1.09 - Complications of Cancer Treatment Flashcards
Most common complication of anticancer treatment.
Febrile neutropenia
Complications of neutropenic sepsis.
- organ failure
- invasive / atypical infection
- coagulopathy (ie. DIC)
- malnutrition
- encephalopathy
- death
- PTSD / anxiety
Risk factors for neutropenic sepsis.
- chemotherapy regimes
- stem cell transplantation
- age (infants; >60 years)
- corticosteroids
- antibiotics
- advanced malignancy
- central venous access
When should neutropenic sepsis be considered?
Any person with known neutropenia or risk factors for neutropenia, plus:
- infective signs
- fever >38°C
- unexpected deterioration
Management of neutropenic sepsis.
Implement the UK Sepsis Six bundle within the first hour following recognition of sepsis.
- Give oxygen therapy to people with reduced oxygen saturation or with an increase in oxygen requirement over baseline, to maintain oxygen saturation above 94% unless contraindicated.
- Take blood tests and microbiology samples including:
- Blood gas including glucose and lactate measurement — hypoglycaemia may result from depleted glycogen stores; hyperglycaemia may result from the stress response to sepsis; hyperlactataemia is a non-specific indicator of cellular or metabolic stress and is a marker of illness severity, with a higher level predictive of higher mortality rates.
- Blood culture — ideally done before antibiotic administration.
- Full blood count — white cell count may be high or low; thrombocytopenia may indicate disseminated intravascular coagulation (DIC), but may also be chemotherapy- or tumour-related.
- C-reactive protein (CRP) — may indicate infection and/or inflammation.
- Creatinine, urea and electrolytes — may indicate dehydration and/or acute kidney injury.
- Liver function tests — increased bilirubin or alanine aminotransferase (ALT) levels may indicate cholestasis or other liver dysfunction, and may be chemotherapy-induced.
- Clotting screen — if abnormal may indicate coagulopathy/DIC.
- Urine analysis and culture, sputum microscopy and culture, chest X-ray, and additional investigations such as chest CT or bronchoalveolar lavage may be indicated if there is severe or prolonged neutropenia. - Give an intravenous broad-spectrum antibiotic at the maximum recommended dose.
- Give an intravenous fluid bolus to restore tissue perfusion.
- Check serial lactate measurement.
- Check urine output, monitor fluid balance hourly and monitor the person’s clinical condition.
What advice should be given to patients at ongoing risk of neutropenia?
- infection prevention (ie. good personal and oral hygiene, handwashing)
- access to thermometer to check temperature at home
- safety netting of when to seek escalating care
Prognosis of neutropenic sepsis.
Mortality rates vary with the Multinational Association of Supportive Care in Cancer (MASCC) prognostic index, between 5-40%.
What is tumour lysis syndrome?
Oncological emergency that occurs when malignant cells rapidly break down, releasing their contents into the blood stream.
This causes significant changes to the levels of electrolytes within the blood.
Trigger for tumour lysis syndrome.
12-72 hours after initiation of chemotherapy, most commonly in lymphoproliferative malignancies.
NB: less commonly occurs in response to corticosteroids, hormonal therapy and radiotherapy.
Pathophysiology of tumour lysis syndrome.
Cancer cells typically have a high turnover rate, producing large amounts of nucleic acids and phosphate.
When chemotherapy is started, these cells break down rapidly, releasing intracellular contents. These contents can quickly overwhelm the body’s normal haemostatic response.
Electrolyte abnormalities typical of tumour lysis syndrome.
- hyperuricaemia
- hyperphosphataemia
- hypocalcaemia
- hyperkalaemia
Malignancies at high risk of TLS.
- poorly differentiated lymphoma
- leukaemia
- fast-growing solid tumour (SCLC, breast cancer)
Risk factors for TLS.
- large tumour burden
- extensive bone marrow involvement
- high tumour sensitivity to chemotherapy
- pre-existing renal impairment
- dehydration
Symptoms of TLS.
Vague and non-specific:
- N+V
- confusion
- muscle cramps
- diarrhoea
- lethargy
- reduced urine output
- syncope
- chest pain
- palpitations
Signs of TLS.
