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Cancer care (Y4) > 12- Acute presentations in cancer (secondary to treatment) > Flashcards

12- Acute presentations in cancer (secondary to treatment) Flashcards

1
Q

acute presentations secondary to cancer therapy e.g. chemotherapy/radiotherapy

A
  • Neutropenic sepsis
  • Tumour lysis syndrome
  • Immune related colitis
  • Radiation mucositis
  • Thrombocytopenia
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2
Q

Neutropenic sepsis
background

A

Definition
- Patient undergoing systemic anticancer treatment (SACT)
- Temp >38 or over 37.5 degrees over 1 hour
- Neutrophil count < 0.5 x 10 9 per litre or <1.0 and falling
- Patient can have infection and no fever

Remember
Suspect in all chemo patients who become unwell as some chemo patients cannot mount a fever (corticosteroids)

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3
Q

what is neutrophil nadir

A

Neutrophil levels reach a low point about 7 to 14 days after treatment. This is called the nadir. At this point, you are most likely to develop an infection. Your neutrophil count then starts to rise again.

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4
Q

when does neutrophil nadir typically occur

A

day 10

  • Haematological malig Rx; deeper nadir, greater duration of neutropenia
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5
Q

newer biological/targeted therapies and neutropenic sepsis

A

less propensity to cause neutropenia

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6
Q

causes of neutropenic sepsis

A

Gram-negatives: can all produce extended-spectrum beta-lactams
* E.coli
* Klebsiella
* Enterobacter spp. - can get carbapenem-resistant strains (CRE)
* Pseudomonas aeruginosa
* Acinetobacter
* Gram-positives:
Coagulase-negative staphylococci (e.g. staph epidermidis)
* Staphylococcus aureus (including MRSA)
* Enterococcus (including VRE)
* Viridans group strep
* Strep pneumoniae
* Group A streptococci
Fungal:
* Candida
* Aspergillus

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7
Q

Risk of infection increased with

A
  • Prolonged neutropenia (>7 days)
  • Severity of neutropenia
  • Significant comorbidities (COPD, DM, renal/hepatic impairment)
  • Aggressive cancer
  • Central lines
  • Mucosal disruption
  • Hospital inpatient
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8
Q

presentation of neutropenic sepsis

A
  • Fever >38 or over 37.5 degrees over 1 hour
  • Tachycardia >90
  • HYPOTENSION < 90 systolic= URGENT
  • RR > 20
  • Symptoms related to a specific system e.g. cough, SOB, line, mucositis
  • Drowsy
  • Confused
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9
Q

investigations for neutropenic sepsis

A

Investigations
Blood tests
- FBC (with differential)
- U&Es
- LFTs
- Lactate/ABG
- CRP

Cultures/swabs

Urine

Sputum

Wound swabs

CXR

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10
Q

initial management of suspected neutropenic sepsis

A

DO NOT WAIT TO DO TESTS OR GET TEST RESULTS

GIVE STAT DOSE: IV TAZOCIN +- PIPERACILLIN (TAZOBACTAM)

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11
Q

full management of neutropenic sepsis

A
  • Prompt assessment by HCPs who are familiar with NS
  • Don’t wait for the FBC
  • Empiric IV broad spectrum antibiotics within the
  • hour (NICE guidelines)
    o Tazocin
    o Meropenem +/- Vancomycin if no improvement after 48h
  • Fluid resuscitation
  • Oxygen
  • Consider catheterisation
  • Involve senior members of the team – SpR/Consultant
  • Consider need for escalation of care
  • Usually need 5/7 broad spectrum ABx, may switch to oral ABx after 48 hours if risk low
  • GCSF (Granulocyte colony stimulating factor) can reduce severity and duration of neutropenia (sub cut injection)
    o Side effects: bone pain, headache, fatigue and nausea
  • NOT used routinely, may be considered in patients who are profoundly septic/neutropenic

When the neutrophil count is normal, has been afebrile for 48 hours and blood tests have normalized, antibiotics can be stopped.

