12/29/2019

Cancer and
Oncologic
Emergencies
John D. Gonzalez DNP, APRN, ACNP-BC

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Epidemi
ology
• Please read the power point presentation by the American Cancer
Society
• The link is provided in blackboard

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Tumor
Classification
s
• Benign Tumors- Nonmalignant new growth
• Characteristics
• slow growing
• well encapsulated- do not invade surrounding tissues
• well differentiated cells- usually looks like the tissue it arose from and is named after
it
• Lipoma-benign fatty tumor
• Leiomyoma- (leio=smooth, myo= muscle)- benign tumor of the smooth muscle of the
uterus

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Tumor
Classification
• Malignant Tumors
• Rapid growth rate of cells
s
• poorly differentiated and disorganized cells
• invade surrounding tissues and structures
• are capable of metastasis
• are named after the cell of origin but in addition to the “oma” they have the root words “carcino” or “sarco”
• Tumors involving epithelial tissue usually have “carcinoma” plus the organ of origin.
• Hepatocellular Carcinoma- malignant tumor of the surface epithelial tissue of the liver
• adeno- refers to the glandular epithelial tissue (deeper epithelial tissue or glands)
• adenoma-benign tumor of the glandular tissue
• adenocarcinoma- malignant tumor of the glandular tissue

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Malignant Tumor Classification cont.

• Carcinoma in Situ- very early and pre-invasive carcinoma of the glandular or squamous epithelial
tissue. It has not broken thru the basement membrane. The basement membrane is a very thin layer of
tissue which separates the epithelium (skin, respiratory tract, GI tract, etc.), mesothelium (pleural
cavity, peritoneal cavity, pericardial cavity etc.), and the endothelium (blood vessels, lymph vessels)
from the underlying connective tissue.
• Malignant Tumors of Connective Tissue
• Have the root word “sarcoma”
• osteosarcoma- malignant tumor of the bone. (osteo=bone)
• osteoma- benign tumor of the bone
• Chondrosarcoma- malignant tumor of joint cartilage (chondro= cartilage)

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Malignant Tumor
Classification cont.
• Malignant Tumors of the Muscle Tissue
• These tumors are named using the specific muscle type “sarcoma” and
“myo”
• Uterine Leiomyosarcoma- malignancy of the smooth muscle of the uterus
• Rhabdomyosarcoma- malignancy of the skeletal muscle
• Malignant Tumors of Nervous Tissue
• Name is assigned based on the nerve cell type plus “blastoma”
• Neuroblastoma- malignancy of the nerve cell
• Neuroma- benign growth of nerve cell

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Malignant Tumor
Classification cont.
• Exceptions to the Rule
• Lymphoma- malignancy of the lymphatic system, i.e. Hodgkin Lymphoma
• Leukemia- (leuk= white)- cancer of the WBCs, or leukocytes. There are
several categories
• myleocytic- excessive production of granulocytes
• lymphocytic- excessive production of lymphocytes
• multiple myeloma- excessive production of plasma cells

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Paraneoplastic
Syndromes
• Are manifestations of cancer which are caused by other factors than direct
tumor invasion or compression. Their presence does not necessarily mean
metastasis is present. Their presence is a sign of a cancer. They should trigger
the nurse practitioner to consider the diagnosis of cancer in someone who is
undiagnosed.
• The broad categories of paraneoplastic syndromes: endocrine, dermatologic,
neurologic, rheumatologic, and hematologic. They each come with their own set
of clinical manifestations and are associated with certain type of cancer.
• I have provided you with a table of paraneoplastic syndromes which includes
their clinical manifestations and associated cancers. You are only required to
know the ones with an asterisk sign next to it and the others are provided for
you as FYI.

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Ovarian
Cancer
• Is the leading cause of death from a gynecologic malignancy in the US. It is the seventh most common
type of cancer in women. Epithelial ovarian cancer is the most common type. The incidence increases
with age.
• Risk factors
• Family history
• Presence of the BRCA1 and BRCA 2 mutations.
• Persons with BRCA 1 mutation develop ovarian cancer on average 10 years earlier than those with BRCA2 mutation.
The absolute risk of developing ovarian cancer over a lifetime associated with a BRCA 1 mutation is 35-45% and for
BRCA 2 mutation is 15-25%.
• Early menarche or late menopause- it is thought that the increased number of ovulations leads to a pattern of ovarian injury
and repair which contributes to the development of the cancer. The opposite is true.
• Risk is decreased by pregnancy, use of contraceptives, and breast feeding > 1year, tubal ligation, hysterectomy,
salpingo- oophorectomy.

