Oncologic Emergencies &Symptom Management

Anna Ertel NP & Kate Springman NP

Oncology Symposium

September 18, 2019

Disclosure

➔I have no conflict of interest to disclose.

Objectives

➔Recognize Oncologic Emergencies➔Prevent unnecessary utilization of

Emergency Department services➔Recognize side effects of cancer

treatment➔Manage side effects of cancer

treatment

CANCER FACTS

➔In 2019, the American Cancer Society estimates 1,762,450 new cancer cases will be diagnosed and 606,880 cancer deaths will occur in the US (ACS, 2019).

➔Cancer accounts for 1 in 4 deaths in the US (WHO, 2019).

➔Tobacco is single largest preventative cause of cancer in the world accounting for 22% of cancer deaths (ACS, 2019).

➔77% of cancers are diagnosed in people 55 years or older (ACS, 2019).

Oncologic Emergencies

➔Result from disease itself

➔Result from cancer therapy

● Patients may present to PCP office and ED; even when under the care of Oncologist; usually for convenience and transportation reasons

Oncologic Emergencies:General Categories

Metabolic Emergencies:

◆Hypercalcemia

◆Tumor Lysis Syndrome

Neurologic Emergencies:

◆Malignant Spinal Cord Compression

◆Brain Metastases

Oncologic Emergencies:General Categories

Cardiovascular Emergencies:

◆Malignant pericardial

effusion

◆SVC Syndrome

Infectious Complications:

◆Neutropenic fever

Scenario

➔ A 45 yo female arrives to her PCP office with CC fever of 101.5 x 2 days. She denies any other associated S/S (no cough, shortness of breath, diarrhea, urinary burning, or new pain).

➔ She has history of breast cancer and currently receiving adjuvant chemo. Her last cycle of chemo was 5 days ago.

➔ She is sent for labs including CBC which reveals a WBC 2.0, Hgb 10, Platelets 150. The differential showed Neutrophils 22%.

➔ Her calculated ANC is 440.

➔ What is the next step?

Febrile Neutropenia➔ What is it?

◆Presence of a fever >38 Celcius(100.4 Fahrenheit) with an absolute neutrophil count (ANC) <0.5 or ANC <1.0 with predicted decline in 48 hours.

◆Highest risk occurs (NADIR) 5-10 days after chemotherapy

Febrile NeutropeniaPresentation:

➔Fever is usually only symptom

➔May range from fever to severe sepsis

Careful physical exam is KEY—attention to skin, oral cavity, indwelling catheters and perianal area—rectal exam is discouraged

Physical Exam Revealed…..

Management of Febrile Neutropenia

➔ Admit for broad spectrum IV antibiotics (Cefepime and Vancomycin) to be initiated, complete ID work-up and in this case port to be removed.

➔ID work-up includes blood cultures, CXR, UA/culture, stool or sputum culture (if needed)

➔Granix or Neupogen if indicated (if pt did not receive Neulasta)

PROTOCOL GOAL

➔ 1 hour to antibiotic within presentation to office with fever……..

Severe Neutropenia in Oncology patient on chemotherapy with Uncontrolled Diabetes and Severe Peripheral Neuropathy, only

symptom reported was fever……….

Discovered on physical exam---

Review of Systems in Febrile Neutropenia

➔ EYES-conjunctivitis, orbital cellulitus

➔ ENT-otitis media, sinusitis, tonsillitis, pharyngitis, oral candidiasis

➔ TEETH-dental carries, abscess

➔ CHEST-pneumonia

➔ ABDOMEN-diarrhea, neutropenic enterocolitis, colitis

➔ PERINEUM-perianal abscess, perianal candidiasis

➔ SKIN-cellulitis, abscess, varicella rash, other rashes

➔ CNS-meningiti, meningioencephalitis

➔ URINARY TRACT-UTI

➔ INTRAVASCULAR CATHETERS

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Oral Mucositis in the Presence of Severe Neutropenia

Initiate Mary’s Magic Mouthrinse & pain medicine if needed—will improve as WBC

and ANC recover

Oral Candidiasis in Setting of Severe Neutropenia

Scenario

➔ A 65 yo male presents to PCP office with his wife due to increased confusion, lethargy, weakness and new bone pain to his left rib area.

➔ He is has previous history of Multiple Myeloma but reports being in remission for last 10 years.

➔ He is sent for further labs which reveal Calcium level 13, Creatinine level 3.0, Hgb 8.0

➔ What next?

Hypercalcemia of Malignancy

Common PRESENTING S/S

◆Polydipsia/Polyuria

◆Pain

◆Digestive problems (nausea, constipation, poor appetite, vomiting

◆Muscle twitches, weakness

◆Irritability, memory loss

Treatment of Hypercalcemia of Malignancy

➔ IVF’s

➔IV Bisphosphonates—Options….

