Oncologic Emergencies

Transcription

1 Oncologic Emergencies Oncologic Emergencies KELLY YOUNG, CNP DNP MN ONCOLOGY Neutropenic Fevers Disseminated Intravascular Coagulation (DIC) Tumor Lysis Syndrome (TLS) Infusion related reaction Spinal Cord Compression Brain Metastases Superior vena cava (SVC) syndrome Immune mediated reactions Case Study Neutropenic Fever 57 year-old male, hx metastatic prostate CA, status post 1 cycle of docetaxel 8 days prior. Fever of 101.6, chills. Denies dysuria, shortness of breath, cough, or diarrhea. Labs: WBC 1.2, ANC 0.6, hemoglobin 12.8, platelet 175,000 Neutropenia definition: An ANC of < 1500 cells/microl, severe neutropenia < 500 cells/microl, profound neutropenia < 100 cells/microl Neutropenic Fever: For the purpose of our discussion, ANC < 1000 cells/microl and a single oral temperature of 38.3 C (101 F) or a temperature of 38.0 C (100.4 F) sustained over a one-hour period Given immunosuppression, may not have a fever. Monitor for decompensation, hypotension, signs of sepsis Sources: CVC, oral/skin, perianal, lungs, abdomen... Case I: Work-Up What Next? CBC/differential, CMP Directly admitted CXR Blood cultures x 2 (if CVC, ALL LUMENS) UA As directed by sxs (diarrhea>>>c diff, abd tenderness>>> CT) AllinaHealthSystems 1

2 CASE I: Treatment Case 1 START ANTIBIOTICS WITHIN 60 MINUTES!!!! Empirically treat for gram negative: Cefepime, Piperacillintazobactam Add gram positive coverage w/ vancomycin if suspect CVC, pneumonia, skin, or pt is unstable. Additional coverage as per specific source (i.e. fluconazole>>>thrush, PO vancomycin>>>c-diff, or based on sensitivities) Granulocyte-colony stimulating factor (Filgrastrin, tbo-filgrastrim) Same patient (prostate CA, neutropenic ) Started on Cefipime and Vancomycin Positive blood cultures from port reveals MRSA: Continues on vancomycin Continued fevers, hypotension, tachycardia. IV site oozing, noted petechiae, SOB, Case 1 Labs CBC: WBC 0.8, ANC 0.3, hgb 12.0, platelet count 68,000 Coags: INR: 2.2 PT 28 seconds PTT 75 seconds Fibrinogen 92mg/Dl D-Dimer 3.0 micrograms/ml Disseminated Intravascular Coagulation (DIC) Typically, body maintains a homeostasis of thrombosis (clot formation) and fibrinolysis (clot breakdown). Tissue injury Vasoconstriction and platelet attraction Platelet Plug Clotting cascade Then initiates fibrinolytic pathway Dissolving of the clot and repairing of tissue Disseminated Intravascular Coagulation (DIC) Overstimulation of the coagulation system w/ imbalance of coagulation and fibrinolysis Risk factors: sepsis, malignancy (APL), liver failure Case 1: Diagnosis and Treatment Clinical and laboratory diagnosis Labs: CBC: Thrombocytopenia CMP: Monitor organ damage Peripheral smear: schistocytes (cell fragments) Coags ( prothrombin time [PT], activated partial thromboplastin time [aptt], fibrinogen, and D-dimer) AllinaHealthSystems 2

3 Case 1: DIC Treatment Case 2 Treat the underlying cause (abx, chemo, etc.) Supportive cares FFP/Cryopercipitate (less volume): serious bleeding and a significantly prolonged PT or aptt, or a fibrinogen level <50 mg/dl and serious bleeding Platelets: if platelet count is < 50,000 and bleeding/need of procedure or if < 10, yo female, new dx DLBCL. PET scan shows bulky adenopathy above and below the diaphragm. BM negative for malignancy Labs, initially CBC unremarkable. CMP pending Received first dose of RCHOP in office Labs: CMP: Creatinine 3.0 (baseline 0.9) Potassium: 5.1 ( mmol/l) Uric acid 13 ( mg/dl) Phosphurus 5.0 ( mg/dl) LDH 230 ( U/L) Tumor Lysis Syndrome (TLS) Treatment Seen in malignancy with a high proliferation, high tumor burden, highly sensitivity to treatment Massive cell lysis (tumor breakdown) resulting in the release of intracellular contents: k+, phos, and nucleic acid (catabolism>>>uric acid) Results in hyperkalemia, hyperphosphatemia, hypocalcemia and hyperuricemia Hyperkalemia: cardiac arrhythmias Hypophosphatemia >>> secondary hypocalcemia cardiac arrhythmias Hyperuricemia >>> crystal precipitation >>> deposition in renal tubules >>> acute kidney injury Monitor: urine output and q 6 hours uric acid, kidney function, lytes. Allopurinol (prevents by decreasing formation, but does not reduce preexisting uric acid. May start when uric acid normalizes) Rasburicase IV fluids Sodium Bicarbonate: prevents urate deposition in renal tubules Treat electrolyte abnormalities Renal involvement:? Dialysis (persistent electrolyte abnormalities, oliguria, etc) Case 2 Case 2 60 yo female, new dx DLBCL. PET scan shows bulky adenopathy above and below the diaphragm. BM negative for malignancy Directly admitted for first cycle given risk of TLS Receiving R CHOP (Rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) Begin IV hydration and give premedications of acetaminophen and benadryl. Start infusion at 25ml/hour and up titrate to 50ml/hour Develops rigors, chest pain, and BP now 96/54 AllinaHealthSystems 3

