Lec 4 Heme/Onc

  1. What are the 4 types of cancer-related complications?
    • 1. metabolic or hormonal
    • 2. structural
    • 3. chemotherapy-related
    • 4. hematologic
  2. Give examples of metabolic or hormonal cancer-related complications.
    • 1. tumor lysis syndrome (TLS)
    • 2. hypercalcemia of malignancy
    • 3. SIADH
    • 4. paraneoplastic syndrome
  3. Give examples of structural cancer-related complications.
    • 1. superior vena cava syndrome
    • 2. pleural or pericardial effusion
    • 3. spinal cord compression
  4. Give examples of chemotherapy-related cancer-related complication.
    • 1. extravasation 
    • 2. diarrhea/constipation
  5. Give examples of hematologic cancer-related complications.
    • 1. febrile neutropenia
    • 2. hyperviscosity syndrome
    • 3. thromboembolic risk associated with cancer
  6. What is tumor lysis syndrome (TLS)?
    • metabolic cancer-related complication resulting from abrupt release of cellular components into the blood
    • may result in acute renal failure
  7. What is the pathophysiology of TLS?
    • release of nucleic acids --> HYPERuricemia -->uric acid crystals precipitate in renal tubules --> acute obstructive nephropathy
    • HYPERphosphatemia
    • HYPERkalemia
    • HYPOcalcemia
  8. What are the tumor-related risk factors of TLS?
    • 1. type of malignancy - more common w/ acute hematologic malignancies
    • 2. high tumor burden
    • 3. chemotherapy - sensitive disease
  9. What are the patient-related risk factors of TLS?
    • 1. pre-existing renal dysfunction
    • 2. elavated uric acid, WBC, LDH
    • 3. dehydration 
  10. What is the Cairo-Bishop Classification?
    2 or more laboratory changes up to 7 days after chemotherapy
  11. What are the laboratory changes associated with TLS?
    • uric acid: > 8.0 mg/dL or > 25% increase from baseline
    • potassium: > 6 mEq/L or > 25% increase from baseline
    • phosphorus: > 6.5 mg/dL (children), > 4.5 mg/dL (adults) or > 25% increase from baseline
    • calcium: < 7 mg/dL or 25% decrease from baseline
  12. What is the clinical presentation of TLS?
    • not making urine
    • may not have swelling
    • feeling more "gouty"
    • non-specific complaints = just don't feel right
    • renal failure
    • arrhythmias (heart racing)
    • weakness/tetany
    • EKG will probably show an abnormality
  13. What are the goals of therapy for TLS?
    • prompt management and treatment of TLS while maintaining renal & cardiopulmonary support
    • recognition of high reisk patients and prevention (prophylaxis to prevent TLS & prevent those at high risk)
    • avoid acute renal failure complications (stay hydrated)
  14. What is the treatment outline for TLS?
    • 1. potentially aggressive emergency care
    • 2. fluids and hydration 
    • 3. management of hyperuricemia
    • 4. management of electrolytes
    • 5. monitoring and follow-up
  15. What is the hydration schedule for a patient with TLS receving chemotherapy?
    • Maintain UOP 80-100 ml/m2/hour
    • Hydrate 24-48 hours prior to chemo (esp if high risk) and continue 48-72 hours after chemo ==> in order to maintain a good urine output
  16. How is hyperuricemia managed in patients with TLS?
    • allopurinol  (renally adjust)
    • does NOT work on already produced uric acid!
    • prophylaxis with allopurinol before starting chemo to make sure pt doesn't develop hyperuricemia 
  17. Which drug is a recombiant modified urate oxidase that can be used for management of hyperuricemia secondary to leukemia, lymphoma or solid tumor malignancies?
