Oncologic EmergenciesOncologic Emergencies

Dr Karenza AlexisDr Karenza Alexis

Spinal Cord CompressionSpinal Cord Compression

1-5% of patients with systemic cancer1-5% of patients with systemic cancer

MUST BE TREATED IMMEDIATELYMUST BE TREATED IMMEDIATELYCan lead to irreversible paralysis or loss Can lead to irreversible paralysis or loss

of bowel and bladder functionof bowel and bladder function

Tumor or collapsed fragments in the Tumor or collapsed fragments in the epidural spaceepidural space

Spinal Cord CompressionSpinal Cord Compression

Most Common sitesMost Common sites Thoracic spine (70%)Thoracic spine (70%) Lumbrosacral (20%)Lumbrosacral (20%) Cervical (10%)Cervical (10%)

Most common malignanciesMost common malignancies LungLung BreastBreast Unknown primaryUnknown primary ProstateProstate RenalRenal Multiple myelomaMultiple myeloma LymphomaLymphoma

Spinal Cord CompressionSpinal Cord Compression

Symptoms and SignsSymptoms and Signs

Localized pain to the spineLocalized pain to the spine Exacerbated by movement, recumbency, coughing, Exacerbated by movement, recumbency, coughing,

sneezing, strainingsneezing, straining May appear weeks to months before neurological symptomsMay appear weeks to months before neurological symptoms

Radicular painRadicular pain

Weakness +/- sensory lossWeakness +/- sensory loss

Autonomic dysfunctionAutonomic dysfunction Urinary retention, constipationUrinary retention, constipation

Spinal Cord CompressionSpinal Cord Compression

Evaluation- complete neurologic and Evaluation- complete neurologic and physical exam that includes:physical exam that includes:

Gentle percussion of spinal columnGentle percussion of spinal columnPassive neck flexionPassive neck flexionStraight Leg raiseStraight Leg raiseMotor and sensory exam, ReflexesMotor and sensory exam, Reflexes

Pinprick testing toe to head- sensory levelPinprick testing toe to head- sensory level Is there a “sensory level”Is there a “sensory level”RECTAL examRECTAL exam

Spinal Cord CompressionSpinal Cord Compression

Diagnosis- image the ENTIRE spineDiagnosis- image the ENTIRE spine

XrayXray 66% will have bony abnormalities66% will have bony abnormalities Erosion, loss of pedicles, vertebral body collapse, Erosion, loss of pedicles, vertebral body collapse,

paraspinous soft tissue massparaspinous soft tissue mass Cannot exclude epidural mets Cannot exclude epidural mets Does not exclude cord compression if normalDoes not exclude cord compression if normal Follow-up with MRIFollow-up with MRI

MRIMRI STANDARD!!!!!!!STANDARD!!!!!!!

CT scanCT scan

Spinal Cord CompressionSpinal Cord Compression

Goal of treatment:Goal of treatment: recovery and maintenance of normal neurological recovery and maintenance of normal neurological

function,function, stabilization of the spinestabilization of the spine Local tumor control Local tumor control pain controlpain control

Treatment Outcome:Treatment Outcome: Degree of neurologic impairment Degree of neurologic impairment Radiosensitivity of tumorRadiosensitivity of tumor

Spinal Cord CompressionSpinal Cord Compression

Treatment:Treatment:SteroidsSteroids

START DEXAMETHASONE IMMEDIATELY if you START DEXAMETHASONE IMMEDIATELY if you suspect cord compressionsuspect cord compression

10 mg IVP followed by 4 mg IV every 6 hours 10 mg IVP followed by 4 mg IV every 6 hours (higher doses be used if patient presents with significant (higher doses be used if patient presents with significant neurological impairment)neurological impairment)

RadiationRadiationStable spine with radiosensitive tumors, non-Stable spine with radiosensitive tumors, non-

surgical candidates with spinal instability, surgical candidates with spinal instability, Port includes area of epidural involvement plus two Port includes area of epidural involvement plus two

vertebral bodies above and belowvertebral bodies above and below

Spinal Cord CompressionSpinal Cord Compression

SurgerySurgery

Tissue diagnosis neededTissue diagnosis needed Spinal instabilitySpinal instability Prior radiation to affected areaPrior radiation to affected area Progression of cord compression despite steroids and Progression of cord compression despite steroids and

radiationradiation

Resection followed by radiation therapy vs radiation Resection followed by radiation therapy vs radiation alonealone