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Ovarian
• Most are diagnosed around age 65
Cancer
• There are no effective screening tools to help with early diagnosis.
• Clinical Presentation
• Disease that is localized to the ovary rarely has symptoms.
• Advanced disease – manifestations are vague
• Abdominal fullness or bloating
• Pelvic heaviness, pelvic pain
• Painful intercourse
• Vaginal bleeding or discharge3
• Lack of appetite, nausea, vomiting, constipation
• Other symptoms include: urinary frequency or urgency, difficulty eating or feeling full fast.
• Patients can present acutely with pleural effusions or bowel obstructions.
• They rarely have paraneoplastic syndromes but if they include: cerebellar degeneration, polyneuritis, dermatomyositis, hemolytic anemia, IDC, acanthosis, or
nephrotic syndrome.

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Ovarian
Cancer
• Diagnostic
evaluation
• Pelvic examination
• Transvaginal US
• CA125 marker –
elevated in 80%
of women
• A definitive diagnosis can only be made via surgical exploration. This is done if there is enough
data to suspect ovarian cancer. The patient should have a preoperative evaluation prior to surgery.
• Referral
• GYN Oncology Surgery
• Advanced cancers will need surgical debulking
• Will need chemotherapy

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Ovarian
Cancer
• Screening and prevention
• There are no good reliable screening tests which can be used. The USPSTF
recommends against screening. The society of gynecologic oncology
recommends against screening low risk females.
• Those women who are BRCA1 and BRCA2 positive should have a prophylactic
bilateral salpingo-oophorectomy at age 35 or after completion of childbearing.
This reduces the risk by 90%, although these women remain at risk for primary
peritoneal carcinoma.

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Uterine
Cancer
• Is the most common gynecologic malignancy in developed countries.
Adenocarcinoma of the endometrium is the most common type. Average age
at diagnosis is 61.
• Risk factors include: unopposed estrogen, tamoxifen therapy, obesity,
diabetes mellitus, advanced age, polycystic ovarian disease, nulliparity, late
menopause.
• Lynch syndrome increases the lifetime risk of developing this cancer. It is recommended
that these women have a total hysterectomy to reduce their risk after they have finished
having children. These women should be screen yearly with an endometrial biopsy
starting at age 30 or 5-10 years before the earliest age at diagnosis of a lynch syndrome
related malignancy in the woman’s family. Other than these women routine screening is
not recommended.

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Uterine
Cancer
• Clinical Features
• The most common presenting symptom is abnormal vaginal bleeding, mainly in
the post menopausal woman. Any bleeding (spotting or staining or otherwise) in
a post menopausal woman should be evaluated for endometrial cancer.
• Women age 45 to menopause who have bleeding between menses, or heavy bleeding
(> 80ml) or prolonged menses (> 7days) should be evaluated for endometrial cancer.
• Women younger than age 45 with abnormal bleeding which occurs in the setting of
unopposed estrogen exposure (obesity, chronic anovulation) or failed medical
management of bleeding or in women at high risk of cancer (i.e. has lynch
syndrome)

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Uterine
Cancer
• Evaluation
• Pelvic examination
• Women of child bearing age should have a pregnancy test
• Pelvic sonogram is the first line diagnostic and if the endometrial lining is < 4mm in a post
menopausal woman a endometrial biopsy is not required. However for ongoing bleeding a biopsy
should be performed even if the endometrial lining is < 4mm.
• Endometrial biopsy
• Treatment
• In the early stages is a hysterectomy is the treatment of choice and adjunctive chemotherapy is not
required.
• Chemo and radiation may be require in advanced stages.