  18. How is rasburicase administered/dosed?
    • single course of treatment
    • not given prophylactically
    • works on uric acid already produced
  19. What are the black box warnings for rasburicase?
    • anaphlyaxis
    • heolysis
    • methemoglobinemia 
  20. What are the adverse effects of allopurinol use?
    diarrhea, nausea, increased LFTs, toxicity (if not renally adjusted)
  21. What is the important monitoring issue associated with rasburicase?
    • need to collect blood for uric acid analysis in pre-chilled heparinized tubes
    • immerse in ice water
    • analyze samples within 4 hours
    • crystals will form if not done properly
    • can't use if pt has a G6PD deficiency
  22. What patient monitoring must occur in patients with TLS?
    • electrolytes
    • EKG
    • renal function (ins/outs) --> SCr lags behind ~2 days before accurate reflection 
  23. What is the incidence of hypercalcemia of malignancy?
    • ~25% of cancer patients
    • most common cancers: lung, breast, hematologic, etc.
  24. How is corrected calcium calculated?
    observed calcium + 0.8 (4 - albumin)
  25. What kind of prognostic sign is hypercalcemia of malignancy?
  26. What is the pathophysiology of hypercalemia of malignancy?
    • increased osteoclastic bone resorption (cytokines & tumor-released products)
    • enhanced renal tubular and intestinal reabsorption 
    • medication causes (Ca supplements --> Tums, thiazides, lithium)
  27. What is the clinical presentation of hyepralcemia of malignancy?
    • "stones, bones, abdominal groans, psychic moans"
    • Renal: kidney stones, polyuria, polydipsia, dehydration, decreased urine output
    • GI: constipation, N/V, anorexia, loss of appetite
    • Neurologic: fatigue, lethargy, depession, loss of deep tendon reflexes, seizures, etc.
    • Cardiovascular: EKG changes, arrhythmias that may lead to cardia arrest
  28. What is the therapy for hypercalcemia of malignancy?
    • discontinue exogenous sources of calcium
    • ultimate management is therapy for cancer
    • hydration (normal saline 200-500 ml/hr)
    • diuresis (to enhance renal excretion of calcium AFTER establishing rehydration 
    • inhibiting accelerated bone resorption --> bisphosponate therapy
    • alternatives (if Ca elevated after 2nd dose of bisphosphonate) --> glucocorticoids, calcitonin, mithramycin, gallium nitrate, dialysis 
  29. Describe how superior vena cava syndrome occurs.
    • tumor is pressing against SVC and may be affecting BP
    • tumor is invading the vessel walls and pressing against SVC
    • possible thrombosis of the vessel
    • over time, if the tumor remains stable and isn't growing the SVC can make collateral veins and bypass it
  30. What are the causes of SVC syndrome?
    • 1. malignancy: lunch cancers most common
    • 2. non-oncologic: TB, aneurism 
  31. What are the signs and symptoms of SVC syndrome?
    • facial/neck swelling
    • upper extremity swelling
    • dyspnea
    • cough
    • dysphagia, stridor (high pitched wheezing sound d/t blockage of larynx)
    • syncope
    • sensation of fullness in head
    • distended neck and chest veins
    • facial, neck, arm edema
    • facial plethora (flushed)
    • cyanosis 
  32. How is SVC syndrome classified?
    • based on symptoms
    • 0 = asymptomatic
    • 5 = death
    • 1-4 = how bad symptoms are and what the patient is experiencing
  33. How is diagnosis of SVC syndrome made?
    • signs/symptoms
    • imaging studies
  34. How is SVC syndrome managed?
    • 1. treat underlying cause - chemo/radiation therapy (cancer or infection as cause)
    • 2. endovascular revascularization
    • 3. supportive measures (elevate head of bed for easier breathing; oxygen)
    • 4. corticosteroids or diuretics (can use if other options aren't working; do it if it doesn't hurt the patient)