ASCO proceedings 2003: combine modality patients had higher ASCO proceedings 2003: combine modality patients had higher ambulatory rate and retained ability to walk longerambulatory rate and retained ability to walk longer

Spinal Cord CompressionSpinal Cord Compression

In addition to initial evalutaion, imaging, In addition to initial evalutaion, imaging, steorids: multidisciplinary managementsteorids: multidisciplinary management

Neurology ConsultNeurology ConsultOncology ConsultOncology ConsultNeurosurgery ConsultNeurosurgery ConsultRadiation oncology ConsultRadiation oncology Consult

Superior Vena Cava SyndromeSuperior Vena Cava Syndrome

Malignant causesMalignant causes intrathoracic malignancies (60-85%)intrathoracic malignancies (60-85%)Lung cancer (more common in small cell), breast Lung cancer (more common in small cell), breast

cancer, testicular cancer, thymomacancer, testicular cancer, thymoma lymphoma and other malignancies with mets to lymphoma and other malignancies with mets to

mediastinummediastinum

Non-malignant causesNon-malignant causesThrombosis (most common cause in cancer Thrombosis (most common cause in cancer

patients)patients)Substernal thyroid goiter, TB, RT, sarcoidosisSubsternal thyroid goiter, TB, RT, sarcoidosis

Superior Vena Cava SyndromeSuperior Vena Cava Syndrome

Signs and symptomsSigns and symptoms Facial edema/ erythemaFacial edema/ erythema Dilatation of veins of upper bodyDilatation of veins of upper body Laryngeal or glossal edemaLaryngeal or glossal edema Periorbital edemaPeriorbital edema DyspneaDyspnea CoughCough OrthopneaOrthopnea Arm and neck edemaArm and neck edema HoarsenessHoarseness DysphagiaDysphagia HeadachesHeadaches DizzinessDizziness syncopesyncope

Symptoms worse with positional changes: bending forward, Symptoms worse with positional changes: bending forward, stooping or lying downstooping or lying down

Superior Vena Cava SyndromeSuperior Vena Cava Syndrome

Can Result in:Can Result in:

Life-threatening cerebral edemaLife-threatening cerebral edema

Laryngeal edema- airway compromiseLaryngeal edema- airway compromise

Superior Vena Cava SyndromeSuperior Vena Cava Syndrome Diagnosis- determine etiologyDiagnosis- determine etiology

Thorough Physical ExaminationThorough Physical Examination

CXRCXR May show mediastinal wideningMay show mediastinal widening

Doppler USG of jugular or subclavian veinDoppler USG of jugular or subclavian vein Differentiate thrombus from extrinsic compressionDifferentiate thrombus from extrinsic compression

CT scan or MRICT scan or MRI

BronchoscopyBronchoscopy

thoracoscopythoracoscopy

Superior Vena Cava SyndromeSuperior Vena Cava Syndrome

TreatmentTreatment Goal: alleviate symptoms and treat underlying diseaseGoal: alleviate symptoms and treat underlying disease Initial management depends on Grade of SVCS, Initial management depends on Grade of SVCS,

underlying disease, anticipated resposbseunderlying disease, anticipated resposbse

Determine underlying cause- especially if SVCS is presenting Determine underlying cause- especially if SVCS is presenting symptomsymptom

Pace of progression of symptomsPace of progression of symptoms

Treatment goal- Cure vs PalliationTreatment goal- Cure vs Palliation

Superior Vena Cava SyndromeSuperior Vena Cava Syndrome

TreatmentTreatment Symptom management: Elevation of head of bed, O2, bed restSymptom management: Elevation of head of bed, O2, bed rest

