Oncologic Emergencies Flashcards
S&S of SVC syndrome
Head fullness, chest pain, facial/neck/arm swelling, distension of superficial veins of chest, neck and upper arms
S&S of cardiac tamponade
Anxiety, jugular vein distension, tachycardia, pulsus paradoxes (decline in blood pressure on inspiration), substernal chest pain
What is Beck’s Triad?
Distended neck veins, hypotension, distant heart sounds
(Sign of cardiac tamponade)
What can untreated pneumonitis lead to?
Fibrosis
What are confusion and restlessness early signs of?
Hypercalcemia
What is the most common underlying disorder that leads to acute (rapid onset) DIC?
Infection —> sepsis
Which oncologic emergency is most often associated with APL?
DIC, as many as 85% of APL patient experience this
Tissue factor is released by promyelocytes
What causes the hypercoagulation in DIC?
Release of tissue factor leases to release of thrombin leads to plasminogen to convert to plasmin, causing fibrinolysis which leads to excessive fibrin degradation products (FDPs) which leads to bleeding.
Simultaneous hemorrhage and clot formation compromised blood supply to vital organs
What is the hallmark sign of DIC?
Bleeding simultaneously from at least 3 unrelated sites
What do the labs look like in DIC?
Decreased platelets, fibrinogen, antithrombin III, plasminogen, alpha-2 antiplasma level, protein C
Increased FDPs, D-dimer, thrombin time, fibrinopeptide A level
What is the treatment for DIC?
Treat the underlying condition
Chemo, hormonal therapy, abx, blood products
What are the symptoms in chronic DIC?
Minimal bleeding and diffuse thrombosis (most often with solid metastatic mucin outs adenocarcinoma (prostate & breast)
What S&S are these for: Bleeding, acidosis, hematuria, oliguria, uterine hemorrhage, dyspnea, hemoptysis, cough, tachypnea, dim breath sounds, pleural friction rub, jaundice, Petechiae, skin necrosis of lower limbs, thrombosis, fever?
DIC
What are late stage symptoms
of DIC?
Thrombus formation - may manifest as organ dysfunction or failure (infarct, ischemia, necrosis)
What is thrombotic thrombocytopenia purpura?
Excessive clot formation throughout body causing thrombocytopenia as platelets are consumed in the clotting process
What gene is TTP linked to?
ADAMTAS13 (breaks down vonWillebrand factor that clumps together with platelets to form clots and lodges itself in blood vessels)
What are these S&S linked to: bruising, petechiae, pale or jaundice, fatigue, fever, tachycardia, tachypnea, oliguria, neurologic changes?
TTP
What labs do you see in TTP?
Decreased RBCs, platelets and ADAMTS13, negative Coombs test, schistocytes on smear, elevated LDH and bili
What would you be highly suspicious for in a patient with an elevated LDH and thrombocytopenia?
TTP
What is the treatment for TTP?
Inherited : FFP
Acquired: plasmapheresis
What is the treatment for refractory TTP?
Corticosteroids and/or rituximab or splenectomy
What cancers are most often associated with SIADH?
Bronchogenic lung cancer (mainly SCLC), mesothelioma, thymoma, head and neck, lymphoma, Ewing’s sarcoma, GI, GU, CNS tumors
What other risk factors are there for SIADH?
Advanced age, severe pain, anxiety, stress
Which chemos can induce SIADH?
Cyclophosphamide, vinblastine, cisplatin, carboplatin, vincristine, melphalan, bortezomib, ifosfamide
What oncologic emergency are these S&S related to: Hyponatremia, increased urine osmolality, decreased serum osmolality
SIADH
NO signs of fluid overload. Normal BP, HR, no edema
What are mild symptoms of SIADH?
Maybe asymptomatic, muscle cramps, fatigue, headache, anorexia, nausea, vomiting, thirst
What are moderate symptoms of SIADH?
Weight gain, confusion, irritability, lethargy, abdominal cramping, diarrhea, oliguria/concentrated, hypoactive reflexes, extrapyramidal symptoms, Na 126-130
What are severe symptoms of SIADH?
Cerebral edema, papilledema, ataxia, seizures, psychosis, coma, death, Na <120
What is the treatment plan for SIADH?
If possible, eliminate the drug causing it.
