oncologic challenges in the ed (besides not getting the old chart from tbcc) grand rounds gord...

Oncologic challenges Oncologic challenges in the EDin the ED

(besides not getting the old chart from TBCC)(besides not getting the old chart from TBCC)

Grand RoundsGrand Rounds

Gord McNeilGord McNeil

6 Cases6 Cases

ApproachApproach

ManagementManagement

Calgary perspectiveCalgary perspective

Case 1Case 1

52 year old female with breast cancer 52 year old female with breast cancer presents to the ED with mid back presents to the ED with mid back discomfort, progressive weakness of left discomfort, progressive weakness of left leg X 1 week and today urinary leg X 1 week and today urinary incontinenceincontinence

Recent radiation at TBCC (no old chart Recent radiation at TBCC (no old chart available)available)

ApproachApproach

PhysicalPhysical T=37.3 Hr=92, RR=14, BP=172/89T=37.3 Hr=92, RR=14, BP=172/89 Decreased sensation left abdominal wall and Decreased sensation left abdominal wall and

right lower leg right lower leg Decreased power at right knee and ankleDecreased power at right knee and ankle

LabsLabs Hg=109, Plts =302, WBC =6.8, normal lytes Hg=109, Plts =302, WBC =6.8, normal lytes

and INR.and INR.

Differential diagnosisDifferential diagnosis

Epidural abscessEpidural abscess

Epidural hematomaEpidural hematoma

Metastatic spinal cord compressionMetastatic spinal cord compression

Routine causes of back painRoutine causes of back pain

TreatmentTreatment

Dexamethasone IV 10mg Dexamethasone IV 10mg priorprior to MRI, to MRI, then 4-8 mg q6-8hours then 4-8 mg q6-8hours

Emergent MRI of entire spine (because pt Emergent MRI of entire spine (because pt can have synchronous, multifocal, can have synchronous, multifocal, asymptomatic MSCC.asymptomatic MSCC.

TreatmentTreatment

Call Spine serviceCall Spine service Decompression of spinal cord is the key to Decompression of spinal cord is the key to

salvage of functionsalvage of function

Patchell et alPatchell et al2 2 in 2005 - radiation for 10 in 2005 - radiation for 10 days and decompressive surgery within 24 days and decompressive surgery within 24 hours improved outcomes of ambulation, hours improved outcomes of ambulation, continence and functional abilities from continence and functional abilities from 84% compared to radiation alone for 57%84% compared to radiation alone for 57%

Metastatic spinal cord compressionMetastatic spinal cord compression

CausesCauses breast(30%), breast(30%), lung (15%) lung (15%) prostate (15%)prostate (15%) OtherOther

SitesSites thoracic, then lumbar then cervicalthoracic, then lumbar then cervical

MSCC - causesMSCC - causes

1.1. Expansion of vertebral bone metastasis into Expansion of vertebral bone metastasis into epidural space causing cord compressionepidural space causing cord compression – – radiation helpsradiation helps

2.2. Neural foramina extension by a paraspinal Neural foramina extension by a paraspinal mass. mass. – radiation helps– radiation helps

3.3. Destruction of vertebral cortical bone Destruction of vertebral cortical bone --requires surgical intervention.requires surgical intervention.

PrognosisPrognosis

Start of onset of symptoms:Start of onset of symptoms:Onset:Onset: 1-7 days1-7 days 8-14days8-14days >14 days>14 daysAmbulate: 35%Ambulate: 35% 55% 55% 86% 86% (1)(1)

Faster onset = worse prognosisFaster onset = worse prognosis

Start of therapy:Start of therapy:dexamethasone and time to surgerydexamethasone and time to surgery

Favorable histology - radiosensitive tumorsFavorable histology - radiosensitive tumors

TreatmentTreatment

Radiation only arrests the progression of Radiation only arrests the progression of nonradiosensitive tumors and does not nonradiosensitive tumors and does not stabilize the spinestabilize the spine

Surgery allows immediate cord Surgery allows immediate cord decompression whereas radiotherapy decompression whereas radiotherapy typically takes several days to weeks.typically takes several days to weeks.


Radiation oncology – Dr. Elizabeth YanRadiation oncology – Dr. Elizabeth Yan

Radiation did have an important initial role Radiation did have an important initial role prior to 2005. Now acute surgical prior to 2005. Now acute surgical decompression and post op radiation is the decompression and post op radiation is the standard of care.standard of care.


