Oncologic Emergencies: You

Don’t Have to Pronounce the

Drugs to Treat the Patient!!!!

Grand Rounds: Huntsville

October 15th , 2014

Dave McLinden

Rural Family Physician

Huntsville, Ontario

Assistant Clinic Prof. McMaster Dept. of

Family Medicine

Associate Prof. Northern Ontario School of

Medicine

Disclosures

Overview

Why learn about oncologic emergencies

Goals

Case-based presentation of some common

or important not to miss oncologic

emergencies

Cases are additive

Educational Concepts with each case

Case #1: 55 year old male

Presents to ER feeling the “the most

tired I’ve ever felt

Case #1

Old charts show a recent diagnosis of

Duke’s C (IIIB, T2N2aM0) bowel cancer

He has been “out of town” the past two to

three weeks “getting chemo”

Case #1: Further History

Received his first cycle of 5 days of daily

5-FU and leucovorin starting 14 days ago

His surgery was 2 months ago

Nausea post chemo, but no other side

effects

Drinking well, but not eating much

Case #1: Examination

Some mucositis, but H&N otherwise N.

Well healed mid-line incision scar, norm

bowel sounds

Chest and CVS normal

Case #1: Bloodwork

WBC: 4.0, Hgb 100, Plt 120

Man Diff: Neuts – 0.2, Bands – 0.001,

Lymphs – 0.4

Renal and lytes: normal

Coagulation: normal

Case #1: Educational Concepts

Absolute Neutrophil Count

Post-chemo Nadir

Directed History and Physical

Case #1: ANC

ANC equals (%neuts plus %bands)x

total WBC

Case #1: Nadir

The time post chemo and/or radiation

when bone marrow suppression is at

its maximum

Case #1: Directed History

Cancer: type, staging, when

Chemo/radiation: type, timing, bloodwork,

where

Catastrophes: specific & constitutional Sx,

hydration, nutrition

Complications: medical/surgical, chemo

Case #2: 63 yr old female

Presents feeling “warm”

Mastectomy for stage IIIA breast ca several

months previously

Received chemo 18 to 20 days ago at your

local chemo unit

Case #2: Further History

Received CMF 18 days ago: first cycle

Vomitting 24 hrs after responded to

metaclopramide

Eating and drinking well

Blood 7 days ago normal but ANC 0.7

Case#2: Examination

Temp 39 C, Pulse 110, BP 105/60

Chest clear

CVS normal

H&N normal

Abdo normal

Skin: no cuts, lesions, etc.

Case #2: Blood

WBC: 2.1

Hgb: 95

Plt: 130

Manual Diff: Neuts- 0.1, Bands-0.02,

Lymphs-0.4

LFTs, renal, coag within norm post chemo

Febrile Neutropenia

Temp > 38 C

Absolute Neutrophil Count <0.5

Febrile Neutropenia

70% mortality rate if no antibiotics within

48 hours

Cause of fever is not identified in 60 to

70% of patients

Febrile Neutropenia: Workup

Culture, Culture,Culture……CXR

Empiric Abx…..Ceftazidime 1g IV q

8h………Cefazolin 1g IV q8h with

tobramycin 1.5 mg/kg

Febrile Neutropenia: Treatment

Frequent and thorough exams

Stop Abx after 5 to 7 days if ANC >0.5 and

afebrile

Empiric antifungal if pt febrile after 1 week

or recurrent fever

Febrile Neutropenia: Treatment

Antifungals: amphotericin B, 5-

flurocytosine, fluconazole, itraconazole

Acyclovir for herpes simplex or varicella

zoster

Febrile Neutopenia: Educational

Concepts

Temp >38 C, ANC <0.5

Treat empirically

Look aggressively for a cause

Think fungal, herpes, varicella if no

improvement

Case #3: 60 year old male

Newly diagnosed non-small cell lung

cancer. Wife phones saying patient

can’t remember her name.

Case #3: Further History

Keeps asking for water

Diagnosed 3 weeks ago on pleural tap

No treatment yet- to see oncologist

Little SOB and cough but otherwise OK

Case #3: Examination

Afebrile, vitals stable

Oriented to person only

Chest: decreased air entry to L base (not

new)

CVS: normal

Neuro: fine tremour to hands, otherwise N

Case #3: Bloodwork

CBC normal

Renal and liver fn normal

Total serum calcium: 3.1 mmol/L

Serum albumin: 20 g /L

Case #3: Corrected Serum

Calcium

CSC equals measured serum calcium

plus (0.8 x (4 – serum albumin))

