Emergencies In Oncology Neutropenic fever SVCO Malignant pericardial tamponade Hypercalcemia Tumour lysis syndrome Cord compression Brain metastases Pain

1. Emergencies in
Oncology

2. 1. Neutropenic fever
2. SVCO
3. Malignant pericardial tamponade
4. Hypercalcemia
5. Tumour lysis syndrome
6. Cord compression
7. Brain metastases
8. Pain

3. Neutropenic fever

4. • Fever
• Single reading >38.3ºC
• Sustained (> 1 h) reading >38ºC
• Neutropenia
• ANC <500 cells/uL (pedantic)
• ANC 500 to 1000 cells/uL with a predicted nadir of <500 (pragmatic)
• Risk is inversely proportional to ANC

5. high index of suspicion
• Signs of inflammation may be absent
• Erythema, induration, pus
• Pulmonary infiltration
• Pyuria
• Pleocytosis
• Fever is not always present
• Elderly, pts receiving steroids
• May present with hypothermia and hypotension

6. Most common causes
• Majority are bacterial in origin
• 30% have bacteremia
• 80% are endogenous
• Gram (-) used to predominate
• Gram (+) are on the rise

7. Bacterial infection
• Gram (-)
• E coli
• Klebsiella
• Pseudomonas
• Enterobacter
• Gram (+)
• Staphylococcus species
• Streptococcus species
• Enterococcus
• Corynebacterium

8. Anaerobic infection
• Represents 3.4% of cases
• Routine cover is not necessary
• Except for special sites
• Oral and sinus infections
• Intra-abdominal or pelvic infection
• Perirectal infection
• Anaerobic becteremia

9. Fungal infection
• Usually a secondary infection
• Prolonged neutropenia
• Prolonged antibiotic use
• Candida and Aspergillus species
• One-third of febrile neutropenic pts who fail to respond after
7 days of antibiotic have systemic fungal infection

10. Viral infection
• Predominantly in BMT and hematologic cancer patients
• Predominantly herpesviruses (HSV, VZV, CMV, EBV)
• Sometimes respiratory viruses
• There is usually no indication for empiric anti-viral therapy
without evidence of viral infection

11. Treatment
• evaluation for subtle signs & symptoms of infection
• Full blood count
• Liver and renal panels
• CXR
• Blood and urine cultures

12. Treatment
• Perform blood culture from ALL PORTS and the peripheral
vein
• Start antibiotic therapy IMMEDIATELY!

13. Monotherapy
• Broad spectrum b-lactams with anti-pseudomonal coverage
• Ceftazidime 2 g q8 hrly
• Cefepime 2 g q8 hrly
• Imipenam 500 mg q6 hrly
• Meropenam 1 g q8 hourly
• Tazocin 4.5g q8 hourly

14. Two-drug therapy
• The addition of an aminoglycoside to
• Tazocin
• Ceftazidime or Cefepime
• Imipenam or Meropenam
• Synergistic against gram (-) bacilli with less risk of emergence of
resistance
• Indicated when severe sepsis, septic shock, high prevalence of
multi-drug resistance gram (-) bacilli

15. ? Vancomycin
• Addition to initial empiric antibiotic regimen has not been shown to
decrease mortality
• Considered when
• Clinically suspected serious catheter related infection
• Known MRSA colonization
• Gram (+) bacteremia
• Hypotension

16. CVC-related infection
• Classification
• Exit wound infection
• Tunnel infection
• CVC-associated bacteremia
• Septic thrombophlebitis

17. CVC-related infection
• Most commonly
• Coagulase-negative staph
• S aureus
• Less commonly
• Gram (+) bacilli (Corynebacterium and bacillus specie)
• Candida
• Mycobacteria

18. Catheter removal
• Tunnel infection
• Septic thrombophlebitis
• Septic emboli
• Culture (+) after 72 hrs of therapy

19. Catheter removal
• Selected pathogens
• Corynebacterium
• Bacillus
• S aureus
• VRE
• Candida
• Mycobacterium

20. Typhlitis
• Neutropenic enterocolitis
• ? when neutropenia + “appendicitis”
• Distended cecum, edematous cecal wall, pneumatosis
intestinalis on CT
• Typically pseudomonas + clostridium
• Primary treatment: antibiotics!
• Surgery if with bowel complications