Case scenariosCase scenarios Highly suspicious for occult CA and back pain Highly suspicious for occult CA and back pain

then plain films and MRI – no steroidsthen plain films and MRI – no steroids

Known CA and back pain without neuro deficit Known CA and back pain without neuro deficit then MRI, steroids and radiation oncologythen MRI, steroids and radiation oncology

Known CA with neuro deficit, then steroids, Known CA with neuro deficit, then steroids, MRI and spine serviceMRI and spine service

Case 2Case 2

48 yr old male presents to ED with large 48 yr old male presents to ED with large hemoptysis X 2hemoptysis X 2

Recently treated at TBCC for lung CA Recently treated at TBCC for lung CA (old chart not available)(old chart not available)

HR =129, RR=32, sat=90% 5L, HR =129, RR=32, sat=90% 5L, BP=167/96BP=167/96

ApproachApproach

Mobilize team earlyMobilize team early PulmonaryPulmonary DI/ IRDI/ IR ICUICU ThoracicsThoracics

Approach Approach

StabilizeStabilize Unstable airwayUnstable airway

ETT – large size to faciliate bronchoscopeETT – large size to faciliate bronchoscope Not the panaceaNot the panacea

Pulmonary toilet – very importantPulmonary toilet – very important

Selective placement of ETT Selective placement of ETT

ApproachApproach

StabilizeStabilize CXR –localizes bleeding CXR –localizes bleeding

Patient position – bleeding side downPatient position – bleeding side down

Blood products/ fluids prnBlood products/ fluids prn

ApproachApproach

ImagingImaging CT scan can be done if pt not intubated and CT scan can be done if pt not intubated and

has stable airway prior to interventional has stable airway prior to interventional radiology for bronchial artery emobilizationradiology for bronchial artery emobilization

If ETT then often bronch before IR to localize If ETT then often bronch before IR to localize bleedingbleeding

ApproachApproach

Hemoglobin not important Hemoglobin not important patients die of hypoxia not anemia patients die of hypoxia not anemia not like GI bleednot like GI bleed

CausesCauses

1.1. Friable endobronchial tumorsFriable endobronchial tumors

2.2. tumor eroding into a small intrapleural tumor eroding into a small intrapleural vessel vessel

3.3. tumour eroding in to one of the major tumour eroding in to one of the major vessels of the thorax.vessels of the thorax.

4.4. Large vessels bleeds = deathLarge vessels bleeds = death


Dr. Alain TremblayDr. Alain Tremblay One of the few indications for stat call for One of the few indications for stat call for

pulmonary in the middle if the night – involve pulmonary in the middle if the night – involve pulmonary earlypulmonary early

Mobilize CT and Interventional radiology earlyMobilize CT and Interventional radiology early

Supportive management essentialSupportive management essential

Case 3Case 3

73 yr old male with thyroid cancer c/o 73 yr old male with thyroid cancer c/o increased secretions, stridor and SOB.increased secretions, stridor and SOB.

HR = 112, RR=36, BP=178/102, HR = 112, RR=36, BP=178/102, sat=91%on NRBsat=91%on NRB

ApproachApproach

StabilizeStabilize O2, suctioning of secretions and allowing O2, suctioning of secretions and allowing

patient to sit uppatient to sit up

Labs, CXRLabs, CXR

Why is it happening?Why is it happening?

Usually a subacute process unless an already Usually a subacute process unless an already marginal airway is suddenly compromised by an marginal airway is suddenly compromised by an acute infection, bleeding or the patient’s inability acute infection, bleeding or the patient’s inability to handle secretions.to handle secretions.

Thyroid and esophageal carcinomas may Thyroid and esophageal carcinomas may compress the trachea by invading the compress the trachea by invading the surrounding soft tissue surrounding soft tissue

Can occur from scarring from prolonged Can occur from scarring from prolonged intubation or from radiation therapyintubation or from radiation therapy

TreatmentTreatment

ConsultantConsultant Pulmonary – Pulmonary – Rigid scopeRigid scope for endobronchial for endobronchial

stenting or laser abalationstenting or laser abalation

Steroids – not helpfulSteroids – not helpful (only (only if known lymphoma)if known lymphoma)


Needs rigid scope Needs rigid scope Drs Tremblay and Michaud only 2 Drs Tremblay and Michaud only 2

pulmonologist in Calgary who do rigid scope pulmonologist in Calgary who do rigid scope (Some thoracic surgeons do as well)(Some thoracic surgeons do as well)

Can call pulmonary at any site and then can Can call pulmonary at any site and then can help management patient and arrange for help management patient and arrange for rigid scoperigid scope

Case 4Case 4

86 yr old female with metastatic lung CA 86 yr old female with metastatic lung CA with progressive SOBOE over last 2 with progressive SOBOE over last 2 weeks, now SOB at rest.weeks, now SOB at rest.

