HEMATOLOGY-ONCOLOGY Saulius Girnius 07/19/2013 Hem/Onc Emergencies.

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Transcript of HEMATOLOGY-ONCOLOGY Saulius Girnius 07/19/2013 Hem/Onc Emergencies.

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  • HEMATOLOGY-ONCOLOGY Saulius Girnius 07/19/2013 Hem/Onc Emergencies
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  • Section of Hematology-Oncology Summary 2 Neutropenic Fever Spinal Cord Compression Tumor Lysis Syndrome Hypercalcemia Superior Vena Cava Syndrome
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  • Section of Hematology-Oncology Neutropenia Fever: Definitions 3 What is a fever? Single temperature >101 F Sustained temperature >100.4 for one hour What is neutropenia? ANC
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  • Section of Hematology-Oncology Subtleties of Neutropenia 4 21 yo woman with Hodgkin Lymphoma with fever on day 14 after ABVD with following CBC WBC [L] 2.9 K/UL 4.5-11.0 HCT [L] 28.8 % 38-47 PLATELET 387 K/UL 150-400 POLY [L] 17 % 45-85 LYMPH 50 16-50 MONO [HH] 24 % 0-10 EOS 4 % 0-6 BASO [H] 5 % 0-1 ABSOLUTE POLY [LL] 0.5 K/UL 1.8-7.7 71 yo man with Non Hodgkin lymphoma with Fever on day 6 after R-CHOP with following CBC WBC [LL] 1.0 K/UL 4.0-11.0 HCT [L] 36.6 % 40-54 PLATELET [LL] 25 K/UL 150-400 POLY 64 % 45-85 LYMPH 32 % 16-50 MONO 1 % 0-10 EOS 3 % 0-6 BASO 0 % 0-1 ABSOLUTE POLY [L] 0.6 K/UL 1.8-7.8 G-CSF does not prevent neutropenia Time of Nadir: Commonly 10 days
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  • Section of Hematology-Oncology Management of Suspected Neutropenia Fever 5 Be a decider! Mortality Rate: 5-20% >60 minute delay of antibiotics: OR:1.81 Shoot first, ask questions later sorta
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  • Section of Hematology-Oncology Ask questions sorta: Work Up while waiting for antibiotics Talk to patient Physical Exam: Line, cellulitis, localizing symptoms Nothing in rectum Blood Cultures: 1 from port, 1 from periphery CBC + Differential UA and urine culture Culture Omaya No Lumbar Puncture if circulating blasts pCXR (I would prefer 2-V CXR) 6
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  • Section of Hematology-Oncology Shoot: Empiric Treatment GNR Coverage: Within 1 hour Cefepime 2 gm q8 hours (now at BMC Cefepime 500 mg q6h) Ceftazadime 2 gm q8h If PCN/Cephalosporin Allergy Imipenem 0.5 gm q6h (do not use if Type I hypersensitivity) Aztreonam 2 gm q8h + vancomycin 1 gm + gentamicinx1 Ciprofloxacin plus clindamycin Gentamicin if severe sepsis GPC Coverage Skin breakdown, inflammed line/port, h/o MRSA, s/sx of pulmonary source Vancomycin 15 mg/kg (usually give 1 gm) 7
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  • Section of Hematology-Oncology Management As Outpatient? MASCC Scoring System 8 Score >21 consider outpatient monitoring, with fluoroquinolone + amox/clavulanate (or clindamycin if penicillin allergy) JCO 2000:3038-3051; Flowers et al JCO 2013 29
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  • Section of Hematology-Oncology Febrile Neutropenia Summary Must assess patient Pan-culture Antibiotics within 1 hour (esp GNR coverage) 9
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  • Section of Hematology-Oncology Arghh.what next? 10 Neutropenic Fever Spinal Cord Compression Tumor Lysis Syndrome Hypercalcemia Superior Vena Cava Syndrome
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  • Section of Hematology-Oncology Spinal Cord Compression Differential Diagnosis for Back Pain Musculoskeletal disease Spinal epidural abscess (instrumentation, IVDU) Vertebral mets without epidural extension Radiation myelopathy 11
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  • Section of Hematology-Oncology Spinal Cord Compression: Type of Cancers 12 90% of cases are due to metastatic tumor in vertebrae and are therefore anterior
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  • Section of Hematology-Oncology Spinal Cord Compression: Clinical Features Pain is present in 90% of patients Delay in Diagnosis 7 weeks from onset of pain 10 days from onset of neurologic symptoms to rx 3 due to patient 4 to PMD 4 by hospital Weakness 75% of patients Symmetric lower extremity weakness >50% are non-ambulatory Loss of bladder and bowel function in 50% 13
