Oncological Emergencies

Neutropenia and Fever

The most common oncological emergency is fever and neutropenia.
Fever is defined as a single temperature > 100.05ºF or 3 temperatures > 100 in a
24 hour period.
Neutropenia is defined as an absolute neutrophil count <1000/mm³
Absolute Neutrophil Count = (total WBC) x (neutrophils + bands) / 100.

The most common reason for neutropenia is myelosuppressive chemotherapy.

However an infiltrative malignancy in the bone marrow may present as neutropenia. The most common
hematological malignancies affecting the bone marrow are AML, ALL, CLL, or NHL. The most common solid
tumors infiltrating the bone marrow are prostate, renal, thyroid, breast, or lung.

The febrile and neutropenic patient usually presents with few signs or symptoms except fever. The lack of
symptoms may be from the lack of leukocytes to cause inflammation.

The patient with fever and neutropenia is at great risk for sepsis from gram negative
bacteria and urgent treatment is needed. The etiology of the fever is usually due to breakdown of normal
gastrointestinal barriers with mucositis allowing enteric and oral bacteria to become pathogens.

Assessment:

A thorough physical examination should include:

1. Oral exam- to r/o fungus, mucositis, herpes simplex, and anaerobic infections.
2. Indwelling catheters and soft tissue for exit site and tunnel tract infections, cellulitis, and septic phlebitis.
3. Perirectal exam- to r/o induration, fluctuance, and tenderness. Cultures should be obtained from:
1. All indwelling catheter ports and peripheral blood cultures.
2. Sputum- induced by respiratory if needed.
3. Urine culture and analysis.

Chest Xray- PA/LAT

Chemistries to include a metabolic panel with Ca, Mg, and PO4 as well as LFT's.

Treatment:
The goal of urgent treatment is to prevent the morbidity associated with gram
negative bacteremia. The- patient should receive broad-spectrum antibiotics to cover for Pseudomonas and
other gram-negative organisms.

Suggested regimen:
1. A third generation cephalosporin or semisynthetic penicillin plus an aminoglycoside.
2. Vancomycin is used empirically if-a gram (+) cocci is found and awaiting sensitivity results or if there is an
obvious tunnel infection.

3. Clindamycin or Flagyl are used if peridontal or perirectal infections are suspected.

4. Antifungal therapy such as diflucan if thrush or esophagitis is suspected.

Patients who remain febrile and neutropenic without a source need evaluation with blood cultures and CXR
every 72 hours and physical examinations every day. After 5-7 days of neutropenia and fever a fungal infection
is highly likely. At this point it is reasonable to add empiric Amphotericin at 0.5 to 1 mg/kg. If the fever
continues you need to consider second bacterial isolate, abscess, anaerobic infection, resistant gram positive
bacteria, atypical organisms, fungi, viruses, or drug fever.
Once a site of infection is identified the antibiotics should be tailored to the source and the broad-spectrum
antibiotics continued until neutrophil recovery. Catheters are removed immediately for any documented tunnel
infection or fungal bacteremia.

Antibiotic therapy is continued for 2 weeks for a documented site and ANC > 1000. If the patient is afebrile and
ANC > 1000 with no source of infection antibiotics may be stopped. Spinal Cord

Compression

Back or neck pain warrants immediate attention in a patient with a known malignancy.
Intraspinal lesions usually have unrelenting pain and are worsened by straining, sneezing, coughing, movement,
and recumbency. The most commonly involved spinal areas are thoracic>lumbar>cervical. If an intraspinal
lesion is present the back or neck pain progresses to radicular pain → weakness →sensory loss → paralysis →
and or loss of bowel or bladder function.

Early recognition is key. If a patient is ambulatory and maintains bowel and bladder function the outcome is
good. Less than 15%of patient who are paraplegic or lose sphincter tone will regain function. If a patient has
back pain and an abnormal neurological exam emergent dexamethasone administration of 10 mg IVP followed
by 4-6 mg IVP Q 6 hours while obtaining an emergent MRI is warranted.

If the MRI is positive for spinal cord compression emergent radiation therapy may be needed. Surgery is
indicated if a tissue diagnosis is needed, neurological dysfunction progresses despite radiation, recurrent spinal
cord compression in a previously radiated area, or spinal instability.

