1 It’s Not A Tumor! Oncologic Emergencies Diane M. Birnbaumer, M.D., FACEP Professor of Medicine University of California, Los Angeles Senior Clinical Educator Department of Emergency Medicine Harbor-UCLA Medical Center Oncologic Emergencies n Increasing incidence of cancer n Improved survival n Patients with malignancies may present to EDs and general medical offices n Oncologic emergencies n Those resulting from the disease itself n Those resulting from cancer therapy Oncologic Emergencies: General Categories n Metabolic Emergencies n Hypercalcemia n Tumor Lysis Syndrome n Neurologic Emergencies n Malignant spinal cord compression n Brain metastases and increased ICP n Infectious Complications n Neutropenic fever Oncologic Emergencies: General Categories n Cardiovascular Emergencies n Malignant pericardial effusion n Superior vena cava syndrome n Hematologic Emergencies n Hyperviscosity due to dysproteinemia n Hyperleukocytosis and leukostasis
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It’s Not A Tumor! Oncologic Emergencies
Diane M. Birnbaumer, M.D., FACEP
Professor of Medicine
University of California, Los Angeles
Senior Clinical Educator
Department of Emergency Medicine
Harbor-UCLA Medical Center
Oncologic Emergencies
n Increasing incidence of cancer
n Improved survival
n Patients with malignancies may present to EDs and general medical offices
n Oncologic emergencies
n Those resulting from the disease itself
n Those resulting from cancer therapy
Oncologic Emergencies: General Categories
n Metabolic Emergencies
n Hypercalcemia
n Tumor Lysis Syndrome
n Neurologic Emergencies
n Malignant spinal cord compression
n Brain metastases and increased ICP
n Infectious Complications
n Neutropenic fever
Oncologic Emergencies: General Categories
n Cardiovascular Emergencies
n Malignant pericardial effusion
n Superior vena cava syndrome
n Hematologic Emergencies
n Hyperviscosity due to dysproteinemia
n Hyperleukocytosis and leukostasis
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Oncologic EmergenciesNeutropenic Fever
n Fever
n Single oral temperature > 38.3C (101.3F)
n Sustained temperature > 38C (100.4F) for > 1 hour
n Neutropenia
n Absolute neutrophil count < 1,000
n Severe neutropenia
n Absolute neutrophil count < 500
Oncologic EmergenciesNeutropenic Fever
n Most commonly seen after chemotherapyn Also seen in myelogenous cancers
n Risk of infection depends on…n Depth of neutropenia
n Duration of neutropenia
n Comorbid conditions (e.g. mucositis)
n Nadir usually 5-10 days after last chemo dosen Recovers 5 days after nadir (usually)
Oncologic EmergenciesNeutropenic Fever
n Organisms
n Multiple organisms implicated
n Enteric gram negatives
n Gram positives
n Frequently no organism recovered
Oncologic EmergenciesNeutropenic Fever
n Presentation
n Fever usually only symptom
n May range from fever only to severe sepsis
n Neutropenia leads to atypical presentation with common infections
n E.g. pneumonia patients may have no infiltrate; UTI patients may have no pyruia
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Oncologic EmergenciesNeutropenic Fever
n Presentation
n Careful physical examination crucial
n Particular attention to skin, oral cavity, sites of indwelling catheters, perianal area
n Rectal examination discouraged
Oncologic EmergenciesNeutropenic Fever
n Evaluation
n Blood cultures
n Peripheral vein AND any indwelling catheters
n Urine cultures
n Sputum cultures
n Stool, CSF cultures if indicated
Oncologic EmergenciesNeutropenic Fever
n Evaluation
n CXR may be normal
n Consider CT for higher resolution
Oncologic EmergenciesNeutropenic Fever
n Treatment
n All febrile neutropenic patients should receive antibiotics ASAP
n Afebrile neutropenic patients with high suspicion of infection also should get rx
n Broad spectrum to start; narrow later
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Oncologic EmergenciesNeutropenic Fever
n Treatment
n Most patients should be admitted
n Highly selected patients MAY be treated as outpatients
n Very close follow-up necessary
n Must have ready access to health care
n Assess personal / social situation
Oncologic EmergenciesNeutropenic Fever
n Multinational Association Scoring Systemn No or mild symptoms 5
n No hypotension 5
n No COPD 4
n Solid tumor or no previous fungal infxn 4
n No dehydration 3
n Moderate symptoms 3
n Outpatient status 3
n Age < 60 years 2
Score • 21 low risk for serious medical complications
Neutropenic FeverAntibiotic Strategies
n Broad empiric coverage + coverage for any suspected/ known infections
n Gram-negative coverage for all patients
n Gram-positive coverage for selected patients per IDSA recommendations
n Use bactericidal antibiotics administered through alternate ports to indwelling lines
Neutropenic Fever Treatment
n Clinical Practice Guidelines
n Clinical Infectious Diseases CID 2011:52 (15 February)
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IDSA Management Algorithm
Clin Infect Dis 2002; 34: 730-51.
