Medical Problems And Emergencies In Oncology

Front 1

common types of problems and etiologies

Back 1

1. anemia
2. leukopenia
3. pain
4. depression
5. metabolic derangements
6. tumor impingements

Front 2

Medical problems

Back 2

1. obstruction
2. Secondary neoplasm
3. infertility
4. hypothyroidism
5. DVT/PE- primary sequela as well as a complication in cancer
6. lymphedema
7. anorexia
8. Cachexia
9. Fatigue- MOST COMMON
10. anxiety/insomnia
11. N/V- almost completely eliminated

Front 3

Cachexia

Back 3

-chronic disease which may occur in pts despite adequate caloric intake
-pts may experience poor wound healing secondary to decrease protein stores

Front 4

Complications of Radiation therapy

Back 4

1. early effects: during tx or within the first few wks after its completion
2. intermediate effects: several wks-months after completion
3. late effects: rare but may occur many months to yr later

Front 5

the incidence and severity of nml tissue toxicity from RT depend on...

Back 5

1. total dose
2. fraction size
3. interval b/t fractions
4. quality and type of RT
5. dose rate
6. intrinsic radiosensitivity
7. specific tissue irradiated

Front 6

Common radiotherapy toxicities

Back 6

1. oral mucositis
2. erythema and desquamation of skin
3. ulceration/necrosis
4. chronic skin changes
5. esophagitis
6. xerotomia
7. thick saliva
8. radiation pneumonitis
9. diarrhea/N/V (radiation to rectal or GI system)

Front 7

Febrile Neutropenia

Back 7

-low WBC with fever causing risk of life threatening infxs
-any pt receiving chemo is at risk
-nml WBC (4.5-11) nml ANC (1.8-7.7)
-neutropenia: dec # of neutrophils in blood by evidence of ANC<1
-ANC = absolute neutrophil count

Front 8

work-up for Febrile Neutropenia

Back 8

1. CBC
2. Blood cultures x 2
3. UA
4. stool cultures
5. CXR (however, if no WBCs infx might not be apparent on x-ray)

Front 9

tx for febrile neutropenia

Back 9

1. admit pt (isolateD)
2. diet
3. immediate initiate broad spectrum abx

Front 10

DIC

Back 10

-a complex systemic thrombohemorrhagic disorder (forming of clots and bleeding)

Front 11

risk factors for DIC

Back 11

1. most common malignancies associated with DIC are AML & mucin producing adenocarcinomas such as colon cancer
2. infx (sepsis) = MOST COMMON
3. trauma
4. transfusion
5. obstetric (s/p delivery, eclampsia)

Front 12

DIC ssx

Back 12

-widespread systemic thrombosis and bleeding
1. petechiae
2. ecchymosis
3. fever
4. thrombosis
5. end organ damage

Front 13

DIC diagnosis

Back 13

-no single test exists: clinical correlation with following combo of tests:
1. inc PT/PTT
2. inc D-dimer
3. increase fibrin degradation products
4. decreased fibrinogen
5. decreased plts
6. decreased H&H

Front 14

DIC tx

Back 14

-GOAL is to treat underlying cause!
1. supportive care
2. bleeding
3. thrombus

Front 15

DVT/PE risk factors

Back 15

1. malignancy alone
2. tx for cancer (Tamoxifen, megace)
3. immobility
4. smoking
5. obesity
6. pregnancy

Front 16

DVT/PE ssx

Back 16

1. lower extremity swelling, tenderness, erythema, warm to touch (unilateral)
2. can occur in upper extremity as well
3. fever
4. SOB
5. tachycardic

Front 17

DVT/PE diagnosis

Back 17

1. dopple/US for DVT
2. V/Q scan for PE
3. D-dimer
4. PT/PTT

Front 18

DVT/PE treatment

Back 18

1. acute: heparin drip (can start oral warfarin min 4 days after heparin)
2. DVT - treat for 3 months
3. PE - treat for 6 months

Front 19

Spinal cord compression

Back 19

-most commonly seen in lung, breast, prostate & renal cancer, as well as, multiple myeloma
-sites of involvement:
1. thoracic spine- MOST COMMON SITE
2. lumbosacral
3. cervical

Front 20

spinal cord compression- ssx

Back 20

1. Pain- 90% of patients have pain localized to area of spine or radicular in nature and can proceed for months prior to neurological symptoms
2. pt may come in with sudden onset of upper or lower extremity weakness or gait instability

Front 21

spinal cord compression dx

Back 21

1. high index of suspicion if hx of malignancy with back pain
2. neurology/muscle/reflex exam
3. MRI most sensitive test

Front 22

spinal cord compression tx

Back 22

1. radiation therapy
2. dexamethazone
3. surgery
4. chemotherapy

Front 23

Malignant pleural effusion

Back 23

-approx 40% of pleural effusions are due to malignancy
-anywhere from 10% to as high as 50% have as initial presentaion
-most common malignancies: Lung, Breast, unknown primary, lymphoma