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  • Section of Hematology-Oncology Spinal Cord Compression: Imaging MRI vs Myelography 33% will have multiple epidural tumor deposits on scanning At a minimum, thoracic and lumbar spine should be imaged in addition to clinically suspicious region will miss only 1% of cervical lesions 14
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  • Section of Hematology-Oncology Initial Treatment: Steroids 15 High dose dexamethasone RCT: IV Dex 100 mg vs 10 mg 16 mg PO daily Results: Pain Scale: 5.2 3.8 at 3hrs 2.8 at 24hrs 1.4 at 1 week No difference in pain, ambulation, and bladder function Vecht et al. Neurology 1989;39(9):1255 (Really) High Dose Dexamethasone RCT: XRT +/- dex 96 mg IV/PO x4 day 10 day taper Results: Ambulation at conclusion of therapy: 81% vs 63% Ambulation at 6 mos: 59% vs 33% No dif in OS; increased toxicity Sorenson et al. Eur J Cancer 1994;30A(1):22
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  • Section of Hematology-Oncology Recommendations Most authorities reserve high dose treatment (100 mg IV and half dose Q3days) for paraplegic or paraparetic patients. Low dose (10mg IV followed by 16 mg daily) for patients with minimal neurologic dysfunction Lower dose reduces AE (psychosis, infection, ulcers) 16
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  • Section of Hematology-Oncology Cord Compression: What to expect from XRT Radiation rays/particles only work M-F, 7 AM 4 PM Pain: 70% with improvement 50% without spinal instability have resolution of pain Neurologic Function If ambulatory 67-82% remain ambulatory If non-ambulatory 1/3 become ambulatory If paraplegic 2-6% become ambulatory Duration of motor neuropathy matters Type of Malignancy Radiosensitive: less likely to relapse Radioresistant: consider SRS 17
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  • Section of Hematology-Oncology Cord Compression: Surgery Laminectomy: No effective for anterior tumors No spine stabilization No treatment of tumor Tumor Debulking and Spine Stabilization 18 Closed at interim analysis. Surgery Arm Better Median retained ambulation: 122 vs 12 days OR for ambulation: 6.2 If paraplegia on Dx, increased ability to walk 10/16 vs. 3/16
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  • Section of Hematology-Oncology Cord Compression: Summary Image entire spine immediately Start dexamethasone If paraplegia: 100 mg IV and halve dose q3days If just pain: 10 mg IV, then 4 mg q6h PO/IV Call Radiation Oncology and Neurosurgery 19
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  • Section of Hematology-Oncology Is he really not even halfway through? 20 Neutropenic Fever Spinal Cord Compression Tumor Lysis Syndrome Hypercalcemia Superior Vena Cava Syndrome
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  • Section of Hematology-Oncology Tumor Lysis Syndrome: Pathophysiology Hyperuricemia: due to catabolism of purines Hyperphosphatemia: Phos concentration 4x higher in malignancy cells Uric acid precipitates in calcium phosphate readily Uric acid is poorly soluble in kidneys Crystals deposit in renal tubules ARF 21 Howard et al. NEJM 2011
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  • Section of Hematology-Oncology Tumor Lysis: Clinical Presentation Electrolyte Derangement Hyperuricemia Hyperphosphatemia Hyperkalemia Secondary hypocalcemia Acute Renal Failure Symptoms Nausea, vomiting, diarrhea, anorexia, lethargy Cardiac dysrhythmia, syncope Tetany Death 22
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  • Section of Hematology-Oncology Tumor Lysis Syndrome: Risk Factors Tumor Factors High proliferative rate Chemosensitive disease Tumor burden WBC>50K >10 cm diameter Bone Marrow Involvement Most commonly hematologic malignancies, not solid tumor Clinical Features Serum uric acid >7.5 mg/dL or hyperphosphatemia Nephropathy Oliguria Inadequate hydration 23
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  • Section of Hematology-Oncology Who is at risk 24 Howard et al. NEJM 2011
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  • Section of Hematology-Oncology Tumor Lysis Syndrome: Prevention/Treatment 25
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  • Section of Hematology-Oncology Tumor Lysis Syndrome: Summary Check Tumor Lysis Labs/G6PD Aggressive hydration Start Allopurinol Consider rasburicase IF TLS Consult renal early 26
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  • Section of Hematology-Oncology 60% Done!!! 27 Neutropenic Fever Spinal Cord Compression Tumor Lysis Syndrome Hypercalcemia Superior Vena Cava Syndrome
