Oncologic Emergencies

Dr Karenza Alexis

Spinal Cord Compression

 1-5% of patients with systemic cancer  MUST BE TREATED IMMEDIATELY  Can lead to irreversible paralysis or loss of bowel and bladder function  Tumor or collapsed fragments in the epidural space

Spinal Cord Compression  Most Common sites    Thoracic spine (70%) Lumbrosacral (20%) Cervical (10%)  Most common malignancies        Lung Breast Unknown primary Prostate Renal Multiple myeloma Lymphoma

Spinal Cord Compression  Symptoms and Signs  Localized pain to the spine  Exacerbated by movement, recumbency, coughing, sneezing, straining  May appear weeks to months before neurological symptoms  Radicular pain  Weakness +/- sensory loss  Autonomic dysfunction  Urinary retention, constipation

Spinal Cord Compression  Evaluation- complete neurologic and physical exam that includes:  Gentle percussion of spinal column  Passive neck flexion  Straight Leg raise  Motor and sensory exam, Reflexes   Pinprick testing toe to head- sensory level Is there a “sensory level”  RECTAL exam

Spinal Cord Compression

 Diagnosis- image the ENTIRE spine  Xray  66% will have bony abnormalities  Erosion, loss of pedicles, vertebral body collapse, paraspinous soft tissue mass  Cannot exclude epidural mets  Does not exclude cord compression if normal  Follow-up with MRI  MRI  STANDARD!!!!!!!

 CT scan

Spinal Cord Compression  Goal of treatment:  recovery and maintenance of normal neurological function,  stabilization of the spine  Local tumor control  pain control  Treatment Outcome:  Degree of neurologic impairment  Radiosensitivity of tumor

Spinal Cord Compression

Treatment:  Steroids  START DEXAMETHASONE IMMEDIATELY if you suspect cord compression  10 mg IVP followed by 4 mg IV every 6 hours (higher doses be used if patient presents with significant neurological impairment)  Radiation  Stable spine with radiosensitive tumors, non surgical candidates with spinal instability,  Port includes area of epidural involvement plus two vertebral bodies above and below

Spinal Cord Compression

 Surgery  Tissue diagnosis needed  Spinal instability  Prior radiation to affected area  Progression of cord compression despite steroids and radiation  Resection followed by radiation therapy vs radiation alone  ASCO proceedings 2003: combine modality patients had higher ambulatory rate and retained ability to walk longer

Spinal Cord Compression

In addition to initial evalutaion, imaging, steorids: multidisciplinary management  Neurology Consult  Oncology Consult  Neurosurgery Consult  Radiation oncology Consult

Superior Vena Cava Syndrome

 Malignant causes  intrathoracic malignancies (60-85%)  Lung cancer (more common in small cell), breast cancer, testicular cancer, thymoma  lymphoma and other malignancies with mets to mediastinum  Non-malignant causes  Thrombosis (most common cause in cancer patients)  Substernal thyroid goiter, TB, RT, sarcoidosis

Superior Vena Cava Syndrome  Signs and symptoms              Facial edema/ erythema Dilatation of veins of upper body Laryngeal or glossal edema Periorbital edema Dyspnea Cough Orthopnea Arm and neck edema Hoarseness Dysphagia Headaches Dizziness syncope  Symptoms worse with positional changes: bending forward, stooping or lying down

Superior Vena Cava Syndrome

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Can Result in:

 Life-threatening cerebral edema  Laryngeal edema- airway compromise

Superior Vena Cava Syndrome

 Diagnosis- determine etiology  Thorough Physical Examination  CXR  May show mediastinal widening  Doppler USG of jugular or subclavian vein  Differentiate thrombus from extrinsic compression  CT scan or MRI  Bronchoscopy  thoracoscopy

Superior Vena Cava Syndrome

   Treatment Goal: alleviate symptoms and treat underlying disease Initial management depends on Grade of SVCS, underlying disease, anticipated resposbse  Determine underlying cause- especially if SVCS is presenting symptom  Pace of progression of symptoms  Treatment goal- Cure vs Palliation

Superior Vena Cava Syndrome  Treatment  Symptom management: Elevation of head of bed, O2, bed rest  Radiotherapy      Cure vs Palliation Accurate histologic diagnosis needed prior EMERGENT RT needed if life-threatening symptoms/signs (stridor/ CNS symptoms from cerebral edema) If Non-small cell lung cancer Combine with chemotherapy if limited stage small cell lung cancer and Non Hodgkin’s lymphoma  Stenting for life threatening symptoms especially in tumors not sensitive to chemotherapy or radiation or no diagnosis of cancer  Chemotherapy  Lymphoma or germ cell tumor or small cell lung cancer  Consider thrombolysis, angioplasty if thrombosis  Diuretics- transient, may cause dehydration and reduced blood flow  Steroids

Hypercalcemia

 Occurs in 10-20% of cancer patients- bony mets v paraneoplastic  Assocciated most commonly with:  myeloma, lung cancer (squamous cell), renal cancer, breast cancer, head and neck tumors, leukemias, unknown primaries

 Symptoms/ signs Hypercalcemia  Presence may depend on speed at which hypercalcemia develops  General: dehydration, anorexia, pruritis, weight loss, fatigue  CNS: weakness, hypotonia, proximal myopathy, mental status changes, seizure, coma  Cardiac: bradycardia, short QT interval, prolonged PR interval, wide T wave, atrial or ventricular arrythmias  GI: nausea/vomiting, constipation, ileus, pancreatitis, dyspepsia  Renal: Polyuria, nephrocalcinosis

Hypercalcemia of malignancy  Diagnosis  Ionized calcium, Serum immunoreactive PTH- like substance, phosphorus, 1,25 dihydroxyvitamin D  If calcium only mildly elevated (<12) AND NO symptoms: encourage PO hydration, eliminate any offending agents, follow closely

If calcium is >12 OR symptoms:  saline infusion (be aware of cardiac and renal function),  loop diuretics (once euvolemia achieved). Follow urine output and potassium, magnesium.

