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Oncologic Emergencies

Greg V. Manson
Sept 5, 2008 and Sept 18, 2008

Oncologic Emergencies
4 Major types

– Metabolic emergencies (hypercalcemia,
hyponatremia, hypoglycemia, adrenal failure, lactic acidosis)

– Hematologic emergencies
(hyperleukocytosis, DIC, thrombosis )

– Infectious / Inflammatory emergencies
(typhlitis, pancreatitis, chemo infiltration, hemorrhagic cystitis )

– Mechanical emergencies (cerebral
herniation/status epilepticus, cardiac tamponade, SVC syndrome?)

911 VS 30512

Case 1:
77 y/o AAM w/ PMHx of CAD s/p CABG, DM, gout, bipolar I disorder, 5 year history of CLL comes to UCC fast track w/ severe fatigue, nausea, mild abdominal discomfort. Pt admitted to VA on ward 3B. He was seen by heme/onc and started on oral hydroxyurea after diagnosis of acute blastic transformation. You’re signed-out to follow up on PM renal function panel.

3 mg/dL creatinine was normal.3 mEq/L calcium 8. at 1.5 mg/dL lactate dehydrogenase (LDH) 28.Case #1 potassium 5.900 U/L and uric acid 14.1 mg/dL .1 mg/dL phosphate 5.

TUMOR LYSIS SYNDROME .

↓Ca) Uric acid crystals and/or CaPO4 in renal tubules = impaired renal function. ↑K . arrhythmia ↑K = life-threatening arrhythmia .Tumor Lysis Syndrome TLS: Metabolic derangements caused by the massive and abrupt release of cellular components into the blood after the rapid lysis of malignant cells. (↑phos . ↑uric acid . ARF. even death ↑phos leads to ↓Ca : tetany. seizures.

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AML. tumor chemosensitivity ALL. Multiple Myeloma. NHL. Burkitt’s Lymphoma (heme malignancies) Small cell >>> Hodgkin’s disease. GI. Solid Tumors ( breast. large tumor burden.) Signs and Symptoms are non-specific: Can occur before chemo.…Tumor Lysis Syndrome: WHO GETS IT? High tumor cell proliferation rate. but usually within 12 to 72hrs after starting chemo Nausea Vomiting Diarrhea Anorexia Syncope Lethargy Edema Fluid overload Cramps Sudden death . prostate etc.

corticosteroids. bortezomib. fludarabine. and hydroxyurea ) Can occur after radiation therapy. chemoembolization. etoposide. rarely from spontaneous necrosis LDH is considered by some a measure of tumor load and a marker of TLS risk .…Tumor Lysis Syndrome: WHO GETS IT? Usually develops after chemotherapy (paclitaxel. thalidomide. intrathecal chemotherapy.

diuretics (contraindicated in hypovolemia and obstructed uropathy) .” FLUIDS and HYDRATION: – Aggressive hydration and diuresis – Improve intravascular volume.…Tumor Lysis Syndrome Prevention & Management “The best management is prevention. renal blood flow. GFR (decrease [solute] in distal nephron/renal microcirculation) – +/.

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but not based on evidence based practice. NOT RECOMMENDED -Complications of alkalinization outweighs benefits (calcium phosphate precipitation.0 compared to pH of 5.0 -Xanthine/hypoxanthine is also significantly more soluble in basic urine .Historically used. metabolic alkalosis) .…Tumor Lysis Syndrome Prevention & Management ALKALINIZATION OF URINE: -Uric acid > 10x’s more soluble in pH of 7.

Used prophylactically for TLS -Prophylactic option for patients with a medium risk of TLS -Limitations: ----1)ineffective in reducing uric acid levels before chemoTx ----2) Xanthine and hypoxanthine precipitateobstructive uropathy ----3)reduces clearance of some chemoTx (azothiopurine & 6-mercaptopurine) .…Tumor Lysis Syndrome Prevention & Management ALLOPURINOL: -Competitive inhibitor of xanthine oxidase which decreases conversion of purine metabolites to uric acid.

$51.978 for 7 day stay VS.990 for 21 day stay w/ HD) .…Tumor Lysis Syndrome Prevention & Management RASBURICASE (recombinant urate oxidase) : -promotes catabolism of uric acid: Uric acid  allantoin (10x more soluble than uric acid) -100 adult pt (w/ aggressive NHL) got 3 to 7 days of rasburicase beginning day 1 of chemo: 1)Uric acid levels decreased w/i 4 hrs of rasburicase 2)Normalized uric acid levels maintained throughout chemo 3)No increase in creatinine observed 4)No patient required dialysis -One European and one US study showed that rasburicase prophylaxis resulted in net savings in health care costs ($9.

