Oncologic Emergencies Haskell (Gill) Kirkpatrick M.D. 9/22/05.
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Transcript of Oncologic Emergencies Haskell (Gill) Kirkpatrick M.D. 9/22/05.
Malignant Spinal Cord Compression (MSCC)
• Affects 5-10% cancer patients – Most commonly: breast, prostate, lung, lymphoma and multiple
myeloma• 20% MSCC cases are initial presentation• Bone (axial skeleton) common site of metastasis
– Vertebral and epidural venous plexus (Batson’s plexus)• Most common mechanisms
– Hematogenous met to vertebral body extending into epidural space
– Pathologic fracture of vertebral body (infiltrated with tumor) resulting in cord injury from bone fragmentation or instability
• 65% cases affect thoracic spine– 20% cases lumbar spine (colon and prostate predilection)– Cervical and sacral involvement rare
Clinical Presentation of MSCC
• Back pain: In certain cancer patients should be considered metastatic origin until proven otherwise
• Periostium richly innervated– Vertebral body tender to palpation/percussion
• Pain worse with recumbancy• Usually precedes neurologic symptoms (1-2 months) • Radicular pain most common with lumbosacral lesions• Thoracic radicular pain usually bilateral, band-like
Clinical Presentation of MSCC
• Progression of motor findings: weakness, loss of gait, paralysis
• Majority of compressions at thoracic level: paraparesis• Upper lumbar spine: conus medullaris syndrome
– Distal lower extremity weakness, saddle paraesthesias and overflow leakage from bowel and bladder
• Loss of bladder and bowel function generally a late finding
• Majority of patients not ambulatory at time of diagnosis
Diagnosis of MSCC
• Average time from onset symptoms to diagnosis: 3 months
• MRI of whole spine is most sensitive test• Decision to use modality based on history of back pain
– Suspicion for pain secondary to Degenerative disease • mostly affects lower cervical and lower lumbar spine
• Waxes and wanes
• Responds to NSAIDs and bed rest
– Suspicion for pain secondary to MSCC• Thoracic spine
• Progresses despite conservative treatments
• Aggravated by supine position
Treatment of MSCC
• Corticosteroids: Optimal dose?– “High dose” studied in only randomized trial (+/- XRT)
• 96 mg IV bolus then 24 mg 4 X /day (tapered over 10 days)• Serious side effects (GI perforations and bleeding)
– Most common regimen: • 10 mg bolus then 16 mg/day (divided over 4 doses)
• Radiation therapy– Relieves pain in most patients– Pre-treatment neurologic fxn strong predictor of response– Underlying tumor type also predictor
• Aggressive surgery– New data shows that all patients should be considered for
decompressive radical resection
Febrile Neutropenia
• Should be considered an emergency– Early studies have shown high mortality when delay
initiation of appropriate antibiotics– Before era of empiric antibiotics infection accounted
for up to 75% of deaths associated w/ chemotherapy
• Definitions:– Fever: single temp > 38.3°C (101.3°F) or 38.0°C
(100.4°F) sustained greater than 1 hour– Neutropenia: usually ANC < 500
• Absolute neutrophil count (ANC)=total WBC X (%neutrophils + %bands)
Infection as Cause of Death in
Cancer PatientsBodey GP et al, Ann Intern Med 1966;64:328
PatientsAcute
Leukemia LymphomaSolid
Tumors
Number studied atautopsy 315 206 816
Number dying ofinfection 234 (74%) 104 (51%) 380 (47%)
Due to bacterialinfections (%) 76 87 93
Due to gram-negativebacilli (%) 78 60 68
Organisms Causing Infection During Chemotherapy of Acute Leukemia
Bodey GP et al, Ann Intern Med 1966;64:328
Type Number %Gram negative bacilli 617 51Gram positive 52 4Anaerobes 19 2Fungal 68 6Multiple 116 9Viral 9 0.7Pneumocystis and toxoplasma 3 0.3Unidentified 325 27
Infections
0
20
40
60
80
100
1 2 3 4 5 6 7
DAYS
PE
RC
EN
T
MO
RT
ALIT
Y
Pseudomonas sp Klebsiella sp E. coli
Febrile Neutropenia
• Seeding of the bloodstream from endogenous flora in the GI tract most common cause