RadiotherapyRadiotherapy Cure vs PalliationCure vs Palliation Accurate histologic diagnosis needed priorAccurate histologic diagnosis needed prior EMERGENT RT needed if life-threatening symptoms/signs (stridor/ CNS EMERGENT RT needed if life-threatening symptoms/signs (stridor/ CNS

symptoms from cerebral edema)symptoms from cerebral edema) If Non-small cell lung cancerIf Non-small cell lung cancer Combine with chemotherapy if limited stage small cell lung cancer and Non- Combine with chemotherapy if limited stage small cell lung cancer and Non-

Hodgkin’s lymphomaHodgkin’s lymphoma

Stenting for life threatening symptoms especially in tumors not sensitive Stenting for life threatening symptoms especially in tumors not sensitive to chemotherapy or radiation or no diagnosis of cancerto chemotherapy or radiation or no diagnosis of cancer

ChemotherapyChemotherapy Lymphoma or germ cell tumor or small cell lung cancerLymphoma or germ cell tumor or small cell lung cancer

Consider thrombolysis, angioplasty if thrombosisConsider thrombolysis, angioplasty if thrombosis

Diuretics- transient, may cause dehydration and reduced blood flowDiuretics- transient, may cause dehydration and reduced blood flow

SteroidsSteroids

HypercalcemiaHypercalcemia

Occurs in 10-20% of cancer patients- bony Occurs in 10-20% of cancer patients- bony mets v paraneoplasticmets v paraneoplastic

Assocciated most commonly with:Assocciated most commonly with: myeloma, lung cancer (squamous cell), renal myeloma, lung cancer (squamous cell), renal

cancer, breast cancer, head and neck tumors, cancer, breast cancer, head and neck tumors, leukemias, unknown primariesleukemias, unknown primaries

HypercalcemiaHypercalcemia

Symptoms/ signsSymptoms/ signs

Presence may depend on speed at which hypercalcemia Presence may depend on speed at which hypercalcemia developsdevelops

General: dehydration, anorexia, pruritis, weight loss, fatigueGeneral: dehydration, anorexia, pruritis, weight loss, fatigue

CNS: weakness, hypotonia, proximal myopathy, mental status CNS: weakness, hypotonia, proximal myopathy, mental status changes, seizure, comachanges, seizure, coma

Cardiac: bradycardia, short QT interval, prolonged PR interval, Cardiac: bradycardia, short QT interval, prolonged PR interval, wide T wave, atrial or ventricular arrythmiaswide T wave, atrial or ventricular arrythmias

GI: nausea/vomiting, constipation, ileus, pancreatitis, dyspepsiaGI: nausea/vomiting, constipation, ileus, pancreatitis, dyspepsia

Renal: Polyuria, nephrocalcinosisRenal: Polyuria, nephrocalcinosis

Hypercalcemia of malignancyHypercalcemia of malignancy

DiagnosisDiagnosisIonized calcium, Serum immunoreactive PTH- like Ionized calcium, Serum immunoreactive PTH- like

substance, phosphorus, 1,25 dihydroxyvitamin Dsubstance, phosphorus, 1,25 dihydroxyvitamin D

If calcium only mildly elevated (<12) AND NO symptoms: If calcium only mildly elevated (<12) AND NO symptoms: encourage PO hydration, eliminate any offending agents, encourage PO hydration, eliminate any offending agents, follow closelyfollow closely

If calcium is >12 OR symptoms: If calcium is >12 OR symptoms: saline infusion (be aware of cardiac and renal saline infusion (be aware of cardiac and renal

function),function),loop diuretics (once euvolemia achieved). Follow loop diuretics (once euvolemia achieved). Follow

urine output and potassium, magnesium.urine output and potassium, magnesium.

Bisphosphonates inhibit osteoclast function e.g Bisphosphonates inhibit osteoclast function e.g pamidronatepamidronate

Onset of action 24 to 48 hoursOnset of action 24 to 48 hours

CalcitoninCalcitonin Inhibits bone degradation by binding directly to receptors Inhibits bone degradation by binding directly to receptors

on the osteoclaston the osteoclast onset of action is 2-4h but effect of short duration. Dose onset of action is 2-4h but effect of short duration. Dose

is 2-8 U/kg SC or IM every 6-12 his 2-8 U/kg SC or IM every 6-12 h

If calcium >12 or symptomsIf calcium >12 or symptoms

Gallium nitrate- inhibits bone resorptionGallium nitrate- inhibits bone resorption Onset of action 24 to 48 hoursOnset of action 24 to 48 hours 100-200 mg/m2/d IV over 24 hours for up to 5 days in volume 100-200 mg/m2/d IV over 24 hours for up to 5 days in volume

replete non-oliguric patientsreplete non-oliguric patients Once calcium is normal, stop treatment but CONTINUE TO Once calcium is normal, stop treatment but CONTINUE TO