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  • Section of Hematology-Oncology Hypercalcemia: Causes of hypercalcemia Osteolytic metastases: 20% Breast Cancer: mets have PTHrP local osteolysis Multiple Myeloma activate osteoclasts PTH related protein: 80% Squamous Cell Carcinoma (lung, head&neck), renal, bladder, breast, ovarian Affects both bone ( resorption) and kidney ( excretion) 28
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  • Section of Hematology-Oncology Hypercalcemia: Treatment Hydration Normal Saline 29 Isotonic Saline: 200-300 ml/hr UOP: 100-150 ml/hr
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  • Section of Hematology-Oncology Hypercalcemia: Furosemide 30 Use only if volume overloaded
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  • Section of Hematology-Oncology Hypercalcemia: Advanced Management Calcitonin 4 IU/kg q12h SC/IM Efficacy: 48 hours Rapid reduction Use if corrected Ca>14 mg/L Bisphosphonate: pamidronate or zoledronate MOA: analog of inorganic pyrophosphate interfere bone absorption Onset of Effect: 1-2 days Max Effect: 2-4 days Side Effects: fever, renal failure 31 DrugDoseResponse Rate Pamidronate60 mg for Ca13.5 70% Zoledronate4 mg, reduce for CRI88%
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  • Section of Hematology-Oncology Almost done! May page myself out anyway. 32 Neutropenic Fever Spinal Cord Compression Tumor Lysis Syndrome Hypercalcemia Superior Vena Cava Syndrome
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  • Section of Hematology-Oncology Superior Vena Cava Syndrome 33 UTDOL
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  • Section of Hematology-Oncology SVC Syndrome: Clinical Presentation Compression of structures in mediastinum SVC: collateralization of over several weeks to months Facial/arm swelling Cyanosis Flacial plethora Coma 34 Airway: Extrinsic Compression Caution with Anesthesia Airway obstruction Cardiovascular Collapse Facial/Neck/Cord Swelling
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  • Section of Hematology-Oncology SVC Syndrome: Etiology Non-malignancy: Thrombosis Fibrosing Mediastinitis Postradiation fibrosis Malignancy: 60-85% of cases (60% of which are new presentations) Lung Cancer: NSCLC (50%), SCLC (25%) Lymphoma (25%): DLBCL Lymphoblastic lymphoma Primary mediastinal large B-cell lymphoma 35
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  • Section of Hematology-Oncology SVC Syndrome: Treatment vs Diagnosis Immediate Treatment: Indications Central Airway Obstruction Severe laryngeal edema Cerebral edema coma Approach: Endovascular stenting and XRT If severe airway obstuction high dose corticosteroids Need tissue diagnosis, if possible FNA vs Core-Needle Biopsy Bone Marrow Biopsy Mediastinoscopy 36
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  • Section of Hematology-Oncology SVC Syndrome: Treatment Chemosensitive Tumor chemotherapy Chemoresistant Tumor XRT 37
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  • Section of Hematology-Oncology He did what? What an xxxx! 38 Neutropenic Fever Spinal Cord Compression Tumor Lysis Syndrome Hypercalcemia Superior Vena Cava Syndrome Acute Promyelocytic Leukemia
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  • Section of Hematology-Oncology Acute Promyelocytic Leukemia: Even a heme onc fellow will come in Epidemiology Hispanics>White>African Descent/Pacific Islanders Women>Men Age: 20s to 50s Clinical Presentation: variable Hemorrhagic findings Weakness/fatigability Laboratory Leukopenia (usually) Can have anemia/thrombocytopenia DIC 39
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  • Section of Hematology-Oncology APML: Why should I worry? Untreated DIC pulmonary/cerebrovascular hemorrhage: 40% Mortality rate: 10-20% Treated APML CR Rate: 95-100% 2 year PFS: 97% LoCoco et al. N Engl J Med 2013;369:111-21 40
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  • Section of Hematology-Oncology APML on peripheral blood smear 41
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  • Section of Hematology-Oncology APML: If Concerned 1)Check DIC panel 2)Look at PBS, especially feathered edge 3)Ask lab tech to look at smear 4)Call hematology fellow on call 42
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  • Section of Hematology-Oncology Questions? 43