Front 24

pleural effusion ssx

Back 24

1. dyspnea
2. cough
3. pain ranging from dull, aching, heaviness to sharp pleuritic chest pain
4. decreased breath sounds on exam with dullness to percussion

Front 25

pericardial effusion/tamponade

Back 25

-cardiac compression can occur due to pericardial effusion secondary malignancy or radiation fibrosis

Front 26

pericardial effusion/tamponade dx

Back 26

Pleural effusion:
1. CXR- PA/lateral decubitus initially
2. CT scan with contrast
3. Thoracentesis
pericardial effusion:
1. if also suspect malignant pericardial effusion & tamponade is suspected, need echocardiogram
2. pericardiocentesis

Front 27

pericardial effusion/tamponade tx

Back 27

1. thoracentesis
-needed for cytopathologic analysis
-effusions occupying >50% of pleural cavity require gradual drainage with pleurovac
2. Pleurodesis
-for recurrent pleural effusions, sclerosing agent can be placed in pleural space

Front 28

Superior Vena Cava Syndrome (SVC)

Back 28

-compression/obstruction by mass or thrombus of the SVC
-SVC located b/t rigid structures of chest wall-susceptible to obstruction
-low intravascular pressures- prone to thrombus formation
-Causes: malignancy MOST COMMON: bronchogenic carinoma, lymphoma

Front 29

SVC syndrome ssx

Back 29

1, dyspnea
2. upper extremity and facial swelling
3. cough
4. HA
5. lightheadedness/LOC

Front 30

SVC syndrome tx

Back 30

1. mgmt of ABCs
2. steroids
3. radiaiton therapy
4. chemo
5. anticoagulation

Front 31

Tumor lysis syndrome

Back 31

-caused by a rapid breakdown of cells with release of intracellular contents in life threatening concentrations
-characterized high serum uric acid levels and abnml electrolytes with subsequent renal failure
-Occurs after initiation of chemotherapy & RT causing the destruction of cancer cells
-Most commonly seen in hematological cancers (leukemia's & lymphomas)

Front 32

tumor lysis syndrome ssx

Back 32

1. vague sx of weakness and fatigue, overall not feeling well
2. abnml lytes on routine f/u after chemo is often first sign

Front 33

tumor lysis syndrome dx

Back 33

1. Increase serum uric acid
2. Hyperkalemia
3. Hyperphosphatemia
4. Increase BUN/Creatinine
5. Hypocalcemia

Front 34

tumor lysis syndrome tx

Back 34

-Allopurinol- decreases both serum & uric acid levels
-Most leukemic and Lymphoma patients start allopurinol prophylactic ally prior to chemotherapy initiation continuing for minimum of 7 days
-aggressive hydration

Front 35

SIADH (Syndrome of Inappropriate Secretion of Antidiuretic Hormone)

Back 35

-Characterized by increased plasma concentrations of ADH resulting in water retention leading to hyponatremia
-A paraneoplastic condition most commonly seen in Small Cell Lung Cancer
-Other risk factors include medications that impair free water excretion by acting on the renal tubule directly or by inducing vasopressin secretion (morphine, cytoxan, vincristine, steroids)

Front 36

SIADH ssx

Back 36

1. HA
2. anorexia
3. N/V
4. confusion can occur with levels sodium levels b/t (115-120 mEq/L)
5. disorientation, stupor, coma, seizures can occur at levels below 110

Front 37

SIADH dx

Back 37

1. hyponatremia
2. PMHX
3. careful medication hx
4. ADH levels

Front 38

SIADH tx

Back 38

-goal is to rapidly diuresis pt while replacing Na and K
-lasix 1mg/kg BW
-NS with added potassium should not excess 20 mEq/L during first 48 hours
-too rapid of a correction can cause neuro damage and central pontine myelinolysis

Front 39

hypercalcemia

Back 39

-One of the most common metabolic emergencies seen in cancer patients
-Predominately seen with multiple myeloma, lymphoma, prostate, breast, lung & renal cancers.

Front 40

hypercalcemia ssx

Back 40

1. fatigue
2. weakness
3. nausea/vomiting,
4. dehydration
5. constipation
d6. yspepsia

Front 41

hypercalcemia dx

Back 41

-nml serum calcium should be (8.5-10.5)
-dec PTH
-low/nml phosphorus
-low/nml 1,25-dihydroxy vit D
-EKG may show short QT interval, prolonged PR interval, wide T waves, atrial or ventricular arrhythmias

Front 42

hypercalcemia tx

Back 42

-If hypercalcemia is <12.0 mg/dL no need for admission, treat with low calcium diet, increase PO fluid intake
-Patients with Calcium levels >12.0 mg/dl should be admitted for rapid hydration
-Hydrate with NS
-Bisphosphonates (Aredia, Zometa), loop diuretics