Oncologic Emergencies: You Don’t Have to Pronounce the Drugs to Treat the Patient!!!! Grand Rounds: Huntsville October 15 th , 2014
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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