21. Treatment
• No localizable focus
• No s/s of systemic infection other than fever
• ANC > 500/ mm3
• Cancer responding to treatment
• No significant co-morbidity
• No recent hospitalization
• Age <60
• Stable patient

22. Treatment
• Oral Augmentin + Ciprofloxacin x 5 days
• Follow up with Doctor in ≤3 days
• Trace preliminary culture results O/A

23. Colony-stimulating factor
• to shorten duration of neutropenia
• Can reduce neutropenia-related morbidities
• Use of antibiotics
• Cost of management

24. Superior vena cava
syndrome

25. Superior vena cava
• Drains venous blood from head, neck, upper limbs and thorax
• Surrounded by relatively rigid structures
• Thin walled, low pressure and easily compressible
• Completely encircled by chains of lymph nodes that drain the
whole right and lower left thorax

26. Causes
• Lung (65%)
• Lymphoma (8%)
• Other cancers (10%)
• Nonmalignant (12%)
• Undiagnosed (5%)

27. Clinical Presentations
• Most common symptoms
• Dyspnoea (63%)
• Facial swelling (50%)
• Head fullness (24%)
• Most common signs
• Venous distension of neck (66%)
• Venous distension of chest wall (54%)
• Facial edema (46%)

28. complications
• Cerebral edema
• Laryngeal edema

29. Imaging studies
• CXR
• CT scan is often diagnostic
• Upper extremity venography seldom needed

30. CXR findings
Findings Patients (%)
Sup mediastinal widening 64
Pleural effusion 26
(R) hilar mass 12
Bilateral infiltrates 7
Cardiomegaly 6
Calcified paratracheal LNs 5
Ant mediastinal mass 3
Normal 16

31. Treatment
• Raise the upper body
• Transfer iv access to lower limbs
• Supplemental oxygen
• Mist morphine 5-10 mg q4-6 hrly
• Furosemide 20-40 mg om
• Hydrocortisone 100 mg q6-8 hrly

32. Treatment
• Treat underlying cancer
• Radiation therapy
• Chemotherapy
• Re-establish patency
• Thrombolytic therapy
• Endovascular stenting
• Bypass surgery

33. Pericardial Tamponade

34. Causes
• Often (but not always) a preterminal event
• Occurs in about 10-15% of advanced cancer pts
• Lung and breast cancer make up 75% of all the cases

35. Clinical Presentations
• Symptoms similar to CCF
• Signs
• Kussmaul’s sign
• Pulsus paradoxus
• Distant heart sounds

36. imaging studies
• CXR
• Water-bottle silhouette
• Echocardiography
• Echo separation
• RA or RV collapse
• CT chest

37. Treatment
• IV fluids
• Supplemental O2
• Morphine for SOB
• Inotropic support
• Pericardiocentesis

38. Treatment
• Pericardial window
• Pericardial sclerosis
• Radiotherapy
• Treat underlying cancer

39. Hypercalcemia

40. • Elevated levels of ionized calcium in the blood
• Corrected calcium = measured calcium + 0.02 x (40 –
measured albumin) mmol/L
• Normal 2.2 – 2.6 mmol/L
• Symptomatic > 3.0 mmol/L

41. Causes
• The 2 most common causes are cancer and
hyperparathyroidism

42. Causes
• The most common malignancies are
• Multiple myeloma
• Breast
• NSCLC
• RCC
• Hypercalcemia is the most common life-threatening
metabolic oncologic disorder

43. Clinical presentation
• General
• Dehydration, fatigue, lethargy, pruritis
• Neuromuscular
• Confusion, psychosis, obtundation, seizure
• Proximal myopathy, hyporeflexia
• GIT
• Nausea, emesis
• Dyspepsia
• Pancreatitis
• Constipation, ileus

44. Clinical manifestations
• Renal
• Polyuria, ARF
• Cardiac
• Bradycardia, prolonged PR, shortened
QT, widen T, arrhythmia