Nonproductive cough, no fever.Nonproductive cough, no fever.

HR =92, RR=24, BP 164/92 Sat=94% on HR =92, RR=24, BP 164/92 Sat=94% on 2L2L

Effusion CXREffusion CXR

ApproachApproach

StabilizeStabilize

LabsLabs

CXRCXR

PleurocentesisPleurocentesis

Why is it happening ?Why is it happening ?

Most common from lung, breast, ovary Most common from lung, breast, ovary and lymphomaand lymphoma

Pleural seeding by neoplastic cells Pleural seeding by neoplastic cells increases capillary permeability and increases capillary permeability and produces an exudative effusionproduces an exudative effusion

Direct erosion into a blood vessel can Direct erosion into a blood vessel can cause an abrupt hemorrhagic effusioncause an abrupt hemorrhagic effusion


Dyspnea clinicDyspnea clinic Run by Dr. Trembaly and Dr. MichaudRun by Dr. Trembaly and Dr. Michaud

Refer if known CA with symptomatic Refer if known CA with symptomatic effusion or if highly suspicious for cancereffusion or if highly suspicious for cancer Don’t necessarily need tissue diagnosisDon’t necessarily need tissue diagnosis

Dyspnea ClinicDyspnea Clinic

Tap in ED, send referral. Appt usually in 2 Tap in ED, send referral. Appt usually in 2 weeksweeks

Clinic places pleurodex catheter and have Clinic places pleurodex catheter and have home care drain it off as necessaryhome care drain it off as necessary

If tapped in ED and return prior to appt, If tapped in ED and return prior to appt, may need admission to pulmonarymay need admission to pulmonary

Clinic number -521 3511 – Pat BarkleyClinic number -521 3511 – Pat Barkley

Case 5Case 5

64 yr old female with metastatic breast CA 64 yr old female with metastatic breast CA to liver “flu –like” symptoms, N/V, lethargy, to liver “flu –like” symptoms, N/V, lethargy, weakness X 2 weeksweakness X 2 weeks

HR =110, RR=16, BP=100/56, Sat =84% HR =110, RR=16, BP=100/56, Sat =84% RARA

GCS = 13, no focal deficit, clinically “dry”GCS = 13, no focal deficit, clinically “dry”

ApproachApproach

LabsLabs Hg =112, WBC =9.4 Plts =186Hg =112, WBC =9.4 Plts =186 Glc = 7.5, Na =132, K = 3.5Glc = 7.5, Na =132, K = 3.5 Creatinine =364 (new)Creatinine =364 (new) Calcium= 3.64 albumin =29Calcium= 3.64 albumin =29

ManagementManagement

Treatment Treatment

Measure ionized calcium Measure ionized calcium ABGABG

Corrected calcium = measured calcium + Corrected calcium = measured calcium + (0.02 X(40 – measured albumin)(0.02 X(40 – measured albumin)

Lower the albumin and the corrected calcium Lower the albumin and the corrected calcium goes upgoes up

TreatmentTreatment

Replace volume firstReplace volume first Sodium inhibits reabsorption of calciumSodium inhibits reabsorption of calcium Need urine output – 100cc/hrNeed urine output – 100cc/hr

After euvolemic, then lasix with volume After euvolemic, then lasix with volume maintenancemaintenance

Follow K and Mg closelyFollow K and Mg closely

Causes of hypercalcemia in malignancyCauses of hypercalcemia in malignancy

One of the most common complications of One of the most common complications of cancer - 10-20%cancer - 10-20%MC caused by breast, lung, renal and MC caused by breast, lung, renal and cholangiocarcioma and multiple myeloma and cholangiocarcioma and multiple myeloma and lymphomalymphoma