◆Pamidronate 60-90mg IV over 60 mins

◆Zometa 4 mg IV over 15 min (not indicated with renal failure)

◆Denosumab 120 mg subcutaneous

◆Discontinue—Calcium, Vitamin D, thiazides, NSAIDs

◆Determine and treat the underlying cause--

Multiple Myeloma in this case (CRAB criteria)

Scenario

➔54 yo otherwise healthy male presented to PCP office with 6 week history of increasing back pain, lumbar area. He has no relief with OTC pain relievers. He has history of HTN and reports previous smoking history but quit 20 years ago. Bladder and bowel function are intact, but feels abnormal sensation after BM and has also noticed abnormal sensation in his left leg.

➔On exam…mild bilateral leg weakness/numbness, slightly decreased sensation to both feet, plantar reflexes upgoing and DTRs are brisk.

➔What next?

MRI lumbar spine reveals

Malignant Spinal Cord Compression

➔Pain is the most common presenting symptom in 80-90%

of spinal cord compressions

More commonly seen in……

◆Metastatic breast, prostate and lung cancers

◆Myeloma, lymphomas, melanoma

Malignant Spinal Cord Compression

➔Urgent treatment to reduce incidence of paraplegia….very short time from onset of neurologic findings to irreversible cord damage

➔URGENT MRI—put suspected diagnosis on the order

➔¼ of patients with spinal cord compression due to malignancy have no prior history of malignancy

➔Occurs in 5-14% of cancer patients

Malignant Spinal Cord Compression

Treatment

◆High dose Decadron asap

◆Urgent Radiation Therapy

◆If no previous cancer….obtain thorough history, histologic diagnosis is essential-attempt for biopsy or further imaging to determine primary lesion

Malignant Spinal Cord Compression

Scenario➔A 70 yo female presents to PCP office with intense fatigue,

weakness, vomiting, right sided flank pain and hematuria x 1 episode, decrease urine output. She has known daognosis of NHL, Diffuse Large B-cell type. She reports chemo 1 day ago in the form of CHOP-R. She thought it would be easier to get into her PCP rather than Oncologist because she lives closer to PCP office. She is sent for lab work which reveals……

➔K level of 6.0 and Cr of 3.0 (baseline 1.0 on day of chemo)

➔She is immediately sent to ED and further labs reveal elevated Phosphorus level 6.0 and Uric Acid level of 11.

➔She is currently prescribed Allopurinol but reports non-compliance and missed her appt for IVF’s at Oncology office due to above symptoms……

Tumor Lysis Syndrome (TLS)

➔Metabolic complication which occurs after treatment of bulky chemo-responsive neoplasms

➔Massive release of intracellular contents after tumor death

➔Most commonly seen in high grade lymphomas and leukemia or aggressive solid tumor cancers such as small cell lung cancer

Tumor Lysis Syndrome (TLS)

True Oncologic Emergency…immediate hospital admission

➔Prevention..Allopurinol, IVF’s through Oncology office

➔Hospitalization-- IVF’s, Rasburicase, Allopurinol, correct electrolyte imbalances

Scenario

➔A 60 yo male pt presents to PCP office with face and neck swelling x 5 days. He reports slight shortness of breath. His oxygen level is 88% on room air. He reports no home oxygen use. He is a heavy smoker 2 ppd x 50 years. He has no prior history of malignancy. He denies any allergies or changes in medications.

➔He is sent for CT Chest…….

Superior Vena Cava (SVC) Syndrome

Superior Vena Cava (SVC) Syndrome

➔Evaluation—CT chest

➔Treatment depends on respiratory compromise:

● Radiation, chemo, stenting, high dose steroids

➔In this case, biopsy revealed SCLC

Brain Metastases

Presenting symptoms:

➔ Headaches➔ Nausea/Vomiting➔ Confusion➔ Weakness➔ Vision changes➔ Seizures

Treatment of Brain Metastases

➔ Determine the primary site of malignancy--(further imaging, biopsy based on radiological findings, neurosurgery consult if indicated)

➔ High dose steroids to decrease cerebral edema/Anti-seizure medications if indicated

➔ Rad Onc consult for radiation therapy options

Most Common Oncologic Emergencies

➔Neutropenic Fever

➔Hypercalcemia of Malignancy

➔Malignant Spinal Cord Compression

➔Tumor Lysis Syndrome

➔SVC Syndrome

➔Brain Metastases

Conclusion

➔Not all Oncologic Emergencies are created equal……

➔Response, identification and definitive treatment may be required in minutes, hours or even next day

➔Learn to recognize, stabilize and ask for guidance

➔Recognize the emergent nature of the situation

➔Importance of goals of care and treatment intent