45. Treatment
• Forced diuresis
• Saline 4-6 L over 24 hr
• Urine output 150-200 ml/h
• Volume re-expansion
• Calciuresis
• Loop diuretic
• Calciuresis
• may worsen dehydration
• Those at risk of hypervolemia

46. Treatment
• Pamidronate 60-90 mg IV over 2-4 hr
• Inhibits osteoclasts
• Commence when diuresis is achieved
• Calcitonin 2-8 U/kg SC or IM q6-12 hrly
• Inhibits osteoclasts
• Fast, safe but short
• Severe symptomatic hypercalcemia before the onset of
bisphosphonate

47. Treatment
• Hydrocortisone 250-500 mg q8 hrly
• Inhibits osteoclasts
• Helpful in MM, lymphoma, some breast cancers
• No value in most solid tumours

48. Treatment
• Hemodialysis can be considered in those with severe
symptomatic hypercalcemia who are unable to tolerate forced
diuresis

49. Watch for:
• Fluid status
• Hemodynamic status
• Metabolic status
• Hypomagnesemia
• Hypokalemia

50. Supportive Treatment
• Avoid drugs that may worsen hypercalcemia or those that are
nephrotoxic
• Decrease intestinal absorption by restricting dietary calcium
intake or with the use of oral phosphate (1-3 g/day)
• Ensure early mobilization

51. Acute Tumor Lysis
Syndrome

52. ATLS
• Rapid lysis of malignant
• Release of intracellular products
• Exceeds renal excretory capacity
• Resulting in life-threatening metabolic derangements

53. Usual presentation
• Usually during 1st cycle chemotherapy
• Anticipated event
• Treatment is primarily PROPHYLACTIC

54. • Hyperkalemia (3.5-4.5 mmol/L)
• Hyperphosphatemia (0.8-1.45 mmol/L)
• Hypocalcemia (2.12-2.65 mmol/L)
• Hyperuricemia (M < 420; F < 360 umol/L)
• Acute renal failure

55. Prophylaxis
• Identify who is at risk
• Hydration 3 L/m2/day
• Don’t add potassium
• Keep urine flow 150-200 ml/ hr
• Alkalinization
• 50-100 mEq Na(HCO3)2
• Keep urine pH 6.5 to 7
• Allopurinol 300 mg/day
• Institute these measures 24-48 hr before
chemotherapy for treatment of cancer at risk of
ATLS

56. High risk:
• Hematological cancers
• Aggressive lymphomas
• Acute leukemias
• Chemosensitive solid cancers
• Small cell lung cancer
• Germ cell tumour

57. • Bulky disease
• Abdominal disease
• LDH >1500 U/L
• Pre-existing volume depletion
• Pre-existing renal dysfunction
• Post-treatment ARF
• Concentrated urine
• Acidic urine

58. Treatment
• Same measures as those for prophylaxis
• Correct electrolyte derangements but don’t try to correct the
hypocalcemia
• Urate oxidase (Rasburicase)
• Coverts UA to highly soluble allantoins
• Rapid onset of action
• Very expensive
• Hemodialysis

59. Spinal Cord
Compression

60. Spinal cord compression
• Overall frequency about 5%
• 2nd most common cancer neurological complication
• Definition broaden to include
• Conus medullaris
• Cauda equina
• All can be caused by secondaries to the spine

61. Causes of Spinal Cord
Compression
• Breast 29%
• Lung 17%
• Prostate 14%
• Lymphoma 5%
• Myeloma 4%
• Renal 4%

62. Clinical Manifestations:
• Pain
• Most common initial symptom (90%)
• Almost always antedate (days - months)
• Local pain almost always present
•  by coughing, neck flexion or straight leg raising
•  when lying down (c.f. disc disease)
• Radicular pain (nerve root)

63. • Weakness
• Second most common symptom
• Most evident with proximal LL
• Can progress rapidly
• Autonomic symptoms
• Occurs late
• Poor prognosis

64. • Classically, spastic paralysis with sensory level
• But if in cord shock, can present with absent motor, sensory,
reflex and autonomic function