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Multiple
Myeloma
• Is a hematologic malignancy characterized by the malignant transformation
and proliferation of plasma cells in the bone marrow. Often these
malignant plasma cells migrate to the bones and cause osteolytic lesions,
osteopenia and pathologic fractures.
• Multiple myeloma accounts for 1% of all cancers and more than 17% of
hematologic malignancies. It occurs 2-3 times more often in African
Americans than in Caucasians. The risk is lower in Asians from Japan and
in Mexicans. It does occur more frequently in men than women.
Typically occurs between the ages of 50-70. Median age of diagnosis is
66.

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Multiple
Myeloma
• Clinical Manifestations:
• The manifestations result from an infiltration of the malignant cancer cells into the bones or
other organs.
• Multiple myeloma should be suspected when the individual presents with any of the
following:
• Bone pain with lytic lesions seen on routine imaging. Vertebrae are the most common bone sites
affected by the disease. Other bone affected include skull, ribs, femur, and pelvis.
• An increase in total serum protein concentrations
• The present of a monoclonal protein in the urine or serum
• Hypercalcemia
• Acute kidney injury
• Additional symptoms include: normocytic anemia, paresthesias, hepatomegaly,
splenomegaly, lymphadenopathy, fever, weight loss, fatigue, and weakness.

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Multiple
Myeloma
• Individuals with suspected multiple myeloma should be evaluated quickly. A delay in the
making the diagnosis has been associated with negative outcomes.
• Evaluation
• Chemistry
• Obtain a urinalysis. In MM there will be large, waxy, laminated casts. The urine dipstick is usually negative for
protein.
• CBC with peripheral smear. The smear will show leukopenia, thrombocytopenia and rouleaux formation. This is when
the RBCs look like a stack of coins.
• Serum free monoclonal light chain analysis. Will be positive in 20% of person with MM.
• SPEP and UPEP via 24 hour urine, both of which can detect the presence of the monoclonal protein (M protein), which is
characteristic of MM. This is a protein which is produced and released by the malignant cells in 97% of patients.
• Bone marrow biopsy
• Plain radiographs of the painful boney areas. CT/MRI/Pet scans are reserved for persons who have bone pain but a negative
radiograph.

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Multiple
Myeloma
• Diagnostic Criteria
• Clonal bone marrow plasma cells ≥ 10% or a biopsy proven bony or soft tissue
plasmacytoma plus one of the following
• Presence of related organ or tissue impairment
• Presence of a biomarker associated with near inevitable progression to end organ
damage.
• Treatment
• Initially all persons are treated with induction therapy (chemotherapy). Those
eligible for a bone marrow transplant will receive one. If they are not they will
continue with chemotherapy.

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Testicular Cancer
• This is the most common type of cancer in men age 15-35, however it only represents 1%
of cancers in men.
• The survival/ cure rates are relatively high even when the disease is diagnosed in an
advanced stage. It is 90% or higher.
• Risk factors include:
• Occurs most commonly between ages 15-35
• Family history of testicular cancer
• Undescended testicle
• Inguinal hernia
• Infertility

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Testicular Cancer
• Disease presentation
• Presents as a painless, hard, heavy, firm testicular mass.
• May become painful if the tumor begins to hemorrhage inside of itself
• The tumor does not transilluminate
• May present with signs of metastasis
• Neck mass- supraclavicular lymph node mets
• Back pain secondary to mets to the retroperitoneum
• Anorexia, nausea, vomiting or GI hemorrhage- mets to the retroduodenal metastasis.
• Cough or Dyspnea- mets to the lung

• Physical exam
• Check the abdomen and chest for any signs of metastasis
• Check for gynecomastia
• Check for supraclavicular lymphadenopathy which may indicate intrathoracic
malignancy.

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Testicular Cancer
• Evaluation of a testicular mass
• A scrotal US
• It can see intra-testicular lesions as small as 1-2mm.
• It can distinguish between extra-testicular masses and intra-testicular masses. Intra-testicular masses are most commonly malignant.
• A cyst or fluid filled mass is not likely to be cancerous.
• Seminomas- are well defined, hypoechoic lesions with cystic areas
• Nonseminomatous germ cell tumors- are inhomogeneous with calcifications, have cystic areas, and indistinct margins.
• If a diagnosis of Testicular is made, then a CT of the Abdomen and pelvis, and CXR should be completed to evaluate for
metastasis.
• HCG, AFP and LDH tumor markers should be done as part of the evaluation of a testicular mass, especially if you suspect cancer.
• If HCG > 10,000 or the person has multiple lung lesions a CT of the head needs to be completed because they are at a high risk
for brain mets.

