Oncology Emergencies Flashcards
Red flags for cancer
Age > 50 (single most important risk factor) or < 17
Previous history of cancer
Night pain or pain at rest
Unexplained weight loss
Family history (1st generation)
Environment and lifestyle
Failure to improve as expected
Red flags for cancer recurrence
- Positive lymph nodes
- Tumor size > 2cm
- High grade histopathologic
designation - Can reoccur at same location, in local lymph nodes, in distant
lymph nodes, or in metastatic sites
Most Common tumors that metastasize to bone
Breast
Lung
Thyroid
Kidney
Prostate
Multiple Myeloma
Melanoma
What is myelosuppresion
- Common side effect associated with nearly all chemotherapy and immunosuppressive agents
- Inhibition of bone marrow cells resulting in fewer red cells, white cells, and/or platelets
What does myelosuppresion often result in?
anemia, infection, and bleeding as a result of a reduced number of cells
Anemia
- A pathologic state resulting in a reduction of the oxygen carrying capacity of the blood
- Not a disease, rather a symptom of many other diseases
- Frequent complication of cancer treatment especially chemotherapy and radiation
Hemoglobin reference values
Norms
Male: 14-17.4 g/dL
Female: 12-16 g/dL
Anemia: <11 g/dL
Severe anemia: <8 g/dL
Anemia Rehab Implications
- Aerobic capacity is increased with higher levels of hemoglobin
- Worsening anemia reduces exercise tolerance and endurance
- Precautions should be used in prescribing progressive resistance and moderate to
high intensity aerobic exercise in individuals with severe anemia
Rehab implications for hemoglobin less than 11 g/dL
establish baseline vital signs; may be tachycardic or present
with orthostatic hypertension; symptom-based approach to intervention, monitoring
self-perceived exertion
Rehab implication for severe anemia
close monitoring of symptoms and vital signs with interventions; transfusion may or may not be indicated based on individual presentation; short periods of intervention, symptom-limited; education for energy conservation
What is thrombocytopenia
decrease in platelet count below 150,000 of blood
causes of thrombocytopenia
Inadequate platelet production from bone marrow
Increased platelet destruction outside the bone marrow
Splenic sequestration
< 150,000 thrombocytopenia
Symptoms based approach; monitor tolerance to activity
150,000 - 50,000 platelet count
Progressive exercise tolerated; aerobic and resistive with monitoring for symptoms associated with bleeding; swimming; low bench stepping; bicycling (flat only, no grade); manual muscle testing could be performed without restriction
20,000 to 50,000 platelet count
Active range of motion exercises; moderate activity; light weights;
stationary bicycle; walking as tolerated; no prolonged stretching; aquatic therapy based on immune status
10,000 to 20,000 platelet count
Light exercise; no resistive training or activity; avoid Valsalva; AROM exercise only; walking as tolerated, guard carefully; assess fall risk, implement safety plan for falls prevention; understand transfusion status
< 10,000 platelet count
Restricted to ADLs; walking with MD approval; dependent upon individual risk factors and characteristics
Neutrophils
Target bacterial and fungus
General Phagocytosis
45-75%
Lymphocytes
- Produce antibodies
- B cells, T cells, natural killer cells
- 20-40%
Eosinophins
- target large parasites and modulate allergic inflammatory responses
1-4%
Monocytes
Largest WBC
Phagocytosis of large parasites
2-8%
Basophils
Release heparin and histamine during an allergic reaction
0.5-1%
Neutropenia
- A condition associated with a reduction in circulating neutrophils or absolute neutrophil count (ANC)
- Typically, the result of toxicity to neutrophil precursors in the bone marrow
What is neutropenia associated with?
Carcinoma
Malignant hematopoietic disorders that can lead to pancytopenia (reduction in ALL
blood cells)
mild neutropenia
1,000 - 1,500
moderate neutropenia
500 - 1,000
severe neutropenia
< 500
Profound neutropenia
< 100
ANC Nadir
- Chemotherapy induced neutropenia
Point when the ANC is at its lowest after chemotherapy treatment
Typically, 3-10 days after the administration of the chemotherapeutic agent
What does ANC Nadir cause?
- Increased susceptibility to infection
Typical signs and symptoms of infection are often absent in neutropenia
Fever remains the earliest sign of occult infection
Primary sites of infection: GI tract, sinuses, lungs, and skin
What is one of the most common complications related to cancer treatment?
- Neutropenic Fever
80% of people for hematologic malignancy
10-50% with solid tumor
What is neutropenic fever defined as?
- A single oral or axillary temperature of > 101 degrees F
OR - A temperature > 100.4 degrees F sustained over 60 minutes in a patient with ANC <500
Is PT contraindicated with neutropenic fever?