IDSA RecommendationsOutpatient Treatment
n Suggested Antibiotic Regimen:n Ciprofloxacin 500mg PO q8• PLUS
n Amoxicillin/Clavulanate 500mg PO q8•
n Penicillin-allergic Patients:n Ciprofloxacin 500mg PO q8• PLUS
n Clindamycin
n Note: Outpatient therapy not recommended for the pediatric population.
Clin Infect Dis 2002; 34: 730-51.
IDSA Recommendations Inpatient Treatment
n Inpatient Care for Children and “High Risk” Adult Patientsn Monotherapy: Single, broad-spectrum IV agent
n Cefipime (4th generation cephalosporin)n Ceftazidime (3rd generation cephalosporin)n Carbapenem (Imipenem or Meropenem)
n Combination Therapy:n Aminoglycoside (Gentamicin, Tobramycin, or Amikacin) PLUSn Antipseudomonal beta-lactam (Ticarcillin-clavulanic acid or
Piperacillin-tazobactam), ORn Antipseudomonal cephalosporin (Cefipime or ceftazidime), ORn Carbapenem (Imipenem or Meropenem)
n None of these have been shown to be clearly superior.
Clin Infect Dis 2002; 34: 730-51.
Oncologic EmergenciesSpinal Cord Compression
n Relatively common
n 2.5 to 6% of cancer patients
n Most common: Breast, lung, prostate
n Confers poor prognosis overall
n Urgent need to make diagnosis and treat
n Neuro status at presentation and rapidity of onset predict functional outcome
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Oncologic EmergenciesSpinal Cord Compression
n Usually results from extension from spinal bony metastases
n Less commonly extends through foramina
n Lymphomas, sarcomas
n Will not see bony destruction
n Most common in thoracic spine
Oncologic EmergenciesSpinal Cord Compression
n Presentation
n 90% have back pain
n 80% have preceding diagnosis of malignancy
n May have several simultaneous lesions
n BACK PAIN + MALIGNANCY = SCC!!
Oncologic EmergenciesSpinal Cord Compression
n Presentation
n Symptoms
n Radicular pain
n Motor weakness
n Gait disturbance
n Bowel or bladder dysfunction
n Imperative to try to diagnose before neurologic dysfunction occurs
Oncologic EmergenciesSpinal Cord Compression
n Evaluation
n MRI is imaging study of choice
n Consider imaging entire spine (+/- C spine)
n CT myelography second choice
n Plain films / nuclear medicine poor choices
n Limited sensitivity and specificity
n Plain films may show bony lesions
n Negative plain films do NOT rule out SCC
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Oncologic EmergenciesSpinal Cord Compression
n Treatment
n Start as soon as possible; need tissue diagnosis
n Glucocorticoids
n Dexamethasone 10-16 mg IV, then 4 mg every 6 hours