Oncologic Emergencies Flashcards
1
Q
Hypercalcemia
Path:
S/Sx:
Dx:
Tx:
A
Hypercalcemia
Path:
- Humoral vs. local osteolysis
- Majority: squamous cell ca -> increased PTHrP -> Humoral hypercalcemia of malignancy
S/Sx:
- Acute pancreatitis, acute renal insufficiency, nephrolithiasis
- Less common: short QT, ST elevation, MI-like, AMS
Dx:
- PTH and PTHrP
- Chem panel + Mg, Phos
- ECG
Tx:
- Mild-Mod: No urgent tx, avoid increased Ca by increasing hydration, minimizing thiazides, lithium, and bedrest
- Severe:
- Hydrate NS 200-300cc/h and maintain UO at 100-150cc/h
- Block Ca reabsorption: calcitonin 4 IU/kg, recheck Ca
- If persistently high continue calcitonin every 6-12h
- Add bisphosphonate/Zoledronic acid/pamidronate
- Dialysis if Ca > 18-20 with (+) Neuro symptoms
2
Q
Tumor Lysis Syndrome
Path:
S/Sx:
Dx:
Tx:
A
Tumor Lysis Syndrome
Path:
- Tumor cells die -> renal tubular damage -> electrolyte abnormalities
- More common in heme malignancy or large solid tumor burden
- High LDH and bone marrow involvement lead to higher risk
S/Sx:
- HYPERphosphatemia and HYPOcalcemia
- AKI, hyperkalemia, hyperuricemia
- Arrythmia, seizure, death
Dx:
- Chem panel: phos, ca, K, uric acid
- ECG
- Cairo-Bishop score = 0-5
Tx:
- All: Prevent AKI with hydration pre-, intra-, and post-chemotherapy
- Mod risk: Ppx allopurinol to decrease xanthines
- High risk: Rasburicase IV
3
Q
SIADH
Path:
S/Sx:
Dx:
Tx:
A
SIADH
Path: Tumor (sclc primarily) -> ectopic ADH over-production
S/Sx:
- H2O retention with decreased UO
- HYPOnatremia and HYPOosmolality
- AMS, somnolence, weakness
Dx:
- Low serum osmolality: Hyponatremia + Hypo-osmolality
- High urine osmolality: Urine Osm > 100 + Urine Na > 40
- Concentrated; Low UO
- Normal K, normal pH
- Low serum uric acid
Tx:
- Severe / symptomatic:
- Hypertonic Saline
- Do NOT correct more than 8-12 mEq in 24h
- Fluid restriction, salt tablets
- Loop diuretic vs vasopressin –> reabsorb sodium
- Tx underlying cancer
4
Q
Lambert Eaton Myasthenic Syndrome
Path:
S/Sx:
Dx:
Tx:
A
Lambert Eaton Myasthenic Syndrome
Path:
- Autoimmune Ab block calcium channel -> decreased acetylcholine available at synapse
- SCLC and some Hodgkin lymphoma are most common underlying cancers
S/Sx:
- Limb weakness (slow, proximal, progressive)
- Dry mouth, oropharyngeal weakness, ptosis
- Hyporeflexia +/- severe weakness +/- neuromsk respiratory failure
Dx:
- Autoantibodies against Ca channels
- CT chest to look for SCLC
Tx:
- Amifampridine 15-30mg divided into 3-4 doses daily
- Pyridostigmine
- IVIG 2g/kg over 2-5d
5
Q
Adverse effects of Radiation Therapy
Oropharyngeal:
GI:
Neurologic:
Dermatologic:
Chronic:
A
Adverse effects of Radiation Therapy
Oropharyngeal:
- Dental caries, decreased saliva
- Mucositis in 1st week: caked yeast overgrowth -> pain
- Loss of taste 2nd week: dry mouth contributes; anorexia/weight loss ensues
GI:
- Enteritis / proctitis: common in intestinal and pelvic cancers
- Acute: fever, abd cramp, anorexia, N/V, tenesmus, urgency, diarrhea, incontinence, hematochezia
- Tx: analgesics, antispasmodics, antidiarrheals, supportive IV hydration
- Chronic: Endarteritis obliterans (ischemia), progressive worsening, fistula development
- Tx: diet, supportive, CPN, surgical resection/repair if fistula develops
Neurologic:
- Acute encephalopathy (responsive to steroids)
Dermatologic:
- Erythema, increased melanin
- Decreased sweat gland function
- Increased sensitivity
- Hair loss
Chronic:
- Delayed wound healing
- Dry eyes
- Radiation necrosis
- Tissue fibrosis, lymphedema
- Diffuse cerebral atrophy (decades s/p treatment)
- Personality/cognitive/gait changes
6
Q
Colorectal Cancer
Epi:
Risks:
Screening:
S/Sx:
Dx:
Tx:
A
Colorectal Cancer
Epi: 2nd leading cause ca death, 95% are adenocarcinomas
Risks: Age > 60; IBD; AA; Male; Hx cancer; Diet; Family Hx
Screening:
- High Risk: <50 years old, colo q5y
- PMHx adenoma, serrated polyps, colon ca, IBD, genetic syndrome
- FHx 1st degree relative with adenoma or colorectal cancer
- FHx 2nd degree relative with hx colorectal cancer
- Medium Risk: 50 years old
- Fecal occult blood yearly; FIT yearly; FIT-DNA 1-3y
- Flex-sig q5y, or q10y with yearly FIT
- Colo q10 years
- >76 years old: Individualized; >85 years old: Do not screen
S/Sx:
- Fatigue, weight loss, nausea, anorexia
- Change in bowels, discharge, bloating, pain, straining
- Melanic/bloody stool, iron deficiency anemia
- Palpable abd or rectal mass
- Jaundice with liver mets
Dx:
- Gold Standard: Colonoscopy with biopsy
- CBC (anemia), Chem (post renal AKI), LFTs (liver mets)
- CT AP with IV and PO contrast
- Carcinoembryonic antigen (CEA) aids in prognosis
- CT guided needle biopsy
- Metastatic
- PET, MRI, bone scan
- Oncogenes: RAS, BRAF (poor prognosis, no benefit from tx)
- Tumor molecular testing: epidural growth factor receptor (tyrosine kinase receptor target for tx)
Tx:
- Stage 0, I, IIa
- Surgery: resection and surveillance with or without adjuvant therapy
- Colectomy +/- removal of nearby lymph nodes may be needed in Stg II
- Stage III
- Partial colectomy + lymph removal AND…
- Chemo: determined by EGFR, KRAS, BRAF
- First line: Flouroucacil + Oxiplatin, irinotecan, leucovorin
- Second line: Capecitabine, trifluridine, tipiracil
- XRT: used as adjunct in stage IIb or III along with chemo and used in rectal cancer to limit metastasis
- Stage IV
- Targeted monoclonal Ab therapy if mets or non-resectable tumor
- Bevacizumab, cetuximab, panitumumab, regorfenib
- Immune Tx for advanced dz, mets
- Checkpoint inhibitors (Nivolumab, pemrolizumab)
- Targeted monoclonal Ab therapy if mets or non-resectable tumor
- Follow Up
- Physical exam q3 months for 3 years, then q6 months for year 4-5
- CEA q3mo for 3y
- Chest CT yearly for 3y
- CT abd yearly for 3y
- Colo at 1 year then q5 years
7
Q
Breast Cancer
Epi:
S/Sx:
Dx:
Tx:
A
Breast Cancer
Epi:
- Most common Ca in females (other than skin); 12% of US women; nonmet>met
- Risks: Age >50, Hx cancer, nulliparity, late 1st pregnancy, early menarche, late menopause, dense breast, hx radiation, FHx
- Type 1: HER2 (-) and Hormone Receptor (+)
- Type 2: HER2 (+) and Hormone Receptor (+) or (-)
- Familial: 10% d/t mutation in p53, BRCA1, or BRCA2 tumor suppressor genes
S/Sx:
- Palpable, hard, painful breast or axilla lump; focal inflammation
- 60% are in Upper Outer quadrant
- Nipple discharge (unilateral and bloody)
- Change in breast size/shape; skin dimpling, new nipple inversion, ulceration
Dx:
- Screen: >40 or >50 q2y, controversial
- Clinical exam sitting and supine
- Lump is hard, irregular, assymmetrical, fixed to skin/muscle
- Imaging: Bilateral mammogram -> Biopsy (core)
- Vs. MRI for high risk Vs. ultrasound +/- biopsy for < 30y/o
- Pulm Sx: Chest CT w/ contrast
- Abd Sx: A/P CT w/ contrast
- Bone pain or elevated alk phos: Bone scan
- Molecular testing: HER2/neu gene mutation over expression a/w aggressive tumors
- Labs: CBC, CMP, LFTs, Alk Phos
Tx:
- Local/Non-Metastatic:
- Lumpectomy + XRT + axillary LN dissection (if +sentinel LN bx) works as well as mastectomy
- +/- Neoadjuvant (preop) treatment (anthracycline plus taxane +/- XRT)
- Also for systemic tx
- Targeted:
- HER2+ add HER/neu protein with trastuzumab and lapatinib
- HR+ add target progesterone/estrogen (better prognosis than HR -)
- Advanced/Mets:
- Palliative surgery and XRT
