6 - Oncologic Emergencies/pain Mgment Flashcards
Oncologic emergencies types?
Local - Obstruction/pressure
Systemic - metabolic/hormonal complications
Iatrogenically - therapy/treatment complications
MC cause of elevated Ca?
Primary hyperparathyroidism
- dont forget about cancer though
Cancer and hypercalcemia?
Seen w clinically evident cancer
23-30% have it
- associated w poor outcomes
MC cancers w high Ca?
Lung
Breast
MM
MC pathophysiology of malignancy-associated hypercalcemia?
Humoral hypercalcemia or malignancy
- HHM
What is HHM?
Secretions of PTHrP cause increased bone resorption
Pathophysiology of malignancy-associated hypercalcemia?
HHM
activation of osteoclast by cytokines released form cancer cells
Vitamin D secretion by cancer cells
Which cancers like to secrete cytokines to activate osteoclasts?
Breast
MM
What cancers like to secreted 1,25-OH2 vitamin D?
Lymphomas
Sarcoidosis/granulomatous dz
Types of hypercalcemia associated cancer?
Chart on slide 7
Explain HHM’s actions
Tumor secretes PTHrP
- not PTH but look alike/sound alike
This stimulates osteoclasts which increased calcium reabsorption
HHM is MClly associated w?
SCC (lung, head, neck) Renal Bladder Breast Ovarian
Hypercalcemia s/s?
Classic:
- Stones
- Bones
- Moans
- Psychiatric groans
But ultimately based on level and rate or change
Early hypercalcemia s/s?
Not the classic signs
Anorexia Nausea Fatigue Constipation Polyuria
Later hypercalcemia s/s?
Confusion
Psychosis
Tremor
Lethargy
If pt has low albumen the Ca labs will be?
Underestimated
Hypercalcemia of malignancy level?
> 12mg/dL is life threatening
Primary PTH labs have elevated PTH/elevated Ca, if they are low?
If low order PTHrp
Hypercalcemia pts need?
ECG - shortening of QT interval (whatever that is)
Serial Ca2++ labs
Tx for hypercalcemia?
Treat the malignancy But also: - IV fluids - IV furosemide (if hypervolemic) - IV biphosphonates
Refractory hypercalcemia tx?
Calcitonin
Corticosteroids
Dialysis
2nd MC neurological complications of CA
Spinal cord compression
- usually 2/2 brain Mets
Other cancers that commonly cause spinal cord compression
Brain mets
Lung/breast/prostate
Renal
Lymphoma
What about cancer causes spinal cord compression?
Local mass effect
S/s of cancer related spinal cord compression?
Back pain
- at level of tumor (80%)
- worse w sneezing/cough/wt bearing/supine
Neurological sxs
- progressive weakness
- sensory dysfunction
- bowel/bladder dysfunction
DX for spinal cord compression?
MRI
- emergent if neurologic functions
Tx for spinal cord compression?
Immediate corticosteroids - dexmethasone Treat the malignancy Radiation Surgery Chemo
Surgery indications (spinal cord compression)
Ukn etiology Failure of radiation Radio-resistant tumor Pathologic fx Dislocation/unstable spine
Febrile neutropenia definition?
Fever > 100.4 sustained for greater than 1 hr
Or
Single temp of 101.0
- w absolute neutrophil count <1500
ANC
ANC is?
= WBC (total) x neutrophil (%)
S/S of febrile neutropenia?
Fever
HX/PE for febrile neutropenia?
Look for source of fever
Maj will not have documented infection
- still treat w empiric broad-spectrum abx after blood cxs are obtained
With febrile neutropenia s/s of infection may be?
Attenuated due to lack of an inflammatory reaction
Labs for febrile neutropenia?
CBC w diff CMP (creatine, LFT, electrolytes) UA/Urine culture Sputum culture Blood cultures Culture of suspicious sites
Imaging for febrile neutropenia?
CXR - infiltrates w/o neutrophils to make infiltrates
CT - thickened bowel - neutropenic enterocolitis
Any pt w neutropenia and abdominal pain you should consider?
Neutropenic enterocolitis
Tx for febrile neutropenia
Broad spectrum coverage
- gram +, Gram -»_space; anaerobes
W/in 60 min of presentation
Continue 48hrs past end of fever
Abx for febrile neutropenia?