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Testicular Cancer
• Treatment is dependent upon the histologic subtype. Usually
involves chemotherapy, sometimes surgery.
• Prior to doing radiographic evaluation and treatment for a male patient with testicular
cancer the patient should be offered cryopreservation of sperm and one should
discuss saving his sperm prior to radiation exposure if the patient wishes to preserve
fertility.
• Complications
• Bone mets is common but not as common as from prostate cancer.
• Spinal cord compression, SVC Syndrome

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Testicular Cancer
• Screening and Prevention
• Testicular Self Examination
• USPSTF- recommends against testicular examination by the clinician or the patient.
• American Academy of Physicians and the American Academy of Pediatrics do not recommend screening for
testicular cancer in asymptomatic males.
• American Cancer Society- does not have a recommendation on regular self-examination but recommends that men
with a family history, a history of undescended testicle, or previous testicular cancer consider doing self-
examinations.
• Routine Screening
• It is not recommended.
• There is no data on the effectiveness (sensitivity or specificity) of testicular self-examination.
• Biomarkers such as HCG or AFP. They are tumor markers and are elevated in 80-85% of testicular cancers, but they
do not have sufficient sensitivity or specificity to be used as a screening tool.

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Testicular Cancer
• Clinical Pearl
• A testicular mass in a male patient age 60 and over should be considered testicular
lymphoma until proven otherwise. This is the most common cause of testicular
masses in this age group.

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TNM
Staging
• This system is used to classify the size of the tumor, the degree of local invasion and the
extent of distant metastasis. Diagnostic tests such as CT scan, MRI, bone scans assist
with staging.

• Review the following website. The link is provided in blackboard

• http://www.cancer.gov/about-cancer/diagnosis-staging/staging/staging-fact-sheet#q3
• What are the common elements of staging systems?
• What is the TNM System?
• Are all cancers staged with TNM Classifications?

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Patterns of
Metastasis
• Metastasis occurs as direct invasion, hematogenous spread or via the lymphatic
system
• Sites of Metastasis
• Bladder- bone, liver lung
• Breast- bone, brain, liver, lung
• Colorectal –liver, lung, peritoneum
• Kidney- adrenal gland, bone, brain, liver, lung
• Lung- adrenal gland, brain, liver, bone
• Melanoma- bone, brain, liver, lung, skin, muscle
• Ovary- liver, lung, peritoneum
• Pancreas- liver, lung, peritoneum
• Prostate- adrenal gland, bone (commonly to vertebrae), liver, lung
• Stomach- liver, lung, peritoneum
• Testicular- lungs, liver, brain
• Thyroid- bone, liver, lung
• Uterus- bone, liver, lung, peritoneum, vagina

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Tumor
Markers
• Substances produced by the cancer cells that are found on tumor plasma membranes
or in the blood, spinal fluid or urine.
• Are used to help diagnose, detect, or manage some cancers.
• A decrease may mean the cancer is responding to treatment and a resurgence of the
marker may mean recurrence of the cancer. No change in the marker may mean the
cancer is not responding to treatment.
• They are not good screening tools and should not be used as such.

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Tumor Marker Indicator Lab Value

Alph -fetoprotein Hepatocellular Normal range 1-15ng/ml

a Carcinoma Testicular
Cancer
Carci oembryonic Antigen (CEA) Colorectal Cancer Levels > 50ng/ml consistent with cer
n can

Beta Hu man Chorionic Gonadotropin (b- Choriocarcinoma, teratomas, seminomas Normal range < 5mlU/ml
HCG)

Prosta te Specific Antigen Prostate cancer Levels > 4.0ng/ml consistent

with malignancy

CA- 5 Ovarian cancer Normal < 35U/ml

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CA1 -9 Pancreatic cancer, gall bladder cancer Normal < 37.0U/ml
9 and bile duct cancer