Fluid restriction 500-1000ml/day
Treat malignancy
If severe, hypertonic saline 3% - limit correction to 8-12 during 1st 24H, monitor Na levels q1-3H, frequent euro checks, loop diuretics
The presence of two or more of what indicates SIRS?
T>38 or <36
HR>90
RR>20 or PaCO2 <32mmHg
WBC >12,000, <4,000 or >10% bands
What are risk factors for developing SIRS?
Presence of granulocytopenia, <1yo or >65yo, long ICU stays, loss of skin or mucosal injury, malignancy-related immunosuppression, humoral immunity modifications, MM, CLL, Waldenstroms, diabetes, comorbid organ dysfunction, presence of CVAD
What are early S&S of SIRS?
Increased cardiac output and BP, capillary leaks: edema develops, subsequent hypotension, nausea
What are severe S&S of SIRS?
Vasodilation (hypotension, bounding pulse), normal or elevated temp, warm/flushed, tachypnea, tachycardia, N/V, decreased platelets, fibrinogen, increased WBCs, PT/PTT, FDP, hyperglycemia, lactic acidosis, oliguria, mental status changes
What % of patients with septic shock will develop ARDS?
50%
Because of immunosuppression, what may be the only symptom neutropenic patients have with SIRS?
Fever
When is TLS most common?
48-72 hrs after treatment
Which cancers are typical to develop TLS?
Leukemias with high WBC, NHL, bulky, rapid growing treatment-responsive tumors
Pretreatment elevated LDH or preexisting renal dysfunction are strong indicators
Which drugs typically cause TLS?
Cisplatin, cytarabine, etoposide, paclitaxel, fludarabine, hydroxyurea, IT MTX
Immunotherapy: interferons, interleukins, rituximab, TNFs
Hormonal: tamoxifen
What oncologic emergency are these S&S for: N/V, abd pain, distension, dyspnea, dysrhythmias, edema, lethargy, muscle or joint pain, twitching?
TLS
What are some progressive S&S of TLS?
Increased GI symptoms, oliguria, hematuria, azotemia, anuria, CHF, HTN, then tachy then Brady then ventricular arrhythmias, progressive muscle weakness, parasthesias, tetany, seizures
What lab values are you watching for for TLS?
K>6
Phos >4.5
Uric acid >8
Calcium <7
Or 25% different from baseline
Which drugs have a high potential for hypersensitivity reactions?
L-asparaginase, taxanes, platinums, epipodophyllotoxins
What calcium level is considered hypercalcemia?
Ca>10.5mg/dL
What cancers are most often associated with hypercalcemia?
Solid tumor, such as breast, squamous cell lung cancer - they comprise of >50% of HCM
How does hypercalcemia occur?
Excessive osteoclast activity results in bone destruction which releases large quantities of Ca into the circulation and overwhelms the kidneys
What level of Ca do people usually show symptoms by?
14
What are mild symptoms of hypercalcemia?
<12
Restlessness, lethargy, difficulty concentrating, anorexia, N/V, fatigue, weakness, hyporeflexia, polyuria, polydipsia, pruritus, HTN, orthostatic hypotension
What are moderate symptoms of hypercalcemia?
12-15
Confusion, somnolence, abd pain, constipation, weaker, bone pain, acidosis, dehydration, renal calculi, thirst, poor skin turgor, HTN, EKG changes, dysrhythmias
What are severe symptoms of hypercalcemia?
> 15
Obtunded, seizures, coma, death, worse abd pain, progressing to obstipation, ileus, skeletal pain, pathological fracture, renal failure, oliguria, cardiac arrest
Which cancers are the majority of SVC syndrome due to?
SCLC or NSCLC
What are risk factors for SVC syndrome?
Men 50-70 with mediastinal disease, previous radiation to the mediastinum, CVCs or pacemakers (b/c clot risk), aortic aneurysms or TB
What are S&S of SVC syndrome?
Dyspnea, coughing, swelling of face, neck, upper trunk and extremities
Rare: hoarseness, chest pain, dysphasia, hemoptysis, unilateral pros is of eye/constricted pupil (Horner syndrome)
What is the gold standard of treatment for SC and NSC related SVC syndrome?
Radiation
Which cancers have the highest incidence of malignant bowel obstruction?
Ovarian, colon
What drugs are DNA-binding vesicants?
Anthracyclines sucks as doxorubicin, nitrogen mustard, miromycin
Which drugs are non-DNA binding vesicants?
Plant alkaloids, paclitaxel