- Systemic tx with endocrine tx, chemo, and/or targeted tx based on HR, HER2, PDL1, BRCA, comorbidites, severity
8
Q
Lung Cancer
Epi:
Screening:
S/Sx:
Dx:
Tx:
A
Lung Cancer
Epi:
- Central: Small Cell Carcinoma (10%), Squamous Cell Carcinoma
- Peripheral: NSC Carcinoma (90%) (adenocarcinoma, large cell, bronchoalveolar)
- Males: 1st cancer deaths; Female: 2nd cancer death
Screening:
- CXR NOT sensitive screening tool
- Age 55-80, 30pk year hx, quit <15y: Low Dose CT Chest q3 years
- High risk (age, educ, COPD, CXR, smoking): PLCO2 plus Annual CT Chest
S/Sx:
- 25% Asymptomatic with peripheral tumor; dx s/p metastastic lesion
- Nonspecific: dyspnea; pain in chest, ribs, back, pelvis; anorexia, weight loss
- Specific: Cough, hoarse, recurrent laryngeal nerve, hemoptysis
- Central location: atelectasis and SVC syndrome
- Evasion: pleural effusion
- Paraneoplastic syndrome: SIADH, hypercalcemia, hypercoagulable state
- Apiceal: Horner’s syndrome (T1 nerve damage) causing unilateral miosis, ptosis, facial anhidrosis
- Pancoast: Apical tumor with brachial plexus and sympathetic ganglion involvement -> pain, paresthesias, arm weakness
Dx:
- CXR: compare to priors
- Definitive: BIOPSY
- Sputum cytology: high Sp, low Se (better for central tumor)
- Bronchoscopy, percutaneous needle bx, pleural fluid analysis
- VATS
- PET: High Se, moderate Se
- Molecular testing: mutatious analysis guides therapy
- EGFR, ALK, ROS, PDL1
Tx:
- Guided by cell type, comorbidity, lung function
- Refer to onc, IR, pal care, surg
- SCC: 1 lung + ipsilateral LN
- Definitive surgery (wedge resection vs lobectomy)
- Chemo (cisplatin vs carboplatin)
- Survival: 8-12wks untreated; Ch/XRT: 5yr 10-15%
- SCC: BL lung +/- BL LN vs distant mets
- Chemo: cisplatin or carboplatin AND etoposide
- +/- radiation
- Survival: 5y 1-2%
- NSCC:
- Surgery: definitive if early / slow spread
- Resection + chemo: advanced
- Staging
- 1: tracheal/bronchial lining: surgery and XRT
- 2: invading parenchyma: surgery and XRT
- 3a: LN involvement: surg, chemo, XRT, brachytx
- 3b: Widespread lung dz nonresectable: brachytx, chemo, xrt, palliative
- 4: Lung ca and mets: pal chemo
9
Q
Chemo Induced Complications
Cardiomyopathy
Pulmonary
Neurological
Secondary Cancers
A
Chemo Induced Complications
Cardiomyopathy:
- Patho: Damages myocytes -> CHF, LV dysf
- CTX: Anthracycline agents (Doxorubicin)
- Dx: Monitor LV ejection fraction serially
- Tx: ACEIs, carvedilol, antioxidants (Vit E)
Pulmonary
- Patho: Pulmonary fibrosis, esp in older smoker with renal failure
- CTX: Amrubicin, bleomycin, carmustine
- Dx: Monitor serial PFTs
- Tx: D/c agent, admin oral/IV corticosteroids (short term benefit)
Neurological
- Patho: Peripheral Neuropathy (glove and stocking) d/t mitrochondrial toxicity or nerve inflammation
- Common, up to 60% of chemo patients
- Decreased proprioception leads to falls
- CTX: Plantinum (cisplatin, oxaliplatin), taxanes, vinca alkaloids
- Dx: Clinical
- Tx: Duloxetine, Venlafaxine; Ø Gabapentinoids (ineffective)
Secondary Cancers
- Patho: Chemo increases risk for secondary cancer 5-10 years later
- CTX: Non-Hodgkins Lymphoma treatment increases risk for AML and Myeloma
- Dx: Monitor labs periodically
- Tx: Guideline based
10
Q
Neutropenic Fever
Path:
Time course:
S/Sx:
Dx:
Tx:
A
Neutropenic Fever
Path:
- Chemo -> bone marrow suppression -> decreases ALL hemopoetic lineages -> ANC under 500 (or expected to drop in next 24h) -> Fever
- Or, malignancy renders neutrophils ineffective (functional neutropenia)
Time course: 7-14d post chemotherapy
S/Sx:
- Lesions, rash, bruising of skin, perineum, anus
- Hot, red, swollen joint with msk pain
Dx:
- Fever >38.3oC plus ANC <500