Intracranial Metastases

The symptoms and signs of increased intracranial pressure are:

1. Change in mental status.

2. Headache worse in the am.
3. Seizure.
4. Focal neurological deficit.
5. Unrelenting nausea and vomiting.
6. Papilledema.

A head CT with contrast is the initial radiographic technique for diagnosis. If a head CT is negative than a MRI
is the next diagnostic step (a MRI will help differentiate between vascular and metastatic disease.). If still
clinically suspicious for intracranial metastases than a LP should be performed to rule out carcinomatosis. Three
negative LP samples are required to ensure no carcinomatosis present.

If impending intracranial herniation is present the signs and symptoms are:

1. Fixed and dilated pupil(s).

2. Abrupt decrease in consciousness.
3. Hyperventilation.
4. Abrupt increase in the SBP of > 15 mmHg.
5. Widened pulse pressure.

The patient should be intubated and hyperventilated to keep pCO2 between 25-30 mmHg. Mannitol at 1.5
gm/kg every 6 hours and decadron 10-20 mg IVP every 6 hours.
If a lesion is found without evidence of herniation decadron orally is usually started at 4 mg every 6 hours.
Phenytoin is only used if a seizure has occurred. If phenytoin is used regular levels need to be checked as
decadron increases phenytoin metabolism.

Radiation is usually used unless it is a solitary lesion. If there is controlled systemic malignancy then resection
of a solitary lesion improves survival and quality of life.

Surgery would also be used if a tissue diagnosis has not been established.

Superior Vena Cava Syndrome

The most common cause of SVC pre 1940's was syphilitic aortic aneurysms. The most common cause now is
extrinsic compression from a malignancy.

Signs and symptoms:

1. Cyanosis.
2. Facial and upper extremity edema.
3. Venous engorgement of head, neck, arm, chest, and upper abdomen.
4. Airway obstruction.
5. Pleural and pericardial effusion.
6. Nonpitting edema of neck- "Stoke's Collar".
7. Symptoms worsen in the supine position.

Diagnosis:

1. Chest CT.
2. Upper extremity venogram.

Treatment:
1. If the patient is stable a tissue diagnosis is warranted as many causes of SVC are chemosensitive tumors
(small cell lung cancer, Non-Hodgkin's Lymphoma or germ cell cancer).
2. Supportive measures include corticosteroids (anti-inflammation), morphine sulfate (vasodilator),
3. If the tumor is not chemosensitive and if the patient is unstable then emergent radiation therapy is given.
4. Fibrinolytic therapy is reserved for SVC thrombosis that is related to central venous catheters if the patient
has no increased risk for bleeding.

Hypercalcemia

The incidence of hypercalcemia in patients with malignancies is 10 %. The most common malignancy
associated with hypercalcemia is squamous cell carcinoma of the lung with the second most common being
breast cancer.

The mechanism of hypercalcemia with malignancy may be caused by secretion of parathyroid-like hormone
(PTH) that causes increased bone and renal tubular calcium reabsorption. A second mechanism is direct
osteolytic lesions causing calcium reabsorption or factors released to stimulate osteoclasts that cause Ca++
reabsorption.

Assays for both native PTH and PTH-like hormone are available.

Signs and Symptoms:

1. Polyuria and polydipsia.
2. Nocturia.
3. Anorexia.
4. Nausea and vomiting.
5. Abdominal Pain
6. Fatigue.
7. Confusion, psychosis, stupor, or agitation.
8. Obtundation and coma.
9. Dehydration. 10. QT prolongation.
11. Nephrolithiasis.

Treatment:
1. Replete volume status. 0.9 NS at 200-300 cc/hour will cause a calciuresis. Mg++ and K+ levels need
checked frequently.
2. Lasix may be used once patient is euvolemic
3. Calcitonin (4lU/kg) every 8-12 hours will bring Ca++ levels down by 2-3 mg/dl in a few hours. However the
response is of short duration
4. Steroids may be used in hyperca1cemia associated with Multiple Myeloma, NHL, and Breast Cancer.

5. Pamidronate 60-90 mg IVPB q 3 weeks will have an onset of action in 24-48 hours and last 3-4 weeks.

6. Etidronate 7.5 mg/kg/d for 3 days can also be used with an onset of action in 24-48 hours with duration of 3-4
weeks.