Oncological emergencies - 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 tumorsSalsali 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

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 NEUTROPENIADURATION OF ANTIBIOTIC THERAPY:

IDSA guidelines , 2002

FEBRILE NEUTROPENIACOLONY 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 commoneach ~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

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

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

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