He is given 1L IVF and has routine labs drawn as he is transferred to Tower 6.1 C. Pt complains of fatigue and constipation. ICC nurses note temp of 36.Case #2: 55 y/o w/ Hx of AML s/p stem cell transplant several months prior. + orthostasis. Comes to ICC for scheduled and routine RBC transfusion. He is admitted under the diagnosis of “hypotension. BP= 82/58. He is also receiving outpatient chemo therapy via PICC.” .

97% on room air but is actively rigoring when you arrive WBC = 0.Case #2: Upon admission to floor he denies any other complaints. 88.06 . Additionally he has been taking tylenol for 1 day hx of headache and 2 weeks of bisacodyl suppositories His admission vitals : 99. 109/76. ANC=0.2 . and is compliant w/ meds.5. 20.

NEUTROPENIC FEVER .

Sustained Temp of 38.Single temp of 38.Neutropenic Fever Neutropenia: – ANC < 500 or <1000 w/ a predicted nadir of <500 cells – ANC = (WBC) x (% of neutrophils + % of bands) – Nadir usually occurs 5 to 10 days after last chemo dose and usually recovers w/i 5 days of nadir (certain leukemia/lymphoma regimens cause longer lasting and more profound neutropenia) Fever: .4oF) for more than 1 hour .3oF) .3oC (101.0oC (100.

bacteremia w/ only fatigue) Avoid digital rectal exams/manipulations Careful oral exam and exam of catheter sites if any Pan Cx .Neutropenic Fever Before era of empiric antibiotics. Common infections present atypically (asymptomatic UTIs. infections accounted for 75% deaths related to chemotherapy Fever is commonly the only symptom. PNA w/o infiltrates. meningitis w/o nuchal rigidity.

Risk increases w/ duration and severity of neutropenia. blasto. skin. GNR (P. coccidio. TB(prolonged steroids.sinus.Mediports) FUNGAL: . other high risk patients) . Gram + organisms = 62-76% of all bloodstream infections – Trend toward Gram + due to introduction of long-term indwelling lines (Hickmans. aspergillus (immunocompromised.aeruginosa) were the most commonly identified pathogens – 1995-2000. PNA) >>>histo.Neutropenic Fever BACTERIA: – Until 1980s. and number of chemotherapy cycles -Candida (lines). prolonged antibiotic use.

…(Neutropenic Fever) TREATMENT Numerous regimens studied: monotherapy demonstrated equivalent to two drug regimens (i. cefepime.e. meropenem) In critically ill. add on aminoglycoside (better G coverage) Addition of Gram (+) as initial empiric coverage in patients w/o port/catheter/line or mucositis has no proven clinical benefit (↑VRE) Vancomycin or Linezolid : -Clinical deterioration -Hypotension -Mucositis -Skin or catheter infection -Hx of MRSA colonization -recent quinolone proph .: piperacillin/tazobactam .

caspofungin (passed noninferiority trial.…(Neutropenic Fever) TREATMENT Fungal coverage (candida or aspergillus ssp. less nephrotoxic aspergillus failure?) – No fluconazole = ↓ efficacy . voriconazole(? failed noninferiority trial?). ): – Routinely added after 5-7 days of persistent neutropenic fever w/o clear source – Post mortem of fatalities after prolonged febrile neutropenia (1966-1975) = 69% w/ evidence of systemic fungal disease – Tx with liposomal amphotericin B (most common).

…(Neutropenic Fever) TREATMENT Colony Stimulating Factors (CSF): – NOT routinely used for neutropenic fever unless the patient had previous bout of neutropenic fever with prior chemo cycle. organ dysfunction. PNA) – Used in patients whose bone marrow recovery is expected to be especially prolonged. – Not shown to decrease mortality – Beneficial effects are quite modest – Used in neutropenic septic shock/severe sepsis (hypotension. .

currently still working as bartender. He comes to UH ED w/ complaints of persistent and progressive band like lower back pain. . He was discharged home w/ course of high dose NSAIDS.Case #3: 64 y/o WM w/o significant past medical history comes to ED w/ complaints of progressive LBP. He is normally very active and enjoys jogging/biking . which prompted him to come to medical attention. He went to Chagrin Highlands Urgent Care two weeks ago and got routine lumbosacral films which were essentially normal. He notes new unsteadiness when he walks for the last two days. He notes pain initially started approx 6-8 weeks ago w/o inciting event.