• Commonly cultured bacterial pathogens– Gram neg (Pseudomonas, E Coli, Klebsiella etc..)– Gram pos (Coag-neg staph, staph aureus, streptococcus etc…)
• Commonly cultured fungal pathogens– Candida species, Aspergillus
– usually arise later as a secondary infection in patients with prolonged neutropenia and antibiotic use
• Viral pathogens– HSV, VZV
Treatment of Febrile Neutropenia
• Empiric Antibiotics– Appropriate coverage of known or suspected infection based on
history/exam findings/radiographic studies
• Monotherapy:– ceftazidime, imipenem, meropenem, or cefepime
• Double coverage:– beta-lactam and an aminoglycoside
• Awareness of institutional resistance patterns• Addition of empiric Vancomycin
– Skin or catheter site infection, hypotensive, hx of MRSA colonization, mucositis, quinolone prophylaxis
Corey, L. et al. N Engl J Med 2002;346:222-224
Causes of Fever in Patients with Prolonged Neutropenia Who Are Receiving Broad-Spectrum Antibiotics
Treatment of Febrile Neutropenia
• Empiric anti-fungal coverage with persistent fever on broad-spectrum antibiotics and prolonged neutropenia– Amphotericin B (liposomal), caspofungin,
voriconazole
• Colony stimulating factors– Should not be used routinely– Appropriate for critically ill patients
Pizzo, P. A. N Engl J Med 1993;328:1323-1332
General Principles for the Management of Fever in Patients with Neutropenia
Hyperleukocytosis
• Neutrophil count (CML) > 250,000 may cause vasoocclusive complications
• Leukemic blasts (AML) are nondeformable – Cause hyperviscosity at lower counts ( 70,000 +)
• Leukostasis in microvasculature leads to clinical symptoms– Pulmonary: hypoxemia– CNS: headaches, vision changes/loss, focal deficits
• Symptomatic hyperleukocytosis and AML associated with initial high mortality
Treatment of Hyperleukocytosis
• Emergent leukophoresis can be used– Should be used as adjunct to chemotherapy– Temporizing measure
• Initiate cytoreductive therapy ASAP– Blasts are rapidly accumulating– Can result in another oncologic emergency…
Tumor Lysis Syndrome
• Rapid cell death in face of high tumor burden– Large amounts of intracellular metabolites released
• Uric acid, potassium, phosphate..
• Most commonly associated with poorly differentiated lymphomas and leukemias– Burkitt’s– ALL (more commonly than AML)
• Uric acid can deposit in kidney leading to ARF• Dialysis can support patient • Rasburicase or Elitek (urate oxidase): oxidizes uric acid
to allantoin which is water soluble
Prevention of tumor lysis syndrome
• Vigorous hydration• Allopurinol 300-900 mg/day
– Ideally 2 days before cytotoxic therapy
• Role of alkalinizing urine debatable– Increases the solubility of uric acid and decreases
tendency for precipitation but…– Alkalinizing could promote calcium-phosphate
deposition– Animal studies have shown that increased tubular
flow rate is most important protective measure– Vigorous hydration with saline is likely as effective
SVCS: Primary Pathologic Diagnoses
HistologicDiagnosis
Bell159 Cases
(%)
Schraufnagel107 Cases
(%)
Parish86 Cases
(%)
Total352 Cases
(%)
Lung CancerLymphomaOther malignancies
129 (81)3 (2)
67 (63)10 (9)
45 (52)8 (9)
241 (68) 21 (6)
(primary ormetastatic)Non-neoplasticUndiagnosed
4 (3)2 (1)
21 (13)
14 (13)16 (15)
14 (16)19 (22)
32 (9)39 (11)21 (6)
Superior Vena Cava Syndrome
• Invasion or external compression of SVC • Malignant tumors responsible for 80% cases
– Infection and thrombosis account for most of the rest
• Symptoms– Dyspnea– Facial swelling, arm edema, cyanosis
• Signs– Venous distension on neck and chest wall– Facial edema
Superior Vena Cava Syndrome
• 60% cases due to malignancy present without known diagnosis
• CT preferred diagnostic tool• Importance of biospy
– Short delay not compromise outcome most cases– Histology helps determine treatment and prognosis
• Treatment responsive tumors: SCLC, germ cell tumors, NHL
• Role for intraluminal stents?