CA1 -3 Breast cancer Normal < 30U/ml

5

CA27-29 Breast cancer Normal < 38U/ml

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Metastatic
Work up
• Metastatic evaluation involves the search for a site of distant metastasis when
the primary site of cancer is known. The evaluation will typically call for a
CT of the head, CT of chest or CXR, CT of the abdomen and pelvis and/or a
bone scan. Allow the clinical scenario to help guide the evaluation.
• Normal calcium, normal alkaline phosphatase, and no bone pain you do not need a
bone scan at this point
• Most commonly you will need to scan the head, chest, abdomen and pelvis. Typically, a
CXR is enough for screening but if a mass is identified a CT will need to be completed.
Generally, you will use contrast. Contrast is contraindicated with elevated creatinine.
• Hemorrhagic brain tumors should be ruled out prior to initiating anticoagulation for DVT
prevention or treatment.

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Diagnosis of Unknown
Primary
• Cancer of unknown primary is defined by a pathologically confirmed site of mets and the primary site is not
known.
• Is rare and more commonly affects men. Prognosis is poor
• Diagnostic evaluation
• H&P including rectal exams, pelvic exams, breast and testicular exams. Identify possible risk factors
• Labs: CBC, CMP, UA, urine cytology
• Serum tumor markers may help identify the primary source
• Tissue biopsy of the site of metastasis (core or excisional biopsy)
• CT of thorax, abdomen, pelvis
• Positron emission tomography (PET scans)
• Reveal highly metabolically active tissues
• Can be used with CT scans
• Their use us debatable.
• Endoscopic evaluations
• Colon, EDG, bronchoscopy, laryngoscopy
• In women the evaluation should include a mammography and pelvic examination.
• Goal of evaluation is to identify the most appropriate treatment

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Oncological
Emergencies
and
Complications

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Neutrop
enia
• Results from chemotherapy adverse reactions or from aplastic anemia or leukemia, or radiation therapy
• Defined as a ANC < 1500/mcl
• This definition will vary but this is what we will use for our purposes.
• Absolute neutrophil count (ANC)
• Is used to determine immune status
• ANC = WBC x (% neutrophils + %bands) x 1000
• < 500 significant risk of infection (severe neutropenia)
• <100 high risk of infection within days (profound neutropenia)
• Count is used to determine when to order granulocyte stimulating factor (neupogen) which is typically not ordered unless the count is <
500.
• The risk of infection increases if the neutropenia lasts > 7days and/or with a count < 500.
• Risk of infection by gram positive and negative bacteria and fungi. The risk increases for bacteremia when the ANC is < 500.
• Fever in the setting of neutropenia is always considered to be infectious and should be treated.

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Neutropenic
•
Fever
Fever in the setting of an ANC < 500 or < 1000 if the nadir has not been reached. The infectious disease association defines it as isolated fever of 101 or a fever
of
100.4 that has been sustained for an hour.
• Is considered a medical emergency and infectious until proven otherwise
• Most common presentation is fever
• The Multinational Association for Supportive Care in Cancer Score is a scoring system used to identify the risk of complications from neutropenic fever and is used
to help stratify patients.
• High risk patients are those with ANC < 500 for > 7 days
• With a Multinational Association for Supportive Care in Cancer Score of < 21
• Low risk patients are those with ANC < 500 for ≤ 7 days
• With a Multinational Association for Supportive Care in Cancer Score ≥ 21.

• Diagnosis
• H&P with good ROS
• CXR, UA, Urine culture, Blood cultures
• CBC, CMP, Procalcitonin if available
• Assess central access for infection

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Neutropenic
Fever
• Management
• Initiate empiric antibiotic therapy for high risk patients
• Make sure to provide broad coverage. Gram negative organisms are the most common cause
but you should provide broad coverage.
• Antibiotics should be initiated after blood cultures have been obtained and within 60
minutes of presentation of symptoms.
• Fungal pathogens are more common in high risk patients with prolonged, persistent
neutropenic fevers
• Initiate empiric antifungal if still febrile at 4 days, if a new fever develops after it got better, or
new pulmonary infiltrates appear during therapy
• Lipid formulation of amphotericin B, caspofungin, voriconazole, itraconazole