 Bisphosphonates inhibit osteoclast function e.g pamidronate  Onset of action 24 to 48 hours  Calcitonin  Inhibits bone degradation by binding directly to receptors on the osteoclast  onset of action is 2-4h but effect of short duration. Dose is 2-8 U/kg SC or IM every 6-12 h

 If calcium >12 or symptoms Gallium nitrate- inhibits bone resorption     Onset of action 24 to 48 hours 100-200 mg/m2/d IV over 24 hours for up to 5 days in volume replete non-oliguric patients Once calcium is normal, stop treatment but CONTINUE TO MONITOR for its continued effect AVOID use of nephrotoxic drugs  Plicamycin (25 ug/kg)    Direct osteoclast inhibitory effects, may also block Vit D and PTH activity Onset of action is 24-48 h Toxicity with repeated use: renal and liver toxicity, thrombocytopenia

Tumor Lysis Syndrome

  Metabolic triad of hyperuriciemia, hyperkalemia, hyperphosphatemia Can also lead to renal failure and hypocalcemia as secondary complications     Chemotherapeutic agents cause cell lysis and cell death with release of intracellular components into the blood stream Breakdown of nucleic acid, catabolism of hypoxanthine and xanthine leads to elevated uric acid Potassium and phosphate are present at high levels in cytoplasm LDH also released but not considered part of syndrome

Tumor Lysis Syndrome  Risk Factors, Signs or Symptoms  Increased LDH, uric acid, creatinine  Bulky, rapidly proliferating tumors treated with chemotherapy  Most often occurs with treatment of leukemias or high grade lymphomas  Cardiac arrythmias if hyperkalemia or hypocalcemia  Tetany if hypocalcemia  Renal failure if hyperphosphatemia and hyperuricemia

Tumor Lysis Syndrome

 Prophylaxis     Patient at high risk: leukemia, high grade lymphma, rapidly proliferating bulky solid tumor (e.g small cell) Vigorous Prehydration Allopurinol  Inhibits xanthine oxidase   Can cause xanthinuria Prevents

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uric acid formation Careful Metabolic monitoring  Treatment  Rasburicase    (works for prevention and treatment) degrades uric acid to more water soluble form Contraindicated in G6PD deficiency Can cause hemolysis

Hyperuricemia

 Hematological disorders: leukemias, high-grade lymphomas, myeloproliferative disorders (e.g PCV)  Aggressive tumors, extensive disease  Treatment of malignancies  Medications  Renal impairment

Hyperuricemia- treatment

 Prophylaxis  Alkalinization of urine (urine pH >7)  Sodium bicarbonate to IVF  Diamox  Allopurinol

Neutropenic Fever       Medical Emergency Neutropenia: ANC<1000 (multiply total wbc by percentage neutrophils and bands) Single temperature greater than 101.3F or sustained temperature >100.4F for more than one hour (for clnical purposes , single temo>100.4F) Remember there may still be infection in the absence of fever: e.g elderly patients or patients on steroids May present with hypothermia, hypotension, clinical deterioration START BROAD SPECTRUM ANTIBIOTICS ASAP!!!!

Neutropenic Fever

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Risk factors for occult infection

 Degree of neutropenia  Rapid decline in ANC  Prolonged duration neutropenia (> 7 to 10 days)  Cancer not in remission  Comorbid illness  Peripheral lines and central venous catheters  Use of monoclonal antibodies

Neutropenic Fever   Infectious source identified in 30% 80% infection believed to arise from patient’s endogenous flora  Risk for specific types of infection may be influenced by underlying malignancy    Abnormal antibody production in CLL, functional asplenia: encapsulated organisms-

Strep pneum.,hemophilus influenzae, Neisseria meningitidus, capnocytophaga canimorsus

T cell defects e.g lymphoma: intracelluar pathogens-

Listeria monocytogenes, Salmonella, Mycobacterium, Cryptococcus

High dose steroids:

Pneumocystis carinii

  ALWAYS COVER Gram negatives Fungal and viral infections also possible

Neutropenic Fever  Patients should be pancultured including from central line as well as CXR  Further imaging depending on symptoms   Generally start cefipime 2g Q8 (also take into consideration signs, symptoms, recent antibiotic use) GROWTH FACTOR support  Consider vancomycin if hypotension,mucositis, skin infection, presence of catheter, hx MRSA, recent quinolone  Addition of antibiotics (including antifungal) depending on clinical response and duration of neutropenia (add antifungal if anticipate or patient has prolonged neutropenia)  Consider catheter removal   Oncology Consultation Infectious disease consultation