Case #3: Hypercalcemia of

Malignancy

Occurs in 10 to 20% of patients with

cancer at some time during illness

Case #3: Commonly Associated

Cancers

Non small cell lung

Breast

Head and neck

Renal

Myeloma

T-cell lymphoma

Case #3: Rarely Associated

Cancers

Small cell lung

Colon

gynecologic

Case #3: Symptoms

Polydipsia and polyuria

Anorexia, fatigue, constipation, abd pain

Change in mentation

Coma

Cardiac arrhythmia

Case#3: Treatment

Rapid saline rehydration with correction of

lytes

Increase renal Ca excretion

Inhibition of bone resorption

Treatment of cancer

nothing

Case #3: Educational Concepts

Hypercalcemia of Malignancy occurs

relatively commonly

Be aware of its possibility in the cancer

patient complaining of constitutional Sx

No treatment is an option

Case #4: 48 year old male

Presents to ER with “gout” in right

great toe. His father has the same

thing

Case #4: Further History

You want to send his home with some

Indocid, but the medical student with you

actually took a history

Patient has a history of lymphoma and

received his second cycle of chemo within

the past 48 hours

Case #4: Examination

Vitals stable

Head and neck normal

CVS and Chest normal

Abdo: mid-line scar healed

Neuro: hyper-reflexia with 4 beat clonus

Ext: extremely tender MTP on right

Case #4: Bloodwork

CBC: normal

LFT: normal

Lytes: Sodium-146, Potassium-6.4,

Chloride-105, Bicarb-26

Uric acid: 605

Case #4: Tumour Lysis

Syndrome

Rapid discharge of intracellular lytes with

nucleic acid

Large tumour burden

Rapidly progressing tumour

6 to 72 hours post initiation of therapy or

spontaneously

Case #4: Commonly Associated

Cancers

Lymphoma

Leukemia

Some solid tumours

Case #4: The Triad

Hyperuricemia

Hyperkalemia

Hyperphosphatemia with secondary

hypocalcemia

Case #4: Treatment

Anticipate—fluids, diuresis, allopurinol

Alkalinization of Urine

Hemodialysis

Case #4: Educational Concepts

TLS seen soon after chemo

Triad of hyperuricemia, hyperkalemia, and

hypocalcemia seen in TLS

TLS often means that chemo/radiation is

working and aggressive supportive care is

essential

Case #5: 59 yr old trucker

SOB, wt gain, facial swelling

Smokes 1.5 to 2 pkgs/day x 40 yrs

Treated for “pneumonias” twice in past 2

months

Presently on puffers for “emphysema”

Case #5: Examination

Chest: suprisingly clear

CVS: normal

Abdo: normal

H&N: swollen face, distended neck veins,

spider nevi above the nipples only

Superior Vena Cava Syndrome

Extrinsic compression of thin walled

superior vena cava

SVCS: Malignant Mediastinal

Masses

Bronchogenic cancers

Thymic tumours

Mediastinal germ cell tumours

Metastatic cancer

SVCS: Differential

Superior vena cava thrombosis

Goiter

Mediastinal fibrosis

TB mediastinitis

histoplasmosis

SVCS: Treatment

Emergent radiation

Chemo (if failure, think thrombosis)

10 to 20 percent recur after radiation with

chemo

SVCS: Educational Concepts

If mediastinal mass diagnosed or suspected

beware of Superior Vena Cava Syndrome

Case #6: 52 yr old businessman

Presents for 1 yr follow-up after a Duke’s

B bowel cancer was resected

States he still “can’t work the hours I used

to”

Appetite never really returned and sleep is

restless at best

Case #6: Exam

Negative throughout

Case #6: Blood

Negative throughout

Case #6: Educational Concepts

Remember-------cancer patients are at risk

for psychiatric crisis before, during, after

and remotely after cancer treatment

Supportive care as early as possible is

essential

Case #7: 61 yr old native male

Presents with his daughter as translator

Started to limp yesterday and can’t get out

of a boat without help

“healthy” , but some trouble urinating over

the past few months

Blood drawn at the nursing station, but

doesn’t know the results

Case #7: Further History

Cannot use either legs to get up from the

seat of the boat

No weakness 2 days ago

Only other symptom is some mid-back

pain, but was wood-splitting last week

Daughter says “he’s pretty tough”

Case #7: Further Further History

No bowel or bladder symptoms

But back pain worse when he had a BM

Tried to lie down before the plane came to

get him today, but the pain became worse

Case #7: Examination

Ataxic gait

Unable to heel toe walk

Absent lower extremity reflexes bilaterally

Central spinal tenderness lower T-spine

Rectal: large hard prostate with palpable

rectal shelf

Case #7: Bloodwork

Hgb 92, norm wbc and diff, platlets 150

Liver and renal fns normal

Calcium normal

PSA drawn at nursing station last week, but

report unavailable at this time

Case #7: Radiology

Marked bone destruction at T4 and T5.

“Likely metastatic bone disease”

Case #7: Epidural Spinal Cord

Compression

5 – 10 percent of patients with malignancy

Common cancers: breast, lung, prostate,

lymphoma, renal or sarcoma

Site: 70% T-spine, 20% L-spine, 10% C-

spine

Case #7: SCC

95% of patients have pain: local or

radicular

Pain is constant, progressive, and increases

with valsalva, SLR, and recumbency

Local vertebral pain to palp.

Case #7: SCC

Sensory loss distal to lesion: rapidly

progressive

Weakness: bilateral/symmetric/rapidly

progressive in 75% of patients

Autonomic dysfn is a late sign

Case #7: SCC

DURATION and SEVERITY of neuro.

symptoms before initiation of Rx are strong

predictors of whether neuro fn can be

maintained or restored

Ideally Rx within 72 hrs

Case #7: Treatment

Dexamethasone: 4 –100mg q6h (ask

oncologist first)

Radiation is mainstay of Rx

Surgery: can be effective but pts usually

have widespread disease and are poor OR

risks

Case #7: Educational Concepts

Pain (local or radicular) is highly predictive

of SCC in specific known or suspected

cancers

Time to Rx must be as short as possible to

maintain or restore neuro fn.

Conclusion

Oncologic emergencies happen and need to

be looked for

Timely diagnosis and intervention will

prolong, possibly improve and maybe save

the life of the cancer patient

Oncologic Emergencies: Finally

the End

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