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Neutropenic
Fever
Management
• Bacterial coverage
• Antipseudomonal beta lactam
• Cefepime, meropenem, imipenem-cilastatin, piperacillin-tazobactam
• May add other agents (aminoglycoside, fluoroquinolone or vancomycin) if the patient
presents with complications such as hypotension, mental status changes, focal findings
such as pneumonia or cellulitis or if antimicrobial resistance is suspected or proven
• Low risk patients may be treated outpatient with oral cipro in combination
with a beta lactam agent such as Augmentin.

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Tumor Lysis
Syndrome
• Results from the rapid breakdown of cells and usually occurs as result of cancer treatment.
• The cell lysis (cancer) releases large amounts of nucleic acid, phosphorus and potassium into the blood.
• The catabolism of nucleic acids leads to hyperuricemia and increased renal excretion of uric acid. This can trigger
renal vasoconstriction, decreased renal blood flow, and inflammation. All of which lead to AKI.
Hyperphosphatemia leads to calcium phosphate deposition in the renal tubules and can also cause AKI.
• Mostly seen with lymphomas, acute lymphoblastic leukemia, chronic leukemia. Not as common with solid tumors.
Clinical manifestations are largely related to the electrolyte imbalances.
• Clinical Risk factors for Tumor lysis syndrome
• Pretreatment hyperuricemia (uric acid > 7.5 mg/dL)
• Preexisting nephropathy or exposure to nephrotoxins
• Oliguria or acidic urine
• Dehydration, volume depletion, inadequate hydration during chemotherapy.

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Tumor Lysis
Syndrome
• Clinical manifestations include lab abnormalities, nausea, vomiting,
diarrhea, anorexia, lethargy, hematuria, heart failure, cardiac
dysrhythmias, seizures, muscle cramps, tetany, syncope, AKI, and sudden
death.

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Tumor Lysis
Syndrome
• Laboratory Diagnostic criteria (2 of the following within 3 days before or
7 days after chemotherapy)
• Uric acid ≥ 8 mg/dl or 25% increase above baseline
• Potassium ≥ 6 mEq/L or 25% increase above baseline
• Phosphorus ≥ 6.5 mg/dl or 25% increase above baseline
• Calcium ≤ 7mg/dl or 25% decrease from baseline

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Tumor Lysis
• Management
• Monitor electrolyte imbalances and treat
accordingly
•
•
Syndrome
Monitor electrolytes every 4-6 hours

Rasburicase (Elitek) IV should be ordered if it was not given as prophylaxis.

• This is a urate oxidase agent which converts uric acids into an inactive metabolite.

• Given for 1-7 days depending on the patient’s response.

• Box warnings:

• RBC hemolysis. Contraindicated in persons with G6PD deficiency.

• Fatal hypersensitivities have been reported

• Development of methemoglobinemia

• Do not use this medication when using sodium bicarbonate.

• IV Hydration is the main treatment, up to 3000ml/m 2/day

• Use loop diuretics in patients with low urine output < 2ml/kg/h

• Cardiac monitoring

• Use phosphate binders & dialysis if not working

• Do not treat hypocalcemia until the hyperphosphatemia is treated, to avoid calcium/phosphorus precipitation

• Standard hyperkalemia treatments

• Bicarb for metabolic acidosis

• Prevention
• Use allopurinol for persons at intermediate risk of TLS. Use rasburicase for those at high risk of TLS.

• IV hydration, aggressive hydration is the cornerstone of preventing TLS. Should be given to patients who are at intermediate or high risk of developing
TLS.

