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Practical tips for managing oncology emergencies

Dr. Maria Aslam Medical Oncology Advanced Trainee Calvary Mater Newcastle. Practical tips for managing oncology emergencies. What are we talking about. Spinal cord compression Febrile neutropenia Superior vena cava obstruction Hypercalcaemia Tumour lysis syndrome. Not covering today:

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Practical tips for managing oncology emergencies

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  1. Dr. Maria Aslam Medical Oncology Advanced Trainee Calvary Mater Newcastle Practical tips for managing oncology emergencies

  2. What are we talking about • Spinal cord compression • Febrile neutropenia • Superior vena cava obstruction • Hypercalcaemia • Tumour lysis syndrome • Not covering today: • Raised intracranial pressure • SIADH

  3. Febrile Neutropenia • Definition of fever? • Definition of Neutropenia?

  4. Fever • Oral Temp • >38.4 c on one occasion • >38 c for one hour

  5. Definition of neutropenia • ANC <500 cells/microL • ANC<1000 cells/microL and predicted drop to <500 within the next 24 hours • absolute neutrophil count (ANC) <1500 cells/microL

  6. High risk of serious complications • Any organ dysfunction • Haemodynamic instability • Neutropenia expected to last >7 days • Inpatient status at time of neutropenic fever • Mucositis

  7. Pathogenesis- • Breech of mucosal integrity in the alimentry tract • Obstruction of biliary, bronchial, urinary tract • Immunosuppression related to maligancy or treatment

  8. Source of infection • 80% from endogenous flora • Only positive finding in 10-25% patients is bactaraemia • Infective source identified in 20-30% of patients

  9. Urgent treatment is essential • Do not wait for results of investigations • Take blood cultures and start empiric antibiotics

  10. Initial treatment until WCC available-our protocol • Standard • Piperacillin/tazobactam 4.5 g IV q8h and • Gentamycin 7 mg/kg (1 dose) • Add Vancomycin if suspect line sepsis • If hypotension, line infection or severe mucositis • Meropenem 1g IV q8h and • Vancomycin 15mg/kg bd

  11. Re-evaluate at day 3 • Ongoing fever • add vancomycin • Afebrile • continue antibiotics for 5 days or until neutrophils >1 • If an organism is identified • check sensitivity and adjust if necessary • Maintain broad spectrum cover to prevent breakthrough bacteraemia • Duration of antibiotics • depends on site, organism and neutropenic recovery

  12. If still febrile at day 5 • Consider non-bacterial infection (fungal/viral) • Bacterial resistance • Or atypical organism such as mycoplasma,chlamydia • Emerging second infection • Inadequate dose • Drug fever or disease fever • Infection at avascular site • Abscess • catheter

  13. After the febrile neutropenia resolves • Add G-CSF with next cycle if in curative setting • Dose reduction of next cycle of chemotherapy • Prophylactic antibiotics • Drawbacks to this approach • Usually reserved for high risk patients • Haem rather than solid tumours

  14. Spinal Cord compression • Occurs in <5% of all cancer patients • < 0.5% at time of cancer diagnosis • Associated with poor prognosis if significant neurological deficits persist • Paralysis = median survival 2-3 months

  15. Spinal cord compression • Most commonly seen in: • lung cancer • prostate cancer • breast cancer • lymphoma • myeloma

  16. Sites • thoracic (thoraco-lumber) spine 70% • lumber spine 20% • cervical spine 10% • Up to 15% may be multi-level

  17. Presenting symptoms • Back pain - present >90% of patients • Night/early morning back pain • Mechanical • Radicular pain

  18. Neurological deficits: • Ataxia • Power loss • Sensory loss/definitive sensory level • Sphincter dysfunction

  19. Delay in diagnosis is very common • Median delay from symptom onset to treatment is 14 days • 14 day delay accounted for by; • 7 days by patient not seeking review • 3 days by GP not considering diagnosis • 4 days by general hospital not considering diagnosis

  20. Prognosis • Mobility at presentation most sensitive predictor of outcome • Slower onset of symptoms (>14 days) better prognosis • Prolonged dense paraplegia at diagnosis is unlikely to be reversed