MONITOR for its continued effectMONITOR for its continued effect AVOID use of nephrotoxic drugsAVOID use of nephrotoxic drugs

Plicamycin (25 ug/kg)Plicamycin (25 ug/kg)

Direct osteoclast inhibitory effects, may also block Vit D and Direct osteoclast inhibitory effects, may also block Vit D and PTH activityPTH activity

Onset of action is 24-48 hOnset of action is 24-48 h Toxicity with repeated use: renal and liver toxicity, Toxicity with repeated use: renal and liver toxicity,

thrombocytopenia thrombocytopenia

Tumor Lysis SyndromeTumor Lysis Syndrome Metabolic triad of hyperuriciemia, hyperkalemia, Metabolic triad of hyperuriciemia, hyperkalemia,

hyperphosphatemiahyperphosphatemia Can also lead to renal failure and hypocalcemia as Can also lead to renal failure and hypocalcemia as

secondary complicationssecondary complications

Chemotherapeutic agents cause cell lysis and cell death Chemotherapeutic agents cause cell lysis and cell death with release of intracellular components into the blood with release of intracellular components into the blood streamstream

Breakdown of nucleic acid, catabolism of hypoxanthine Breakdown of nucleic acid, catabolism of hypoxanthine and xanthine leads to elevated uric acidand xanthine leads to elevated uric acid

Potassium and phosphate are present at high levels in Potassium and phosphate are present at high levels in cytoplasmcytoplasm

LDH also released but not considered part of syndromeLDH also released but not considered part of syndrome

Tumor Lysis SyndromeTumor Lysis Syndrome

Risk Factors, Signs or SymptomsRisk Factors, Signs or Symptoms

Increased LDH, uric acid, creatinineIncreased LDH, uric acid, creatinine

Bulky, rapidly proliferating tumors treated with chemotherapyBulky, rapidly proliferating tumors treated with chemotherapy

Most often occurs with treatment of leukemias or high grade Most often occurs with treatment of leukemias or high grade lymphomaslymphomas

Cardiac arrythmias if hyperkalemia or hypocalcemiaCardiac arrythmias if hyperkalemia or hypocalcemia

Tetany if hypocalcemiaTetany if hypocalcemia

Renal failure if hyperphosphatemia and hyperuricemiaRenal failure if hyperphosphatemia and hyperuricemia

Tumor Lysis SyndromeTumor Lysis Syndrome ProphylaxisProphylaxis

Patient at high risk: leukemia, high grade lymphma, Patient at high risk: leukemia, high grade lymphma, rapidly proliferating bulky solid tumor (e.g small cell)rapidly proliferating bulky solid tumor (e.g small cell)

Vigorous PrehydrationVigorous Prehydration AllopurinolAllopurinol

Inhibits xanthine oxidaseInhibits xanthine oxidase Can cause xanthinuriaCan cause xanthinuria Prevents Prevents newnew uric acid formation uric acid formation

Careful Metabolic monitoringCareful Metabolic monitoring

TreatmentTreatment Rasburicase Rasburicase

(works for prevention and treatment) degrades uric acid to (works for prevention and treatment) degrades uric acid to more water soluble formmore water soluble form

Contraindicated in G6PD deficiencyContraindicated in G6PD deficiency Can cause hemolysisCan cause hemolysis

HyperuricemiaHyperuricemia

Hematological disorders: leukemias, high-grade Hematological disorders: leukemias, high-grade lymphomas, myeloproliferative disorders (e.g lymphomas, myeloproliferative disorders (e.g PCV)PCV)

