Published on July 22, 2014
ONCOLOGIC EMERGENCIES 2014 A PRIMER FOR NURSING STUDENTS
INTRODUCTION SVC SYNDROME FEBRILE NEUTROPENIA HYPERCALCEMIA OF MALIGNANCY HYPERLEUKOCYTOSIS SPINAL CORD COMPRESSION BRAIN METASTASIS TUMOR LYSIS SYNDROME PAIN
S V C SYNDROME
SVC SYNDROME Superior vena cava syndrome (SVCS) is the mass effect in the mediastinum resulting in obstruction of SVC and compression of other structures. Obstruction may be : INTERNAL : Thrombus EXTERNAL : Mass effect - malignant - non-malignant MALIGNANCIES ASSOCIATED WITH SVCS: Lung Cancer – SCLC , NSCLC N H L Thymoma Germ cell tumors of mediastinum Metastatic tumors Salsali M, Cliffton EE. N Y State J Med 1969 ; Bell DR Med J Aust 1986 ; Parish JM Mayo Clin Proc 1981
SVC SYNDROME CLINICAL FEATURES SYMPTOMS: Early symptoms – Dyspnea and nonproductive cough , headache, dysphagia, hoarseness, chest pain, facial puffiness Late symptoms - Visual disturbances, dizziness, syncope, lethargy, irritability and mental status changes
SVC SYNDROME CLINICAL FEATURES SIGNS : Early signs - Edema of the face, neck, upper thorax, breasts, and upper extremities (Stoke’s sign ) , Facial plethora & dilated veins of face, neck and thorax ( Pemberton’s sign ) Periorbital edema Conjunctival edema & congestion Compensatory tachycardia Late signs - Cyanosis of the face or upper torso Mental status changes Tachypnea, orthopnea, stridor and respiratory distress Seizures, stupor, coma Haapoja & Blendowski, 1999 ;
SVC SYNDROME EVALUATION - C X R May show : » Mediastinal widening » Paratracheal shadow » Pleural effusion » Primary / Secondary lung disease
SVC SYNDROME MANAGEMENT GENERAL MANAGEMENT: Bed rest with the head elevated Oxygen administration Corticosteroids Diuretic No IV line in upper limbs. SPECIFIC MANAGEMENT : SCLC – Chemotherapy ± RT NSCLC – RT + CT NHL – CT ± RT Catheter induced thrombosis - Thrombolysis Stenting
FEBRILE NEUTROPENIA DEFINITION : FEVER : ~ single oral temperature of 101 º F (38.3° C) OR ~ oral temp of 100.4 º F ( 38° C) lasting more than 1 hr NEUTROPENIA : ~ ANC < 500 / mm3 OR ~ count of <1000 cells/mm3 with a predicted decrease to <500 cells/mm3
FEBRILE NEUTROPENIA FACTORS INFLUENCING RISK OF INFECTION BREACH OF SKIN AND MUCOSAL BARRIERS : IV access devices Mucositis Surgery Tumor growth DISEASE & THERAPY RELATED FACTORS : CLL , MM Hypogammaglobulinemia : Pneumococcus, H.influenza, N.meningitidis ALL, HD, NHL defective CMI : P.Carini, Cryptococcus, Salmonella Steroids : Aspergillosis, Crytococcus, P.carini, Mycobacteria & atypical Mycobacteria High dose Cytarabine Mucositis : Streptococcal
FEBRILE NEUTROPENIA INITIAL EVALUATION HISTORY : Time since last chemotherapy administration, Major co-morbid illness, Travel, Others at home with similar symptoms, History of prior documented infections etc PHYSICAL EXAMINATION : To find any focus of infection. » IV access site » Oropharynx » Nasal cavity » Skin including Perivaginal & Perineal regions INVESTIGATIONS : » CXR » CBC, electrolytes, BUN, LFT » Blood culture – 2 sets. » Throat / wound swab as indicated » Urine / Stool culture according to symptoms
FEBRILE NEUTROPENIA CHARACTERISITCS OF HIGH RISK & LOW RISK PATIENTS HIGH RISK - Inpatients - Associated co-morbidities ( hypotension, dehydration, hypoxia ) - Uncontrolled / progressive cancer - Sr. Creatinine > 2 mg/dl - LFT > 3 times normal - HSCT / BMT recipient - Prolonged severe neutropenia anticipated LOW RISK - Outpatients - No associated co-morbidities - Good PS ( ECOG 0 –1 ) - Sr. Creatinine < 2 mg/dl - LFT 3 times normal - Non-transplant, solid tumor or lymphoma patient - Anticipated duration of neutropenia < 7 days I D S A RISK STRATIFICATION * * Infectious Diseases Society of America guidelines , 2002.