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Superior Vena Cava

Syndrome
• Results when tumor expansion results in obstruction of the superior vena cava and
prevents the return of blood to the heart from the head, neck and upper extremities.
• Most commonly seen with lung cancer. May occur with lymphoma and primary
mediastinal tumors.
• Clinical presentation
• Neck and facial swelling, venous distention of the neck and chest wall veins.
• Headache, dyspnea, dysphagia, hoarseness, cough
• Becomes emergent when there are issues with dyspnea
• CXR-mediastinal widening

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Superior Vena Cava

Syndrome
• Diagnosis
• Clinical exam
• Diagnostic imaging
• In persons with life threatening symptoms, the preferred evaluation is catheter-based venography as it
provides the most expedient method for diagnosis and an opportunity for treatment.
• In persons with mild to moderate symptoms a duplex ultrasound is used to rule out a thrombosis in
the subclavian, axillary and brachiocephalic veins. It is the initial test that should be done for
anyone with an indwelling device or a malignancy at low risk for SVC.
• CT of chest with contrast can be used in persons with mild to moderate symptoms with a malignancy
that is known to be associated with SVC. The presence of collateral vessels on CT is a strong indicator
of SVC syndrome.
• A biopsy should be obtained if the patient does not have a known cancer diagnosis.

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Superior Vena Cava

Syndrome
• Management
• Ensuring the airway is your first priority. Persons with airway compromise (stridor)
require immediate, emergent treatment with endovenous recannulization with SVC stent.
Radiation is no longer recommended as emergent treatment. Without this symptom, you
have time to evaluate the patient and it is not considered emergent. The obstruction
tends to occur over weeks and the most important thing in a stable patient is to get a
histologic diagnosis.
• If there is no respiratory compromise it is not an emergency
• Stent placement is an option for a person requiring urgent intervention. Stent placement
is associated with relief in 95-100% of patients.
• Chemotherapy or radiation. Oncology must manage the chemotherapy and radiation
oncology must manage the radiation.

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Hyperleuko
cytosis
• Defined as the presence of a WBC > 50,000 to 100,000 This results in a leukostasis,
impaired microcirculation and tissue hypoxia. High mortality
• Most commonly associated with acute myelogenous leukemia and chronic myeloid
leukemia. It may occur in ALL, but is not very common.
• Clinical presentation
• Headache, blurry vision, confusion, ischemic stroke with hemorrhage conversion, heart failure,
NSTEMI, acute kidney injury, DIC
• Dyspnea and hypoxia
• CNS symptoms may indicate intracranial hemorrhage. They are at an increased risk of
intracranial hemorrhage, until at least one week post resolution of the crisis.
• Many patients will experience a spontaneous tumor lysis syndrome

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Hyperleuko
cytosis
• Management
• Consult Hematology/Oncology
• Patient should receive emergent chemotherapy. Treatment to prevent tumor lysis syndrome should
be given.
• Hydroxyurea may be given for treatment if the patient is unable to start emergent
chemotherapy. Remember to give treatment to prevent TLS.
• Emergent initiation of chemotherapy if diagnosis is known
• Leukapheresis –controversial but used as a temporary measure. Should be used in persons who
cannot receive emergent chemotherapy.
• Correct coagulopathies, do not give any RBC transfusions. This will trigger symptomatic
leukostasis. Give platelet transfusion to keep the counter at 20,000 to 30,000 microL.

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Chemotherapy Complications /Adverse

Effects
• Chemotherapeutic drugs have many toxicities and affect many body systems. Below is a list, which is
by no means comprehensive, of the many side effects which may result from cancer chemotherapy.
• Pancytopenia (neutropenia, anemia, thrombocytopenia), Cardiomyopathy/ heart failure
• Liver toxicity, Pulmonary edema
• Respiratory failure, Nausea and vomiting
• Stomatitis, diarrhea, Nephropathy, Neuropathy
• Alopecia, Hepatotoxicity
• Hearing loss, Myocardial ischemia
• DVT /PE, Leukemia
• Hemorrhagic cystitis

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Chemotherapy Complications /Adverse

Effects
• Certification is now asking questions about specific side effects of specific
chemotherapeutic agents. Please know these medications and their side
effects.
• Cyclophosphamide (Cytoxan)- alopecia, myelosuppression, hemorrhagic cystitis, cardiotoxicity in high doses
• Ifosfamide (Ifex)-alopecia, myelosuppression, hemorrhagic cystitis, neurotoxicity
• Carboplatin (Paraplatin)- myelosuppression, electrolyte imbalances, peripheral neuropathy, nephrotoxicity
• Cisplatin (Platinol)-myelosuppression, electrolyte imbalances, peripheral neuropathy, nephrotoxicity
• Methotrexate (MTX)- myelosuppression, nephrotoxicity, hepatoxocitiy, neurotoxicity, photosensitivity, pulmonary
toxicity
• Dacarbazine (DTIC)- photosensitivity, myelosuppression, anorexia, hypotension, flu-like symptoms
• Cytarabine (Ara-C)-N/V, rash, flu like symptoms,. Myelosuppression, neurotoxicity, ocular toxicity

