Practical tips for managing oncology emergencies

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

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

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

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

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

12. 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

13. 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

14. 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

15. 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

16. 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

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

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

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

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

21. 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

22. 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

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

24. 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

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

28. 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)

30. 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)

31. 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

32. 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

33. Laminectomy in MSCC

34. Anterior Vertebrectomy in MSCC

35. 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

36. 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

37. 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

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

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

40. SVC obstruction

41. SVC obstruction

42. 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

43. 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)

44. 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

46. Before and after treatment

47. 61 year old ex-smoker who presented to GP with 3 week history of neck swelling & SOB

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

49. 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

50. NEJM Stewart et al 2005