FEBRILE NEUTROPENIA MANAGEMENT ALGORITHM -1 Hughes et al. Comm & Inf Dis , 2002, 34: 730-51.
FEBRILE NEUTROPENIA INDICATIONS FOR VANCOMYCIN (1) Clinically suspected serious catheter-related infections (e.g., bacteremia, cellulitis), (2) Known colonization with penicillin- and cephalosporin-resistant pneumococci or methicillin-resistant S. aureus, (3) Positive results of blood culture for gram-positive bacteria before final identification and susceptibility testing, or (4) Hypotension or other evidence of cardiovascular impairment IDSA guidelines , 2002 International Antimicrobial Therapy Co-operative Group of EORTC, NEJM , 1999.
FEBRILE NEUTROPENIA INITIAL EMPIRICAL ANTIBIOTICS IN LOW RISK PATIENTS Oral Ciprofloxacin + Amoxycillin / Clavulanate For those allergic to Penicillins: Ciprofloxacin + Clindamycin IDSA guidelines , 2002 International Antimicrobial Therapy Co-operative Group of EORTC, NEJM , 1999.
FEBRILE NEUTROPENIA MANAGEMENT ALGORITHM -2 IDSA guidelines , 2002
FEBRILE NEUTROPENIA EMPIRICAL ANTIFUNGAL THERAPY For patients with persistent fever after 3 days of antibiotics. IDSA guidelines , 2002
FEBRILE NEUTROPENIA DURATION OF ANTIBIOTIC THERAPY: IDSA guidelines , 2002
FEBRILE NEUTROPENIA COLONY STIMULATING FACTORS: IDSA guidelines , 2002 • Can consistently shorten the duration of neutropenia • Have not consistently and significantly reduced other measures of febrile morbidity, including duration of fever, use of anti-infectives, or costs of management of the febrile neutropenic episode. • Possible use: ~ Conditions in which worsening of the course is predicted and there is an expected long delay in recovery of the marrow eg.pneumonia, hypotensive episodes, severe cellulitis or sinusitis, systemic fungal infections, and multiorgan dysfunction secondary to sepsis ~ For patients who remain severely neutropenic and have documented infections that do not respond to appropriate antimicrobial therapy. Not recommended for routine use to treat febrile or afebrile neutropenic patients.
HYPERCALCEMIA OF MALIGNANCY
HYPERCALCEMIA Occurs in 10 % of cancer patients. Malignancies associated with Hypercalcemia include: Multiple myeloma Breast cancer Lung cancer Lymphomas Renal cell carcinoma Esophageal cancer
HYPERCALCEMIA TYPES OF HYPERCALCEMIA HUMORAL HYPERCALCEMIA ~ PTHrP LOCAL OSTEOLYTIC HYPERCALCEMIA ~ Osteoclast activation ~ IL- 1, IL – 6 , TNF ~ TGF α , PGE 2 ~ RANKL ( receptor activator of nuclear factor kB ligand ) VITAMIN D LINKED HYPERCALCEMIA ~ activated mononuclear cells may secrete calcitriol ~ overexpression of RANKL has been suggested
HYPERCALCEMIA CLINICAL FEATURES GENERAL : Dehydration, Weight loss, Anorexia, Pruritus, Polydipsia NEUROMUSCULAR : Fatigue, Lethargy, Muscle weakness, Seizure, Hyporeflexia, Confusion, Psychosis, Coma. GASTROINTESTINAL : Nausea, Vomiting, Constipation, Ileus . GENITOURINARY : Polyuria CARDIAC: Bradycardia, Prolonged PR interval, Shortened QT interval, Wide T wave, Atrial or ventricular arrhythmias .
HYPERCALCEMIA - CLINICAL FEATURES “stones, bones, groans and moans”
SPINAL CORD COMPRESSION
SPINAL CORD COMPRESSION
SPINAL CORD COMPRESSION • Major emergency requiring radiation treatment • Can lead to permanent neurologic dysfunction – Ambulatory status is most important prognostic feature • 80-90% of patients ambulatory at treatment retain function
SPINAL CORD COMPRESSION • 2.5–5.0% of patients have spinal cord compression (SCC) within the last 2 years of illness. • Prostate, breast cancer, lung cancer most common each ~15–20% NHL, multiple myeloma, and renal cancer ~5–10% of patients Men 40-60 years with prostate cancer = 17% incidence • Thoracic spine affected in 60-80% of cases • 50% present with disease in multiple spinal areas
SIGNS AND SYMPTOMS • New onset back pain – Initially localized, typically increasing in intensity In particular: – Pain that worsens when the patient is lying down – Pain with percussion of vertebral bodies • Weakness – 60-85% of patients present with weakness – ~2/3 are non-ambulatory at presentation • Late neurologic signs are associated with permanent deficits such as paraplegia • Urinary retention • Loss of sensory function
EVALUATION • Non-contrast MRI of whole spine is best test – If MRI not available, can use Myelography/CT • MRI is better because – Multiplanar imaging – No radiation – Contrast/needle not required to delineate lesions – Can detect multiple lesion – Should get whole spine MRI • 97.6% sensitivity; 100.0% speciﬁcity • Able to detect multi-level disease • Biopsy if: – metastatic disease not proven/documented – no previous diagnosis of cancer
TREATMENT Generally , • CORD COMPRESSION WITH FRACTURE AND UNSTABLE BONE FRAGMENTS : Surgical decompression and stabilisation. • CORD COMPRESSION WITH FRACTURE, STABLE FRAGMENTS : Radiation therapy • CORD COMPRESSION, NO FRACTURE : Radiation Therapy • May change depending on histology. Eg . Lymphomas – Chemo. • Start on steroids immediately to reduce edema and further cord compression. • Strict bed rest is absolutely vital.