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12
Q

Neutropenic sepsis and GCSF

A

Granulocyte colony stimulating factor can reduce severity and duration of neutropenia (sub cut injection)
o Side effects: bone pain, headache, fatigue and nausea
- NOT used routinely, may be considered in patients who are profoundly septic/neutropenic

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13
Q

Prophylaxis for neutropenic sepsis

A
  • A neutrophil count of < 0.5 x 109 as a consequence of their treatment they should be offered a fluoroquinolone
  • All patients should be issued with an alert card with 24hr contact numbers
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14
Q

what can be used to risk assess neutropenic sepsis

A

MASCC risk index

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15
Q

Antifungal management for neutropenic sepsis

A

give IV voriconazole

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16
Q

Tumour lysis syndrome background

A
  • Generally triggered by the initiation of cytotoxic therapy – mortality 15%
  • Metabolic emergency that presents as severe electrolyte abnormality
  • Massive tumour cell lysis -> release of large amounts of potassium, phosphate and uric acid into the systemic circulation
  • Requires appropriate prophylaxis and early recognition and treatment
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17
Q

blood test findings for tumour lysis syndrome

A

3 High
- Hyperuricemia
- Hyperkalaemia
- Hyperphosphatemia

1Low
- Hypocalcaemia

AKI from uric acid and/or calcium phosphate crystals in renal tubules

18
Q

tumour lysis syndrome susceptible tumour types

A

Susceptible tumour types
Risk greatest for haematological malignancies
- High grade lymphoma
- Leukaemia
- Myeloma

Bulky chemo-responsive tumour
- Less common in solid tumour

19
Q

Patient specific risk factors for TLS

A
  • High volume/bulky disease
  • Pre-treatment LDH high
  • High circulating WCC
  • Pre-existing renal dysfunction/nephropathy
  • Pre-treatment hyperuricaemia
  • Hypovolemia
  • Pre-treatment diuretic use
  • Urinary tract obstruction from tumour
20
Q

presentation of TLS

A
  • Normally day 3-7 post chemotherapy
  • N and V
  • Diarrhoea
  • Anorexia
  • Lethargy
  • Haematuria-> oliguria -> anuric
  • Fluid overload
  • Cardiac arrhythmia/arrest (peaked T waves, QTc derangement)
  • Muscle cramps/ tetany/ seizures
21
Q

what kills patients with tumour lysis syndrome

A

cardiac arrythmia due to electrolyte problems e.g. high pottassium, low calcium

22
Q

investigations for TLS

A

Important investigations include: U&E (potassium and phosphate are typically raised), calcium (low), uric acid (raised), and ECG (metabolic abnormalities e.g. hyperkalaemia may precipitate life-threatening arrhythmias)

23
Q

management of tumour lysis syndrome

A

1) Hydration
- Pre-hydration and vigorous hydration throughout treatment
- maintain urine output
2) Monitoring of electrolytes and fluid balance
3) Lowering of uric acid levels
- Allopurinol (xanthine oxidase inhibitor –> less hyperuricaemia)
- Rasburicase -> synthesic uricase -> degraded uri acid to allantoin (water soluble)

24
Q

what is given prophylactically to prevent TLS

A

allopurinol

25
Q

Immune related colitis
background

A
  • Increased used of immunotherapy e.g. immune check point inhibitors in cancer treatment has increased prevalence of immune related adverse events such as immune related colitis
  • Causes inflammation of the large intestine
  • Examples of cancers which use immunotherapy
    o Melanoma
    o NSCLC
    o RCC
  • Example drugs
    o Ipilimumab
    o Pembrolizumab
26
Q

Pathophysiology of immune related colitis

A
  • Immune checkpoint proteins reduce the bodies immune response preventing autoimmunity
  • Cancer cells use these immune checkpoints to evade the immune system
  • Inhibiting immune checkpoint proteins, therefore enhancing the immunes system (T cell) ability to destroy cancer cells
  • However other cells such as those found in the GI tract can be affected by off-target inflammation and autoimmunity
27
Q

presentation of immune colitis

A

Immune colitis can develop at any time during therapy
- Diarrhoea
- Abdominal pain
- N and V
- Haematochezia
- Weight loss
- Fever