65. Conus medullaris
• Saddle anaesthesia (S3-5)
• Early sphincter involvement (S4-5)
• Impotent (S2-4)
• Spares the lower limbs (spares S1)

66. Cauda equina
• Radicular pain
• Asymmetrical sensory loss
• Asymmetrical flaccid paralysis
• Relative autonomic sparing

67. Level involved
• Thorax 70%
• Lumbosacral 20%
• Cervical 10%

68. Extent
• Single level (46%)
• Multiple non-contiguous levels (28%)
• Multiple contiguous levels in about (26%)

69. Imaging
• Plain XRAY (+): 70-80% when either back pain or signs present
• MRI is the modality of choice
• CT myelography if MRI unavailable
• Bone scan indicates the presence of spinal metastases but
does not diagnose cord compression

70. Predictor of recovery
• The most single most powerful predictor of treatment outcome is
the pretreatment neurologic status
Pre-treatment Recovery after RT
Ambulatory 98%
Paraparetic 60%
Paraplegic 11%

71. Management
• Pain control
• Preserve spinal stability
• Relieve cord edema
• Relieve autonomic dysfunction
• Confirm diagnosis
• Surgical decompression/stabilization
• Treat the bone mets

72. management
• Mist morphine
• Bedrest
• Dexamethasone 8 mg q6 hrly
• Bladder catherization
• MRI spine
• Refer spine team
• Radiation therapy

73. Surgical indication:
• Need histology
• Retropulsed bone fragment
• Spinal instability
• Previous RT or progression on RT
• Single level
• Rapid progression

74. Brain Metastases

75. Cerebral metastases
• Occurs in 20-40% of cancer patients
• Majority are from lung and breast
• Majority are supratentorial (80%)
• Majority are multiple (70%)

76. causes
• Metabolic such as hypoglycemia
• Cerebrovascular
• Infective
• Nutritional
• Paraneoplastic

77. Features that needs close
monitoring
• Massive lesion
• Haemorrhage
• Extensive edema
• Mass effect
• Hydrocephalus
• Posterior cranial fossa

78. management
• Dexamethasone 8 mg Q8 hourly
• Restrict fluids
• Anticonvulsant only if symptomatic
• Refer neurosurgeon if worrisome features present

79. Pain Management

80. Pain in a cancer
• Concepts of pain
• Physical pain
• Clinical pain
• Total suffering

81. Physical pain
• It is an unpleasant sensory and emotional experience
associated with actual or potential tissue damage

82. Pathophysio classification
• Nociceptive
• Soft tissue pain
• Bone pain
• Visceral pain
• Neuropathic
• Psychogenic

83. • Inadequate analgesia e.g. undertreated, poor compliance
• Breakthrough pain
• Disease progression
• Acute complication e.g. tumour rupture, pathological fracture

84. • Opioid: most pains
• Steroid: inflammatory pains, raised ICP
• NSAID: bone pains
• Antispasmodic: colicky pains
• Anticonvulsants: “shooting’’ pains
• Antidepressants: “burning” pains
• Anxiolytics: muscle pains

85. Analgesics
• Opioid naïve start 5 mg PO
• Scheduled doses q4-6h strictly
• Breakthrough doses 5 mg q2h prn
• Increase dose by 25-50%
• Caution in elderly, liver failure and renal failure

86. doses
• IV Morphine 10 mg (x 1)
• TD Fentanyl 0.1 mg (x 100)
• IV Pethidine 75 mg (x 0.13)
• PO Methadone 20 mg (x 0.5)
• PO Oxycodone 20 mg (x 0.5)
• PO Morphine 30 mg (x 0.33)
• PO Tramadol 120 mg (x 0.08)
• PO Codeine 240 mg (x 0.04)

87. Titration of morphine dose
• For controlling severe pain
• i.v. morphine 1 mg
• Every 1 min until pain relief or drowsy
• Cumulative dose given = dose per 4h
• Calculate dose needed for 24h and run as a continuous
infusion

88. • Source:
Google
Medscape
Harrison’s
Oxford
Old notes in Medical School
http://crisbertcualteros.page.tl