  21. Consider diagnosis if patient has: • Known malignancy • back pain • Especially if severe • Complains of bilateral radicular pain • reduced mobility or ataxia or sensory changes

  22. MRI is gold standard for diagnosis • Whole spine MRI is required • To detect multi-level disease • To assess for operability • If MRI contra-indicated/not available • CT of Spine at likely site of cord involvement

  23. Management • Steroids • Treatment Options: • Surgery followed by radiotherapy • Radiotherapy alone • Chemotherapy alone- • for chemo-sensitive tumour only eg SCLC, lymphoma • minimal neurological deficits only

  24. Benefit of steroids in MSCC • Sorensen et al (Eur J Can 1994) • N=57 pts • 96mg IV Dex. then 96mg oral for 3/7 and taper versus no Dex. • 6 months ambulation: • 59% vs. 33% • Dex. increased 11% serious adverse events (eg psychosis, GI perforation)

  25. Steroids in the management of MSCC • Dexamethasone: • 8 mg IV/PO stat • then 16 mg per day in divided doses (eg 4mg qid) • Then reduce rapidly over 1-2 weeks to avoid side-effects • Consider DVT prophylaxis • Concurrent prescription of PPI (eg pantoprazole)

  26. Indications for Surgery • Medically fit patient • Rapid neurological progression • Histology required for unknown primary • Single level cord compression • Unstable spine • Bony compression • Known radio-resistant tumour • Progression after radiotherapy

  27. Limitations of surgery • Most patients not medically fit for surgery • Extensive operation often required: • Vertebrectomy • Usual approach as most cord compression is anterior or lateral • Laminectomy • Can result in spinal instability • High morbidity (23%) • Slow recovery from spinal surgery

  28. Laminectomy in MSCC

  29. Anterior Vertebrectomy in MSCC

  30. Indications for radiotherapy alone • Patient is medically unfit for surgery • Poor prognosis disease with short overall survival <3/12 • Asymptomatic • Radiosensitive tumour • Stable spine • No bony compression • Prolonged paralysis - >72 hours

  31. Management of cord compression • 1. Early diagnosis essential – educate patient, relatives, nurses, doctors, other medical staff • 2. Surgery first if appropriate then consider radiotherapy • 3. Taper steroids ASAP • 4. Mobilise ASAP unless contraindicated • 5. Rehabilitation ASAP

  32. SVC Obstruction • Learn to recognise and evaluate this • Treatment options will be determined by type of cancer and fitness of patients • radiotherapy or chemotherapy or surgery/stent • You should inform your registrar/consultant, commence steroids, and arrange imaging

  33. Superior vena cava Superior vena cava is major vein draining the head, upper limbs and thorax

  34. Superior vena cava syndrome • Extrinsic compression • Intra-caval venous thrombosis

  35. SVC obstruction

  36. SVC obstruction

  37. Symptoms of SVCO • Most common: • 82% facial and neck swelling/edema • 68% bilateral arm/trunk swelling/edema • 66% dyspnoea • 50% cough • 38% dilated chest veins

  38. Less frequent: 2nd to mediastinal/lung mass: • Chest pain • Dysphagia • Hoarseness of voice • headache • signs of increased intracranial pressure (i.e., somnolence, dizziness, visual disturbances)

  39. Signs of SVCO • Orthopnoea • Supine increases blood flow to upper body • plethora • tachypnoea • venous distention and edema of the head, neck, and upper extremities • collateral vein development in the upper torso

  40. Before and after treatment

  41. 61 year old ex-smoker who presented to GP with 3 week history of neck swelling & SOB

  42. Management of SVCO • Radiotherapy • Chemotherapy • Small cell lung carcinoma • Lymphoma • Germ cell tumours • 70-80% response rates reported in 7-14 days • Surgery • Stenting

  43. Hypercalcaemia • Look for this in oncology patients • More common than you think! • Occurs in up to 30% of patients with cancer at some stage in illness

  44. NEJM Stewart et al 2005

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