28
Q

presentation of immune colitis

A

Immune colitis can develop at any time during therapy
- Diarrhoea
- Abdominal pain
- N and V
- Haematochezia
- Weight loss
- Fever

29
Q

Investigation for immune related colitis

A
  • Bloods
    o FBC, UE, LFTs, TFTs, CRP
  • Stool sample
    o Rule out infective causes e.g. clostridium difficile, Ova and parasites
  • Imaging to rule out bowel perforations
  • Endoscopic investigations
    o Rule out metastasis
30
Q

management of immune mediated colitis

A

depends on grade of symtoms

  • Supportive measures for mild (grade 1 symptoms such as diarrhoea)
    o Loperamide
    o Encourage oral fluids
    o Electrolyte replacement
  • Grade 2 or severe grade 3 symptoms
    o Stop immunotherapy
    o Prednisolone
    –> Bone protection and PPI cover and co-trimoxazole
    o Or IV methylprednisolone
  • If no response to steroid
    o Infliximab – providing no contraindications
31
Q

Radiation mucositis background

A
  • Acute inflammation of mucosa
  • Oral mucosa most affected
  • Debilitating complication – can lead to nutritional problems and increased risk of infection
  • Signif impact on QoL
  • Occurs in 91% of patient with H and N cancer receiving radiotherapy
    o Dose limiting toxicity since can lead to early discontinuation
32
Q

Pathophysiology of radiation induced mucositis

A
  • Mucositis occurs because cancer treatments such as radiotherapy break down rapidly dividing epithelial cells lining the GI tract
    o From mouth to anus
  • Leaves lining open to ulceration and infection
33
Q

Risk factors of radiation induced mucositis

A
  • Most cancer patients receiving chemotherapy in combination with radiotherapy will experience mucositis
  • Poor oral health
  • Smoking
  • Alcohol
  • Females
  • Dehydration
  • Low BMI
  • Methotrexate and fluorouracil
34
Q

radiation mucositis presentation

A

Presentation
Generally begins 5-10 days following initiation of treatment
- Bleeding mouth
- Red, shiny or swollen mouth and gum
- Ulcers
- Soreness
- Painful swallowing and talking
- Dryness
- Increased mucus and thicker saliva

35
Q

management of radiation induced mucositis

A

Prevention
* Good oral hygiene
* Stop smoking and avoid alcohol
* Ice chip therapy
* Mucoadhesive hydrogel rinses and calcium phosphate rinses
* Modify diet to limit trauma to mouth
E.g. avoid spicy, rough food

Prophylactic placement of PEG
- Prevent dehydration and weight loss

Managing
* Topical anaesthetics e.g. lidocaine swish and spit
* Low level laser therapy applied to mucositis lesions
* Morphine mouthwash
* Consider admission to hospital for systemic analgesic

36
Q

Thrombocytopenia

A
  • Common problem which limits chemotherapy dose and frequency
  • Why is it a problem?
    o Platelet count of <10,000/ uL increases risk of spontaneous bleeding
    o <50,000 surgical procedures complicated
  • Other causes
    o Immune thrombocytopenia
    o Coagulopathy
    o Infection
    o Post-transfusion pupura
    o Leukaemia and lymphomas due to pancytopenia
  • Major cause of chemotherapy disruption and delay
37
Q

causes of thrombocytopenia in cancer patients

A
38
Q

RF for thrombocytopenia

A

Risk factors
- Chemotherapy
o Gemcitabine
o Platinum based regimes
- Pancytopenia due to blood cancers

39
Q

Pathophysiology of thrombocytopenia

A
  • Chemotherapy destroys rapidly growing cells, including those in the bone marrow that produce platelets
40
Q

Presentation of thrombocytopenia

A

Occurs 6-10 days following administration of chemo
- bleeding gums, blood in stool, easy bruising etc

41
Q

Management of thrombocytopenia

A

Preventing bleeding
- Use soft-bristle toothbrush
- Wear proper fitting shoes
- Blow nose carefully

Treating thrombocytopenia
- Platelet transfusion
- However associated with complications
–> Anaphylaxis
–> Infections

Cancer care (Y4) (30 decks)

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