NOPE
Rehab implications for neutropenic fever
- Proceed with treatment based on facility guidelines
Special consideration should be given if the patient is experiencing Fatigue, Malaise, Dizziness, Lethargy - PT should monitor at-risk individuals for early signs and symptoms of infection –> expedite medical management * Practice good hand hygiene with antimicrobial products during every patient encounter
What is tumor lysis syndrome
- Collection of metabolic disorders that result from the death of neoplastic cells which
then release their intracellular contents into the circulation = metabolic crisis that can lead to death - Most commonly seen in patients with very aggressive hematologic cancers
** can be fatal if not addressed
When does tumor lysis syndrome occur?
- Occurs after effective therapy is initiated or spontaneously (cytotoxic chemotherapy, glucocorticoid therapy, endocrine therapy,
radiotherapy)
Most commonly as a result of chemotherapy - Typically presents within 7 days of cancer treatment
Tumor Lysis syndrome clinical presentation
Fatigue, signs of dehydration, seizures, cardiac arrythmias, nausea and
vomiting
Key lab findings in tumor lysis syndrome
- hyperkalemia (most immediate threat)
- hyperuricemia
- hyperphosphatemia (leads to hypocalcemia)
What can kyperuricemia lead to
acute kidney injury
hyperphosphatemia
Phosphate binds with calcium to form calcium phosphate crystals leading to
hypocalcemia
Leads to anorexia, vomiting, seizures, or cardiac arrest
tumor lysis syndrome rehab implications
- Patient’s may complain of muscle weakness, spasm, and/or cramping
- ↑ uric acid –> arthralgias and renal colic
Paresthesia and paralysis (hyperkalemia)
Seizures, tetany, lethargy (hyperphosphatemia)
Lethargy, malaise, sleepiness, seizures (hyperuricemia)
Paresthesia, tetany, confusion, delirium, hallucinations (hypocalcemia)
*** type of pain you get with kidney stones
What should you monitor for in tumor lysis syndrome
CV effects during activity: arrythmias, abnormal changes in BP, tachycardia
Volume overload: dyspnea, pulmonary crackles, edema, HTN
GI: anorexia, nausea, vomiting, diarrhea, hyperactive bowel sounds, abdominal pain, bloating or cramps
What can electrolyte imbalances trigger?
clotting cascade, leading to
disseminated intravascular coagulation
Tumor lysis syndrome in the ICU setting
early progressive mobility and rehabilitation interventions improve recovery and maintain functional status after discharge
Hypercalcemia of Malignancy
- Abnormalities in calcium homeostasis –> during active malignancy, late effect due malignancy, or treatment for it
- Poor prognosis – median survival ~35 days from diagnosis
Signs and Symptoms of hypercalcemia of malignancy
- Vague and Diffuse
Lethargy, fatigue, malaise, bone pain, muscle weakness, anorexia, nausea and vomiting, constipation, polyuria, decline in mental function, confusion, delirium, coma
Rehab implications of Hypercalcemia of Malignancy
Assess and ascertain mental status changes and impact on safety judgement
Mild-to-moderate conditions –> weight bearing activities, general aerobic conditioning, consider assistive device for safety with ambulation
Sever conditions –> individuals are relatively unresponsive
Most common cause of Superior Vena Cava Syndrome
- Thoracic malignant disorders
What is Superior Vena Cava Syndrome?
Extrinsic compression or occlusion of the superior vena cava
Symptoms of Superior Vena Cava Syndrome
Common: dyspnea, orthopnea, cough, sensation of fullness in head and face, and headache, often exacerbated by stooping
Less common: chest pain, hemoptysis, hoarseness, dizziness, light-headedness, and even syncope
Physical findings of Superior Vena Cava Syndrome
Facial and neck swelling, arm swelling, and dilated veins in the chest, neck, and
proximal part of the arms
Stridor –> indicate laryngeal edema
Mental status changes = worrisome –> increased intracranial pressure
Rehab implications Superior Vena Cava Syndrome
Symptom recognition and observance of change over time will support differential
diagnosis
Avoid Valsalva maneuvers with activity and exercise
Heart rate response to activity may be impaired –> Use RPE as a more sensitive self-reported measure during activity
Pericardial Effusion
excess fluid between the heart and pericardium
Malignant Pericardial Effusions
- Commonly seen in patients with advanced and
metastatic disease
Related to malignancy OR secondary to radiation therapy
OR manifestation of infection or autoimmune process - Overall prognosis is poor – median survival 130-140 days
Presenting symptoms of Malignant Pericardial Effusions
Small effusions: often asymptomatic, do not require urgent therapy
Large effusion: if rapidly accumulating, can impair ventricular filling and
reduce cardiac output
Signs and Symptoms of Malignant Pericardial Effusions
Dyspnea, cough, chest pain, heart palpitations, cyanosis, tachycardia, hypotension, distant heart sounds, fixed jugular distension, peripheral
edema, engorged neck veins, pulsus paradoxus
Pulsus paradoxus: abnormally large decrease in stroke volume, systolic BP and
pulse wave amplitude during inspiration; drop in BP is >10 mmHg
How are Malignant Pericardial Effusions diagnosed?
