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Reviews some of the emergencies in Oncology. For nursing students. Covers common oncologic emergencies including brain metastasis, spinal cord compression, SVC syndrome / SVC obstruction, Pain, Hypercalcemia, Hyperleukocytosis and Febrile Neutropenia.
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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