Underlying malignancy:
- lymphadenopathy
- splenomegaly
Renal failure:
- peripheral oedema
Hypocalcaemia:
- Trousseau’s sign
- Chovstek’s sign
What is Trousseau’s sign?
What is Chovstek’s sign?
Bedside investigations of TLS.
- ECG (arrhythmia secondary to hyperkalaemia, hyperphosphataemia)
- urine pH (pH<5 = precipitation of uric acid crystals, causing obstruction)
Laboratory investigations for TLS.
- FBC (leukocytosis)
- U&Es (renal impairment and electrolyte abnormalities)
- bone profile (hyperphosphataemia / hypocalcaemia)
- uric acid
- LDH (risk factor)
Laboratory TLS diagnosis.
Two or more of the following, occurring between 3 days before and 7 days after initiation of cancer treatment:
Uric acid ≥476 micromol/L (≥8 mg/dL) or 25% increase from baseline
Potassium ≥6 mmol/L or 25% increase from baseline
Phosphate ≥1.45 mmol/L or 25% increase from baseline
Calcium ≤1.75 mmol/L or 25% decrease from baseline
Clinical TLS diangosis.
Laboratory TLS diagnosis plus one of:
- Increase in serum creatinine ≥1.5 times the upper limit of normal
- Cardiac arrhythmia
- Seizure
- Sudden death
Prevention of TLS.
- regular monitoring of blood tests
- monitor fluid balance + IV hydration
- consider allopurinol if hyperuricaemia is present before chemotherapy
General management of TLS.
- IV fluids (aggressive)
- observations 4-6 hourly
- daily weights
- blood tests every 6 hours
- ECG at baseline; consider cardiac monitor
Management of TLS:
Hyperuricaemia.
IV rasburicase for 3-7 days
Management of TLS:
Hyperkalaemia.
Calcium gluconate for cardiac protection
Glucose/insulin infusion
Management of TLS:
Hyperphosphataemia.
Phosphate-binding agents
Management of TLS:
Hypocalcaemia.
IV calcium gluconate if symptomatic
Complications of TLS.
- acute kidney injury
- cardiac arrhythmias
- seizures
- lactic acidosis
What is the most common immunotherapy related adverse event?
Immune related colitis
What is immune related colitis?
Life-threatening diarrhoea occurring in 50% of patients treated with immunotherapy.
Symptoms of immune related colitis.
- frequent stools
- abdominal pain
- blood in stool
- nausea
- nocturnal diarrhoea
Investigations for immune related colitis.
Bloods: FBC, U&Es, LFTs, TFTs, CRP.
Stool for MC&S.
Abdominal xray.
Sigmoidoscopy +/- biopsy.
Management of immune related colitis.
- loperamide
- oral prednisolone (with tapering regime)
- consider withholding immunotherapy
Causes of oral mucositis.
- high dose chemotherapy
- high dose radiation to head and neck region
Symptoms of oral mucositis.
- oral discomfort and pain
- oral erythema
- ulcers
Pain can interfere with eating and drinking.
How long does oral mucositis last?
2 to 4 weeks following chemo/radiotherapy.
Risk factors for oral mucositis.
- poor oral hygiene
- smoking tobacco products
- using alcohol
- not drinking enough fluids
- dry mouth
- female sex
- younger
Side effects of oral mucositis.
- nutritional problems
- increased risk of infection / sepsis
- disruption of treatment
- reduced quality of life
Managing oral mucositis during and after treatment.
- stop smoking
- avoid alcohol
- drink lots of fluids
- eat lots of protein
- cold foods
- soft, mild foods
- drink through a straw
- good oral care
How long do platelets circulate for?
7-10 days
Causes of thrombocytopenia.
- malignancy
- ITP
- DIC
- splenomegaly
- dilutional
Cancer-related thrombocytopenia causes.
Myelosuppression due to bone marrow infiltration.
Treatment induced thrombocytopenia can be caused by radiation or systemic chemotherapy.
Symptoms of thrombocytopenia.
- epistaxis
- GI bleeding
- gum bleeding
- heavy menstrual bleeding
- post-menopausal bleeding
- skin brusing/bleeding