4 Infusion Related Reaction Infusion Related Reaction Seen in over 50% of first infusion of rituximab. Risk decreases w/ time Typically w/in 2 hours: HA, pyrexia, chills, rash, SOB, nausea, rigors, angioedema (11%), hypotension, bronchospasms (< 10%), death (rare). Higher burden of disease, higher risk Antibody (Rituximab, a monoclonal ab) + antigen (CD 20 on lymphocytes) >>> cytokine release syndrome (release of inflammatory cytokines) Prevention: Prophylaxis with 50 mg PO diphenhydramine and 650mg PO acetaminophen Start at a slow rate and titrate up as tolerating. Subsequent infusions may titrate up quicker. Monitor closely Infusion Related Reaction Case 3 Mild-moderate reaction Stop infusion H2 blocker (famotidine) +/- hydrocortisone Re challenge at a slower rate Management of a severe reaction Hydrocortisone Epinephrine Dex/h2 blocker premed day prior in the future? Call oncologist 39 year old male presents with worsening back pain over one week Seen PCP, given stretches Pain located in lower back, radiating down LE Has not voided in 12 hours and no BM in 3 days Worsening weakness in LEE Pain is a 10/10 Spinal Cord Compression EMERGENCY! NHL, multiple myeloma, breast, lung, prostate Worse outcomes w/ worse presentation. Irreversible w/out prompt treatment Signs and Symptoms of Spinal Cord Compression Back pain Radicular pain Cauda Equina Syndrome Pain, numbness, weakness Numbness of the lower extremities Bowel or bladder dysfunction AllinaHealthSystems 4

5 Spinal Cord Compression Case 4 STAT MRI Dexamethasone 10-16mg x 1, followed by 4-5mg every 4-6 hours. Neurosurgery: Decompression ASAP. XRT w/ or w/o decompression 72 year old female, known history of III NSCLC Underwent concurrent Cisplatin/etoposide/XRT followed by durvalumab Now presents w/: HA x 1 week and now acute right sided motor dysfunction, blurred vision, confusion STAT Contrast MRI brain Brain Metastases Brain Metastases Treatment 20% of oncology patients Highest incidence: lung (SCC, NSCLC), breast, renal cell, melanoma Can result in edema Presentation: Headache, motor/sensory defects, ataxia, seizure, CVA (hemorrhage into met) Best test: Contrast MRI Symptomatic?: Dexamethasone Neurosurgery consult Radiation consult Systemic treatment Prognosis is dependent on disease and extent Case 5 66 y.o. presents with facial swelling. Notes SOB and HA when bending over. ROS reveals dry cough and worsening dyspnea Exam: Neck/facial edema Distended veins on the chest and neck. Left upper ext swelling Work-up: CT scan demonstrates large right pulmonary mass w/ mass effect on the SVC SVC Syndrome Common: Right sided lung CA. Less Common: NHL SVC obstruction >>> impaired venous return to heart from head, neck, thorax, and upper ext. AllinaHealthSystems 5

6 SVC Syndrome SxS Heterogenous presentation Common symptoms: Dyspnea, orthopnea, cough, HA (often positional), facial fullness Less common symptoms: hoarseness, hemoptysis, dizziness, syncope Physical findings: Facial and neck swelling, arm swelling, dilated veins in the chest, neck, and arms. Stridor or LOC changes = emergency (? Laryngeal edema, ICP) SVC Syndrome Treatment Considered an emergency, most cases are not however Establish a diagnosis Stenting if very symptomatic Radiation therapy Antineoplastic treatment Anticoagulation if thrombus Supportive: diuretics, steroids, raise the head of the bed Immunotherapies Immune Mediated Toxicities (YOU WILL BE SEEING MORE!) Checkpoint inhibitor immunotherapy has been a major advancement in the treatment of a wide range of malignancies. Immunomodulatory antibodies enhance the immune system. Inhibition of program cell death receptor 1 (PD 1) and program cell death ligand (PDL 1), resulting in an antitumor immune response. PD- 1 inhibitors: Nivolumab, pembrolizumab PDL 1 inhibitors: atezolizumab, durvalumab Used for multiple malignancies including lung, NHL, melanoma, urothelial, hepatocellular carcinoma, head and neck cancers, colorectal cancer Immune Mediated Toxicities Dermatologic, colitis, hepatotoxicity, pneumonitis, endocrinopathies (hypothyroidism, adrenal insufficiency), nephrotoxicity, ITP Treatment: Dependent on the toxicity. Pneumonitis, ITP, colitis, hepatic toxicity, nephritis: High-dose steroid taper Endocrinopathies: Steroids, Levothyroxine, endocrinology involvement AllinaHealthSystems 6