functional status in order to determine if curative treatment is an option or if the risk benefit ratio is worth it. 53 53