Echocardiography
Treatment of Malignant Pericardial Effusions
Pericardiocentesis
Surgical procedures or instillation of sclerosing agent may be used
Rehab Implications of Malignant Pericardial Effusion
Frequent assessment of heart rate, hemodynamic status and respiratory status,
including oximetry levels, should be carried out during treatment
Assessment of skin color and temperature, capillary refill, and peripheral pulses should be tracked
Awareness of mental status changes, confusion, or seizures is necessary due to
reduced cerebral blood flow
After a cardiac tamponade, patients should have medical clearance before re- engaging in rehab care
Rehabilitation is indicated to provide strengthening and reconditioning activities, pulmonary hygiene, and postural positioning
Cancer Related Pain
- One of the most common symptoms associated with cancer
- Defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in relation to such damage
- One of the symptoms that patients fear most
Cancer related pain is a multifactorial process that may include….
Direct tumor infiltration/involvement
Unintended damage from diagnostic or therapeutic
surgical procedures (e.g. biopsies, resection)
Side effects related to cancer therapies (e.g. chemotherapy, radiation therapy)
Causes of cancer related pain
Pressure on or displacement of nerves
Microscopic infiltration of nerves by tumor cells
Ischemic pain
Bone metastases
Pathophysiologic Classification of Cancer related pain includes…
differentiating between pain
associated with the tumor, pain associated with treatment, and pain unrelated to either
2 Basic types of cancer related pain
Nociceptive: Results from activation of nociceptors after injury to visceral or
somatic structures
Neuropathic –> Injury to the peripheral or central nervous system
What does visceral pain arise from
internal organs and surrounding tissue
what are common causes of visceral pain
compression, infiltration, or dissension of abdominal and thoracic viscera
What is visceral pain described as?
diffuse, vague, deep, burning, aching, gnawing, cramping or
crushing
Visceral Pain referral
May be referred and/or located in dermatomes and myotomes supplied by the neurons that project from the same segments or share the same spinal cord segment as the viscera being affected
Visceral Pain treatment
Pharmacologic
Manual therapy
Interventional
Complementary alternative medicine techniques
Psychosocial support –> integral part of treatment
Somatic Pain
- Arises from activation of nociceptive neurons in the skin or musculoskeletal
tissues (bone, joint, muscle, `connective tissue) - Common causes include metastases in the bone and pain related to surgery
- Skin, bone, joint, muscle and connective tissues
- Sharp, well-localized, throbbing, pressure-like
What is the most common cause of bone pain?
- Tumor involvement of the bone
Metastasis MUST be considered in the differential diagnosis of patients with
history of cancer reporting bone pain
Pain is a warning sign but does not always precede a pathologic fracture
Bone metastases are initially
asymptomatic
common features of bone metastases over time =
pain, loss of function, hypercalcemia, and depression –> ↓ in QOL and performance status
Common sites for bone metastases
Axial skeleton
Femur
Pelvis
Humerus
Ribs
Skull
** vone lesions are typically not solitary
What is the single best predictor of pathological fracture
functional pain
Osteoblastic bone metastasis
- Cancer cells activate osteoblasts increasing deposition of new bone and increasing numbers of irregular bone trabeculae
- Results in dense, sclerotic/hardening of bones
- Prostate cancer
Osteolytic bone metastasis
- Cancer cells cause excessive breakdown of bone
- Results in weak, easily breakable bone
- Multiple Myeloma
Mixed type bone metastasis
- Both osteolytic and osteoblastic lesions present or both types are present in the same lesion
- breast cancer
Nonsurgical management of bone metastases
- Pain relief
- Halt progression of metastatic lesion
- Prevent fractures
- Maintaining/restoring mobility
Surgical Management of bone metastases
- stabilization for pathologic and/or impending fractures
- relief of intractable bone pain
- maintain/restoring mobility
Rehab implications and activity considerations for bone metastases
- Optimize function
- Assistive devices (walker/crutches to unweight; cane for pain control)
- Isometric strengthening
- Low-impact conditioning activities
- Compensatory techniques (e.g., adaptive equipment to minimize bending)
- Avoidance of high-impact, high torque actions
- Fall prevention strategies
- Patient and caregiver education
Neuropathic pain
- Injury to the peripheral or central nervous system
- Burning, sharp, or shooting; often accompanied by numbness or tingling in extremities
- Tends to be more resistant to treatment with conventional pain- relieving medications
causes of neuropathic pain