    • 5. anticoagulation for thrombosis-related obstruction 
  35. What are the most common cancers associated with malignant pleural and pericardial effusions?
    • pleural: lung, breast, lymphoma
    • pericardial: lung, breast, leukemia/lymphoma, GI, sarcomas, melanoma
  36. What is the pathophysiology of malignant pleural and pericardial effusions?
    • impaired balance between normal fluid production and elimination 
    • accumulation of fluid around heart or lungs
    • capillary leak, obstruction of lymphatic drainage to allow fluid to get across
    • increase in hydrostatic pressure or decrease in oncotic pressure
  37. What is the clinical presentation of malignant pleural and pericardial effusions?
    • dyspnea, cough, chest pain
    • PE: decreased breath sounds, dullness to percussion, decreased fremitus, pericardial rub
  38. What is the treatment for malignant pleural and pericardial effusions?
    • thoracentesis or chest tube drainage
    • pleurodesis/sclerotherapy
  39. How does a thoracentesis or chest tube drainage work?
    • diagnostic tap: take a little bit of fluid off to send for culture to make sure not infectious
    • therapeutic: drain off as much as possible
  40. What is pleurodesis/sclerotherapy?
    • instillation of agent/medication into the pleural space
    • makes the inside linings of lung irritated so they don't adhere to one another
  41. What agents/medications can be used in pleurodesis/sclerotherapy?
    • doxycycline
    • bleomycin
    • talc (baby powder)
  42. How common is malignant pleural and pericardial effusions?
    100,000 cases annually
  43. How common is SVC syndrome?
    ~15,000 in US each year
  44. How often does spinal cord compression occur and when does it occur?
    ~ 5% of cancer population withhin the last 2 years of life
  45. What is spinal cord compression?
    a tumor pressing on the spinal cord
  46. What is the clinical presentation of spinal cord compression?
    • pain: mainly back pain
    • motor findings: weakness, hyperreflexia below level of compression (+ Babinski sign, diminished lower extremity deep tendon reflexes)
    • sensory findings: parasthesias (ascending numbess most common = feet moving up)
    • autonomic dysfunction: urinary retention
  47. What are the therapy options for spinal cord compression?
    • high-dose dexamethasone
    • surgery and radiation
    • supportive care
  48. What are the goals of therapy of spinal cord compression?
    • pain management
    • preserving or even improving neurologic function
    • maintaining or improving QOL
  49. How often dose chemo-related extravasation occur?
    ~ 1-7%
  50. Define chemotherapy-related extravasation.
    the accidental leakage of chemotherapy from the vein into the surrounding tissue (damage can involve nerves & tendons)
  51. What agents can cuase extravasation?
    • irritants: cisplatin, oxaliplatin, irinotecan, topotecan, paclitaxel, others
    • vesicants: anthracyclines, vinca alkaloids, paclitaxel, mitomycin
  52. What are the patient-related risk factors of extravasation?
    • collapsed vein
    • dehydrated patient, therefor didn't get a good vein in the first place
    • small veins
    • older patient
    • thin skin (possibly)
    • impaired circulation
    • obese patient
  53. What are the procedure-related risk factors of extravasation?
    • bad insertion site
    • new nurse furst time putting in a line
    • inexperienced staff that hasn't dealt with chemo very much
    • bolus more likely to extravasate
    • pt thrashing around may present a problem
  54. How can extravasation be prevented?
    • patient and staff education (pt should alert staff if burning, warmth, etc.)
    • check patency of lines, appropriate veins and equipment
    • avoid easily "dislodged" lines (make sure line is in good)
    • flush the line before and after administration
    • use thin cannulas with high gauges
    • monitor closely
    • recognition of patient symptoms (pain, swelling, redness, burning, stinging) --> later symptoms (erythema & edema)
  55. How can extravasation be managed?
    • stop infusion - leave needle/cannula/catheter in place
    • aspirate as much drug as possible (use another access site)
    • apply antidote (if applicable)
    • withdraw IV access
    • elevate area to minimize swelling
    • mark affected area and photograph
    • plastic surgery may be necessary
  56. What are the possible antidotes/specific management for extravasation?
    • "localize and neutralize"
    • "disperse and dilute" 
  57. What does "localize and neutralize" mean?
    • application of cold pack to affected area
    • cold causes vasoconstriction to localize the extravasation
    • (DMSO, dexrazoxane, sodium thiosulfate)
  58. What does "disperse and dilute" mean?
    • application of warm compress to affected area
    • warm causes decreased local drug concentrations
    • (oxaliplatin, hyaluronidase, possibly surgery depending on the degree of extravasation)
Card Set
Lec 4 Heme/Onc
Lec 4: Oncologic Emergencies