Case #3: In ED: vitals and labs were within normal limits MRI of spine showed metastatic disease diffusely noted w/ thecal sac impingement at level of L2-L3 PSA sent from ED = 68 .

SPINAL CORD COMPRESSION .

Spinal Cord Compression Neoplastic epidural spinal cord compression Neoplastic invasion of space between vertebrae and spinal cord (epidural invasion) Defined as ANY thecal sac indentation radiographically (spinal cord or cauda equina) .

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LOCATION: Thoracic spine: 60% Lumbosacral spine: 30% Cervical spine: 10% .

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NOT immediately life threatening unless it involves C3 or above Back pain is the precursor to spinal cord injury in almost all (96%)patients w/ spinal mets.Spinal Cord Compression Cord compression is a common complication in oncology patients (5-10% of all cancer patients: prostate. Pain similar to disc disease: except ↑ pain supine. lung. breast) which is a cause of pain and irreversible loss of neurologic function. ↓upright .

Spinal Cord Compression Besides back pain: – Radicular pain – Motor weakness – Gait disturbance – Bowel bladder dysfunction .

Spinal Cord Compression Diagnosis – Back pain + known malignancy = SCC until proven otherwise – Plain films NOT enough – Exam has poor accuracy with localizing level – MRI without contrast is the best test for SCC when suspected – Can resort to CT (myelography) if pt cannot tolerate MRI. or not available. . is not candidate for MRI.

Spinal Cord Compression TREATMENT – Steroids – Radiation Therapy – Surgery .

– Higher doses (100mg) may be associated w/ slightly better outcome in exchange for higher incidence of adverse effects. (low vs high dose studies = equivocal) – Taper once definitive treatment is underway . followed by 4mg q 4hrs. Reserved for paraplegia/paraparesis generally.…Spinal Cord Compression: Treatment Corticosteroids – Provides pain relief and anti-inflammation – Dexamethasone: Loading dose of 10mg to 16mg.

and the field of treatment – For extensive disease. type of tumor. – Doses is variable and determined by the quantity of previous XRT. breast).…Spinal Cord Compression: Treatment Radiation Therapy – This alone can be used for patients who are ambulatory and for pretreatment before paresis occurs. . limited survival = meaningful palliation (short courses) – Chemotherapy can be used but most tumor types not particularly chemosensitive (unless NHL. germ cell. Hodgkin’s.

improvements in instrumentation) . unknown etiology. life threatening compression.…Spinal Cord Compression: Treatment Surgery---evolving science – THEN: Previous studies: Laminectomy w/ or w/o RT vs RT alone = NO difference in outcome – Decompressive resection reserved for unstable spine. tumors that are not reliably radiosensitive or chemosensitive. – NOW: Newer studies show surgical intervention + XRT show BETTER functional status than XRT alone (anterior approach.

steroids – Bed rest: controversial.but generally unnecessary – Anticoagulation: DVT prophylaxis – Bowel regimen: autonomic dysfunction. opioids.…Spinal Cord Compression: Treatment Other Management issues – Quickly involve Rad/onc and NeuroSx / Ortho – Analgesia: opioids. limited mobility all contribute to constipation – Spinal bracing: only in patients with refractory pain .

…Spinal Cord Compression: Prognosis Best predictor is pre-treatment functional/neurologic status – Rapid onset and quick progression = poor Px – 75% of patients treated correctly while still ambulatory. will remain ambulatory – Only 10% of patients presenting with paraplegia will regain ambulatory status .

Mayo Clinic Procedings. Vol 26. et al. Krimsky. 2006. Schiff. Cleveland Clinic Journal of Medicine. Dennis MD. Kasper. June 2006: 81(6). William. Up to Date Online. 16th ed. 2008. March 2002 Treatment and Prognosis of Epidural Spinal Cord Compression. Koyamangalath Krishnan . 3. David et al. eMedicine. Journal of Clinical Oncology. May 31. 577582. Tumor Lysis Syndrome. 2008 Oncologic Emergencies for the Internist. Oncologic Emergencies: Diagnosis and Treatment.References: Guidelines for the Management of Pediatric and Adult Tumor LYsis Syndrome: An Evidence Based Review. Bernard et al. June 1 2008 Harrison’s Principles of Internal Medicine. Robbins. Up to Date Online. 835-848 Fever in the neutropenic adult patient with cancer. May 31. et al. Vol 69. Including Cauda Equina Syndrome.Gregory. Halfdanarsan et al.

Learning Objectives Identification of 3 major oncologic emergencies Management of tumor lysis syndrome Management of neutropenic fever Management of spinal cord compression .