Tumor compressing or infiltrating the nerves or spinal cord
Damage to nervous system caused by cancer treatment
2 types of neuropathic pain
polyneuropathy or peripheral neuropathy
Longest nerves are most vulnerable, especially to the hands and feet
Produces a stocking and glove pattern of involvement
small diameter sensory nerve fibers
Symptoms of pain or temperature perception loss, dysesthesia, and temperature
misperception
Signs include cold, hairless, dry, thinner skin
Large diameter sensory nerve fibers
Loss of vibration sense/proprioception, numbness, loss of fine touch, imbalance, sensory ataxia (when severe)
What is chemotherapy-induced peripheral neuropathy
- Damage to the peripheral nervous system that results from administration of neurotoxic chemotherapeutic
agents (Taxanes, Platinums, and Vinca alkaloids) - Risk of neurotoxicity increases with higher individual and cumulative doses, higher infusion rate and
coadministration of other neurotoxic agents
Dose limiting vs dose-dependent CIPN
Dose-limiting: side effects of a drug or other treatment that are serious enough to prevent an increase in dose or level
of that treatment
Dose-dependent: side effects change when the dose of the drug is changed
What is typical in CIPN
sensory abnormalities and neuropathic pain in hands and feet
Screening for CIPN
Pattern of presentation, timing of symptom onset, and progression of symptoms –>
helpful in differentiating CIPN from other impairments
Thorough history is important: Identify if the patient has received any drugs associated with CIPN –> further screening warranted
Most common subjective complaints in CIPN
Numbness and/or tingling of toes and fingers
If weakness is present = symmetrical distal weakness
Proximal weakness = indicative of steroid-induced myopathy
Unilateral weakness = indicative of central or peripheral nerve impairment
PAIN in hands and feet
Questionnaire for CIPN
Neuropathic Pain (DN4) Questionnaire
> 4/10 indicates neuropathic pain
CIPN Treatment
- Few PT intervention studies
- Education on strategies to increase safety with daily activities –> Decreased touch thresholds which put them at risk for tissue injury
- Infrared treatment for neuropathic pain
- Collaboration with medical team to work towards management of neuropathic pain
- Strength, power, balance training, postural re-education, orthotics
- Task specific training to improve hand function
Malignant Spinal Cord Compression
- Secondary to metastases to vertebral bodies –> collapse or
compression of vertebral body - MEDICAL EMERGENCY as it can lead to permanent. paralysis if treatment is delayed by even a few hours
- Compression of the cord –> edema, vascular congestion,
and demyelination - Thoracic spine is most commonly involved followed by lumbar and cervical
Presenting symptoms of Malignant spinal cord
Pain = 1st sign
– Nociceptive or neuropathic (radicular pain)
– High intensity (8/10)
– Worsens with supine positioning, at night, and with increased thoracic pressure during sneezing, coughing, or straining
Motor weakness = 2nd sign
– More common than sensory deficits
– Below the area of spinal involvement
– Gait disturbance
Treatment for malignant spinal cord compression
radiation therapy or surgical
radiation therapy for MSCC
Mainstay of treatment
Goal: relieve compression of the spine and nerve roots –> pain relief and improving/stabilizing the neuro deficit
Surgical treatment of MSCC
Decompressive surgical procedure
Diagnostic by providing a biopsy or stabilize an unstable spine
May be the only option when there is compression of the cord by bony fragments
following collapse
MSCC rehabilitation implications
Pain – worse in recumbent position, at night and with straining
Thoracic, lumbar, cervical Limb weakness, difficulty walking
Signs of nerve root compression
* After surgical decompression and/or radiation therapy, treat the impairments as needed
5 A’s of Pain Management
Analgesia: optimize analgesia (pain relief)
Activities: optimize ADL’s
Adverse effects: minimize adverse effects
Aberrant drug-taking: avoid aberrant drug taking (addiction-related outcomes)
Affect: relationship between pain and mood
What should you screen for at every visit?
pain and fatigue
pain assessment
- Perform a detailed history and physical examination –> Always ask if there is a history of past primary cancer
- Comprehensive evaluation of pain is essential for proper management
- Patients who have an oncology diagnosis should be
screened for pain on every visit - If pain is present on any given visit, the pain intensity MUST be quantified by the patient
Pain Assessment Tools
- Numeric Pain Rating Scale
- Visual Analog Scale
- Pictorial Scale
- Categorical pain scales
- Brief Pain Inventory
Brief Pain Inventory
Patient reported functional outcome measure
Assesses pain severity in patients with cancer in 2 domains: Intensity of pain and Pain interference
Quantifies the measure using a 0 to 10 rating scale