- CBC w/ diff; chem panel; LFTs; UA; lactic acid; CRP; blood cultures
Tx:
- Low Risk: Neutropenia <7d, no comorbidities, normal CXR, adequate social support, easy access to hospital
- Outpt abx and f/u in 72h
- High Risk: Neutropenia >7d, ANC < 100 following chemo, acute comorbidities (HoTN, AMS, PNA, Abd pain)
- Hospitalize
- Begin empiric broad spectrum abx
- Antibiotics
- High risk + clinically well: B-Lactam with PsA coverage
- High risk + clinically sick: Add aminoglycoside vs. FQ for double gram neg coverage
- Suspicion for Gram Pos: Add Vanco
- Persistent fever s/p broad spectrum: Add Antifungal (ampho B, caspo, itra, vori)
11
Q
DIC of Malignancy
Path:
S/Sx:
Dx:
Tx:
A
DIC of Malignancy
Path:
- Leukemia (APL > AML > ALL) > Adenocarcinomas
- Gradual coagulation activation with chronic consumption of factors and platelets
S/Sx:
- VTE common
- Less fulminant than DIC of sepsis/trauma
Dx:
- Normal coags initially, then progressive decrease in platelets and fibrinogen, with increased INR
Tx:
- Treat underlying malignancy
- APL: initiate chemo within 24h
- Admin blood, cryo, FFP, platelets
- Consider Vena Cava filter
12
Q
Hyperleukocytosis / Leukostasis
Path:
S/Sx:
Dx:
Tx:
A
Hyperleukocytosis / Leukostasis
Path:
- Acute leukoemias (especially AML) -> severe leukocytosis -> hyperviscosity
- Can lead to microvascular obstruction, vessel wall rupture, bleeding, hypoxia
S/Sx:
- CNS: HA, dizziness, decreased LOC, focal deficit, ICH
- Opth: Blurry vision, blindness, papilledema, retinal hemorrhage and thrombosis
- Pulm: Dyspnea, tachypnea, hypoxia, crackles, pulmonary infiltration, respiratory failure
- CV: MI, ischemia
- Other: Fever, renal failure, priapism, VTE, DIC, tumor lysis syndrome
Dx:
- WBC as high as 100 x 109
Tx:
- Leukapheresis
- Hydroxyurea: prevents rapid reaccumulation of blasts during treatment
- Caution with RBC transfusion -> worsen viscosity
13
Q
Hypercoagulability of Malignancy
Path:
S/Sx:
Dx:
Tx:
A
Hypercoagulability of Malignancy
Path:
- All cancer (esp GI, pancreatic, ovarian, and lung) -> prothrombotic / fibrinolytic tumor cell proteins and cytokines -> host cell inflammatory response -> prothrombotic state
S/Sx:
- Unilateral leg swelling
- Chest pain, dyspnea, tachycardia, hemoptysis
Dx:
- Coags, Ultrasound, clinical suspicion
Tx:
- LMWH then transition to PO warfarin vs. DOAC
- Emotional support
14
Q
Typhlitis
Path:
S/Sx:
Dx:
Tx:
A
Typhlitis
Path:
- Heme malignancy vs. chemo -> neutropenic and necrotizing enterocolitis
- Leads to acute, life threatening infection of intestine, cecum, ileocecum
S/Sx:
- Fever with abdominal pain in a neutropenic / immunosuppressed patient
- Especially 3wks s/p chemo
- N/V, liquid bloody stools, distended abd
- Acute abdomen (firm, guarding, rebound tenderness) = bowel perforation
Dx:
- Suspect bowel perf -> CT: Mesenteric stranding with wall thickening, dilated bowel, and free air in abdomen
Tx:
- Free air, GIB -> surgery (high mortality d/t low platelets)
- No peritoneal signs -> abx and bowel rest with NGT
- Will be treating polymicrobial infection
15
Q
Engraftment
Path:
S/Sx:
Dx:
Tx:
A
Engraftment
Path:
- Autologous stem cell transplant (moreso than allogenic) -> release of cytokines -> sepsis-like reaction 1-2wks s/p txp
S/Sx:
- Fever of unknown origin
- May be indistinguishable from sepsis until s/p (-) cultures (or autopsy)
- Mimics GVHD: palmar rash, non-cardiogenic pulmonary edema with hypoxia, weight gain, diarrhea
Dx:
- (-) cultures with classic symptom cluster
- Fever, total body erythema, respiratory distress, AKI, transaminitis, GIB, hematuria
Tx:
- Supportive care, IV fluids
- Presume sepsis initially
- APAP and benadryl
- IV corticosteroids
- MV and CRRT prn