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Chemotherapy Complications /Adverse

Effects
• Know these medications too.
• Fluorouracil (5-FU) – diarrhea, myelosuppression, mucositis, photosensitivity, cardiotoxicity
• Gemcitabine (Gemzar)- N/V, rash, flu like symptoms, fever, diarrhea, myelosuppression, edema, elevated transaminases
• Vinblastine (Velban)- constipation, myelosuppression, alopecia, bone pain, malaise, toxic effects on the colon
• Vincristine (Oncovin)- constipation, toxic effects on the colon, peripheral neuropathy, alopecia
• Paclitaxel (Taxol) -diarrhea, myelosuppression, peripheral neuropathy, alopecia, edema, mucositis
• Danuorubicin (Cerubidine)- N/V, diarrhea, red/orange urine, myelosuppression, dose related cardiotoxicity
• Doxorubicin (Adriamycin) - N/V, diarrhea, red/orange urine, myelosuppression, dose related cardiotoxicity
• Etoposide (Vepesid)- N/V, diarrhea, fever, hypotension, myelosuppression, alopecia, fatigue

• You do not order chemotherapy drugs, unless you work for an oncologist and are trained to do
this.
• Important that you assess any cancer patient that you are working with for the type of chemo,
assess for side effects and determine where they are in their cycle.

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Hypercal
cemia
• Hypercalcemia related to malignancy can be very resistant to
treatment. Review treatment in your fluid and electrolyte lecture
from N5461.

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Spinal Cord
Compression
• Compression most commonly occurs as a result of mets from lung, breast, prostate
cancers.
May occur in Non Hodgkin’s lymphoma, multiple myeloma, and renal cancers.
• Early recognition is important. Restoration of neurologic function is related to the
degree of neuro damage. Early recognition can minimize damage.
• Clinical Presentation
• New onset of back pain in any cancer patient must be evaluated and considered malignant spinal
cord compression. Most commonly affects the thoracic spine.
• Pain usually precedes the onset of any neurologic symptoms by seven weeks. Pain tends to be
worse at night and over time will become radicular in nature. Pain present only on movement is
indicative of spine instability. Neuro symptoms will be dependent upon the level of the spinal cord
affected. Urinary retention may occur. Bowel and bladder dysfunction are late findings.

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Spinal Cord
Compression
• MRI of the entire spine is the diagnostic test of choice. Should be performed with
and without contrast.
• Consultations required by oncology, neurosurgery, radiation oncology
• Treatment
• Dexamethasone 10mg IV bolus then 16 mg total daily dosing in divided doses. Ongoing doses
may be given IV or PO.
• Pain control
• VTE prophylaxis- using LMWH or heparin
• Surgery may be needed. It is generally indicated for instability. Radiation may be able to avoid the
need for surgery. This means you will need to consult neurosurgery and radiation oncology.

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Other
complication
s
• Increased Intracranial Pressure
• Observe for neurologic symptoms
• Treated with dexamethasone
• SIADH- review in endocrine lecture
• DIC – review in disorders of hemostasis
• Septic shock- will be reviewed in the sepsis
lecture

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Geriatric
Considerations
• The overall incidence of cancers as a whole tends to increase with age. So we
tend to see many elderly patients with a cancer diagnosis.
• The treatment for many cancers is very potent and has many toxicities and in
the elderly patient they are likely to be more sensitive to the toxicities.
• Additionally, given that this patient population tends to have higher morbidity
than their young counter parts treatment can potentially be even more
challenging. One must consider the renal function, hepatic function, the patient
nutritional status, functional status in order to determine if curative treatment
is an option or if the risk benefit ratio is worth it.

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