Mobilization of bone calcium more rapidly than it Mobilization of bone calcium more rapidly than it can be cleared by the kidneyscan be cleared by the kidneysSecretion of parathyroid hormoneSecretion of parathyroid hormonePresence of bone mets that cause local Presence of bone mets that cause local destructiondestruction

Case 6Case 6

62 yr old male with CML with a recent 62 yr old male with CML with a recent exacerbation of COPD put on prednisone exacerbation of COPD put on prednisone and levaquinand levaquin

Acute onset of flank pain then new tonic Acute onset of flank pain then new tonic clonic seizure x 3 minutesclonic seizure x 3 minutes

Hr =48, RR =28, BP = 88/52, sat Hr =48, RR =28, BP = 88/52, sat =94%NRB, T=37.6, C/S=6.8=94%NRB, T=37.6, C/S=6.8

ApproachApproach

StabilizeStabilizeLabsLabs Hg = 109, WBC =38, plts=201Hg = 109, WBC =38, plts=201 K = 6.8, Na = 132, glc = 6.9 K = 6.8, Na = 132, glc = 6.9 Cr= 342, urea =32Cr= 342, urea =32 Calcium = 1.87, Phosphate = 2.78, albumin Calcium = 1.87, Phosphate = 2.78, albumin

=38=38

Diagnosis ?Diagnosis ?

Tumor Lysis SyndromeTumor Lysis Syndrome

HyperkalemiaHyperkalemia

HyperphosphatemiaHyperphosphatemia

HypocalcemiaHypocalcemia

Renal failureRenal failure

Renal colicRenal colic

Tumour lysis syndrome - causesTumour lysis syndrome - causes

Large burden of tumor is rapidly and acutely Large burden of tumor is rapidly and acutely destroyed causes outpouring of potassium, destroyed causes outpouring of potassium, nucleic acids and phosphates.nucleic acids and phosphates.Sudden build up of electrolytesSudden build up of electrolytesMC seen with lymphoma and leukemia, but can MC seen with lymphoma and leukemia, but can also occur with solid organ tumorsalso occur with solid organ tumors

Usually within 6 hours to 6 days after the Usually within 6 hours to 6 days after the initiation of therapyinitiation of therapyCan occur with the administration of Can occur with the administration of corticosteroids to a susceptible patientcorticosteroids to a susceptible patient

Symptoms of hyperkalemiaSymptoms of hyperkalemia - - weakness and altered MS and arrthymiasweakness and altered MS and arrthymias

HyperphosphotemiaHyperphosphotemia Causes acute precipitation of calcium in the kidneys and Causes acute precipitation of calcium in the kidneys and

tissues leading to….tissues leading to….

Symptoms of hypocalcemiaSymptoms of hypocalcemia carpopedal spasm and seizurescarpopedal spasm and seizures

Renal failureRenal failure secondary to increased uric acid levels producing renal secondary to increased uric acid levels producing renal

tubular necrosistubular necrosis

Symptoms of renal colicSymptoms of renal colic secondary to increased uric acid levels producing renal secondary to increased uric acid levels producing renal

tubular necrosistubular necrosis

Treatment -Tumor lysis syndromeTreatment -Tumor lysis syndrome

Aggressive hydration if urine output existsAggressive hydration if urine output exists

Alkalinization of urine to pH 7 (can worsen Alkalinization of urine to pH 7 (can worsen hypocalcemia)hypocalcemia)

Correct electrolytes and follow closelyCorrect electrolytes and follow closely

LasixLasix

Allopurinol – 600- 900mg loading doseAllopurinol – 600- 900mg loading dose

HemodialysisHemodialysis

Rad onc, Med onc, no onc…who goes Rad onc, Med onc, no onc…who goes where?where?

Radiation therapyRadiation therapy Patient with active radiation – usually gets s/e 2 Patient with active radiation – usually gets s/e 2

weeks after starting radiation until 2 weeks after weeks after starting radiation until 2 weeks after completing radiation – eg diarrheacompleting radiation – eg diarrhea

Medical oncologyMedical oncology Patient with chemo within the last monthPatient with chemo within the last month Usually febrile neutropenia at 5 days Usually febrile neutropenia at 5 days

No oncologyNo oncologyNo tissue diagnosis?? – hospitalistNo tissue diagnosis?? – hospitalist

QuestionsQuestions

oncologic challenges in the ed (besides not getting the old chart from tbcc) grand rounds gord...

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