Aggressive tumors, extensive diseaseAggressive tumors, extensive disease

Treatment of malignanciesTreatment of malignancies

MedicationsMedications

Renal impairmentRenal impairment

Hyperuricemia- treatmentHyperuricemia- treatment

ProphylaxisProphylaxis

Alkalinization of urine (urine pH >7)Alkalinization of urine (urine pH >7)Sodium bicarbonate to IVFSodium bicarbonate to IVFDiamoxDiamox

AllopurinolAllopurinol

Neutropenic FeverNeutropenic Fever

Medical EmergencyMedical Emergency Neutropenia: ANC<1000 (multiply total wbc by Neutropenia: ANC<1000 (multiply total wbc by

percentage neutrophils and bands)percentage neutrophils and bands) Single temperature greater than 101.3F or Single temperature greater than 101.3F or

sustained temperature >100.4F for more than sustained temperature >100.4F for more than one hour (for clnical purposes , single one hour (for clnical purposes , single temo>100.4F)temo>100.4F)

Remember there may still be infection in the Remember there may still be infection in the absence of fever: e.g elderly patients or patients absence of fever: e.g elderly patients or patients on steroidson steroids

May present with hypothermia, hypotension, May present with hypothermia, hypotension, clinical deteriorationclinical deterioration

START BROAD SPECTRUM ANTIBIOTICS START BROAD SPECTRUM ANTIBIOTICS ASAP!!!!ASAP!!!!

Neutropenic FeverNeutropenic Fever

Risk factors for occult infectionRisk factors for occult infectionDegree of neutropeniaDegree of neutropeniaRapid decline in ANCRapid decline in ANCProlonged duration neutropenia (> 7 Prolonged duration neutropenia (> 7

to 10 days)to 10 days)Cancer not in remissionCancer not in remissionComorbid illnessComorbid illnessPeripheral lines and central venous Peripheral lines and central venous

catheterscathetersUse of monoclonal antibodiesUse of monoclonal antibodies

Neutropenic FeverNeutropenic Fever Infectious source identified in 30%Infectious source identified in 30% 80% infection believed to arise from patient’s 80% infection believed to arise from patient’s

endogenous floraendogenous flora

Risk for specific types of infection may be Risk for specific types of infection may be influenced by underlying malignancyinfluenced by underlying malignancy Abnormal antibody production in CLL, functional Abnormal antibody production in CLL, functional

asplenia: encapsulated organisms- asplenia: encapsulated organisms- Strep Strep pneum.,hemophilus influenzae, Neisseria pneum.,hemophilus influenzae, Neisseria meningitidus, capnocytophaga canimorsusmeningitidus, capnocytophaga canimorsus

T cell defects e.g lymphoma: intracelluar pathogens- T cell defects e.g lymphoma: intracelluar pathogens- Listeria monocytogenes, Salmonella, Mycobacterium, Listeria monocytogenes, Salmonella, Mycobacterium, CryptococcusCryptococcus

High dose steroids: High dose steroids: Pneumocystis cariniiPneumocystis carinii

ALWAYS COVER Gram negativesALWAYS COVER Gram negatives Fungal and viral infections also possibleFungal and viral infections also possible

Neutropenic FeverNeutropenic Fever

Patients should be pancultured including from central line as well as CXRPatients should be pancultured including from central line as well as CXR

Further imaging depending on symptomsFurther imaging depending on symptoms

Generally start cefipime 2g Q8 (also take into consideration signs, Generally start cefipime 2g Q8 (also take into consideration signs, symptoms, recent antibiotic use)symptoms, recent antibiotic use)

GROWTH FACTOR supportGROWTH FACTOR support

Consider vancomycin if hypotension,mucositis, skin infection, presence of Consider vancomycin if hypotension,mucositis, skin infection, presence of catheter, hx MRSA, recent quinolonecatheter, hx MRSA, recent quinolone

Addition of antibiotics (including antifungal) depending on clinical response Addition of antibiotics (including antifungal) depending on clinical response and duration of neutropenia (add antifungal if anticipate or patient has and duration of neutropenia (add antifungal if anticipate or patient has prolonged neutropenia)prolonged neutropenia)

Consider catheter removal Consider catheter removal

Oncology ConsultationOncology Consultation Infectious disease consultationInfectious disease consultation