BRAIN METASTASIS Most common form of malignant CNS involvement Up to 200,000 cases/year in US Most common sites: Lung Breast Melanoma Leukemia/lymphoma Causes symptoms via: Direct compressive effects Vasogenic edema
EVALUATION Signs/symptoms depend on location of mets Common: Headaches Seizures Focal deficits (e.g. weakness) Work up includes Physical Exam delineate neurologic deficits CT head MR head Can show lesions too small for CT Better tissue contrast
GENERAL MANAGEMENT Symptomatic treatment Anticonvulsants – ONLY IF SEIZURES OCCUR. Non-enzyme inducing anticonvulsants are preferred Phenytoin / Phosphenytoin Levetiracetam Hemorrhagic mets more likely cause seizures Prophylaxis may be indicated in these cases Dexamethasone For vasogenic edema • Start with 16 mg IV bolus and switch to 8 mg BD. 20% Mannitol – 100 ml / given over 15 min. TID. Check BP prior to infusion.
TREATMENT • Solitary brain mets : – Surgery RT – WBRT + Boost – SRS / SRT • Multiple brain mets : – Palliative WBRT – 30 Gy / 10 # • No role of chemo.
HYPERLEUKOCYTOSIS A clinicopathologic syndrome caused by the sludging of circulating leukemic blasts ( LEUKOSTASIS) in tissue microvasculature. RISK FACTORS : Younger age Acute leukemias Presence of certain cytogenetic abnormalities - Philadelphia chromosome - 11q23 translocation Mortality rate approaches 40 %
HYPERLEUKOCYTOSIS CLINICAL FEATURES Symptoms arising from involvement of pulmonary and cerebral vasculature are more common. PULMONARY LEUKOSTASIS: ~ symptoms range from mild dyspnoea to respiratory distress ~ CXR diffuse interstitial / alveolar infiltrate ~ ABG pseudohypoxemia INTRACRANIAL LEUKOSTASIS: ~ symptoms may range from confusion & somnolence to stupor & coma ~ may be preceded by focal CNS deficits OTHER MANIFESTATIONS : Retinal haemorrhage, Retinal vein thrombosis, Acute MI, Acute limb ischemia, Renal vein thrombosis , Priapism and DIC.
HYPERLEUKOCYTOSIS TREATMENT GENERAL MEASURES: ~ Hydration ~ Alkalinisation of urine ~ Correction of thrombocytopenia / prevention of DIC SPECIFIC MEASURES : ~ Leukapheresis – single session WBC counts by 20 – 50 % - also permits infusion of blood products. ~ Leukocytoreduction :Cytotoxic therapy - Hydroxyurea ~ Cranial radiation – has been used but not recommended routinely
PAIN • Moderate to severe pain experienced by 40% to 50% of cancer patients. • Very severe pain experienced by 25% to 30% of cancer patients . • 80% of terminal stage cancer experience moderate to severe pain
OVERVIEW OF PAIN • Causes – – Infection – Tumor related –Nervous system, bone, visceral, mucosal – Treatment Related – surgery, radiation therapy, chemotherapy, interventional procedures • Types : – Nociceptive : pain signals from nerve endings – Neuropathic : damage to nerve fibres.
WHO LADDER OF PAIN MANAGEMENT
RADIATION & PAIN RELIEF • Effective for Nociceptive and Neuropathic pain • Effective for mild to moderate and severe pain • Pain relief starting from within 24 hrs. • Complete effects seen after 1 - 2 months. • Brings about alleviation of other associated symptoms – tumor swelling, anxiety and depression, appetite.
RT DOSE / FRACTIONATION • 32.5 Gy / 13 # • 30 Gy / 10 # • 4 Gy / 5 # • 5 Gy / 4 # • 6 Gy / 2 # • 8 Gy / 1 # ALL ARE EQUAL AS FAR AS PAIN RELIEF IS CONCERNED
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