- cefepime
- carbapenem
- piperacillin-tazobactam q
If abx fail w febrile neutropenia, consider?
Fungal
- amphotericin B
- itraconazole
- caspofungin
Contact ID
What is superior vena cava syndrome?
Obstruction of blood flow through the SVC
Superior vena cava syndrome is associated w?
MC - Lung cancer
2nd MC - lymphoma
Etiology of superior vena cava?
Invasion/compression of SVC from - R lung - lymph nodes - mediastinal structures Thrombosis of blood in SVC
S/s of superior vena cava syndrome?
Dypsnea
Facial swelling
Neck/UE swelling
“Congestion” sxs
Worse when bending forward
What is plethora?
A lot of something
In this case, fluid causing facial swelling
Late signs fo super vena cava syndrome?
Thrombosis
Tumor extension into cardiac
Neurologic syndromes
- venous congestion into brain - cerebral edema)
PE for SVCS?
Facial edema
Venous dilation
- distention in neck
- distention in chest
Imaging for SVCS?
CXR - widening of superior mediastinum
CT - chest w contrast
SVCS tx?
Treat the cancer
- radiation
- chemo
- anticoagulation
- balloon angioplasty + stent
- thrombolysis
SVCS prognosis?
Depends on disease progression
- slow = tolerated for years
- rapid = rapidly fatal (days)
Rapid SVCS what kills you?
Increased ICP
Cerebral hemorrhage
What is tumor lysis syndrome?
MC occurs w tx of hematologic malignancies or rapidly proliferating tumor that is sensitive to chemo
- usually the induction phase of chemo
Greatest risk for tumor lysis syndrome
ALL
Burkitt lymphoma
When does tumor lysis syndrome happen?
1-5 days after chemo
What is the pathogenesis of tumor lysis syndrome?
Effective tx kills malignant cells and leads to massive release of cellular material
- nucleic acids
- phosphorus
- potassium
Conditions that arise from tumor lysis syndrome?
Hyperuricemia (catabolism of nucleic acids)
- AKI
Hyperphosphatemia
Hypocalcemia
Hyperkalemia
What causes the hyperphosphatemia w TLS?
- 2/2 hypocalcemia (P binds to CA)
S/s of hyperphosphatemia?
Tetany
Seizures
Arrhythmias
Sudden death
S/s of hyperkalemia?
Arrhythmias
- Coexisting renal failure worsens this
Most important aspect of tumor lysis syndrome?
Recognition of risk and prevention is the most important step of management
Tx for TLS?
Aggressive hydration
- before/after chemo
Allopurinol
- competitive inhibits xanthine oxidase
Rasburicase (exogenous urate oxidase)
- catalyzes the breakdown of uric acid levels
Monitor K, P, Ca, sCr, and uric acid
When to refer TLS?
Refer to nephrology if:
- urine output is low
- sCr is elevated
How do allopurinol and rasburicase work?
In the purine catabolism progression
- allopurinol blocks hypoxanthine and xanthine
- urate oxidase enhances uric acid
See slide 40 for a diagram (makes more sense)
Common failure of cancer tx?
Pain management
- many pts have inadequate control
- pain impact QOL (esp near death)
Prolonged survival (cancer tx) is associated w?
Chronic pain tx w opioids
- honestly they are dying who cares if they are addicted
When prescribing opioids meds for cancer you need to?
Focus on education
- pt education
- family education
- expectation management
- risk/benefit
3 basic approaches to pain?
- Modify the source
- Alter perception of pain
- Block transmission of pain
Complications of pain meds?
Constipation
Decreased mental acuity
Dependence (again who cares)
Order of pain management meds?
1st line - acetaminophen
2nd line - NSAIDS
3rd line - opioids
3rd line - neuropatic pain meds
Biphosphonates and NSAIDS are indicated for?
Metastatic bone lesions
Neuropathic pain meds?
Gabapentin
TCA (amitriptyline)
Pregabalin
Bottom line for pain management?
No pt should be denied pain control in the setting of cancer
- it is a fundamental responsibility of the PA
But dont be afraid to refer to pain/palliative care experts
