Points and Pearls Digest | Managing Oncologic Complications
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Managing Patients with Oncologic Complications in the Emergency Department

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Points

Metastatic Spinal Cord Compression (MSCC)

  • MSCC is best imaged by MRI. If MRI is not avail­able or contraindicated, a noncontrast CT should be performed followed by CT myelography if bony metastases are noted or clinical suspicion is high.
  • Corticosteroids help limit vasogenic edema and reduce mass effect on the cord.
  • Patients with MSCC who do not have a contrain­dication to surgery should be treated first with ste­roids, then undergo surgery, and afterwards should receive radiation therapy.
  • Recurrence of MSCC is common. Prognosis is poor, with a median survival of just 3 to 7 months after initial occurrence. 

Tumor Lysis Syndrome (TLS)

  • TLS occurs when cell turnover outpaces the body’s normal regulatory mechanisms, leading to an excess of intracellular contents in the extracellular space.
  • TLS is both a laboratory and a clinical diagnosis. Clinical diagnosis includes neurologic symptoms (eg, seizure, confusion, coma), cardiac dysrhyth­mias, or acute kidney injury that requires hemodi­alysis.
  • Common laboratory abnormalities of TLS include hyperuricemia, hyperphosphatemia, hyperkalemia, and hypocalcemia.
  • Diuretics may be used to avoid volume overload in patients receiving significant fluids. There is no role for urine alkalinization.
  • Xanthine oxidase inhibitors, such as allopurinol, prevent a worsening of the hyperuricemia. Ras­buricase facilitates the renal clearance of uric acid through the metabolite allantoin.
  • Worsening kidney injury will require hemodialysis or continuous renal replacement therapy. Peritoneal dialysis is not an option.

Febrile Neutropenia

  • To determine severity of neutropenia, calculate the absolute neutrophil count (ANC). Use the MDCalc online tool at: www.mdcalc.com/absolute-neutro­phil-count-anc
  • The most common sites of infection are the lung, anorectal area, skin, oropharynx, and urinary tract.
  • Determine the risk index for febrile neutropenia with the MASCC Risk Index, at: www.mdcalc.com/mascc-risk-index-febrile-neutropenia
  • For patients determined to be at high risk, current guidelines recommend broad-spectrum coverage with an antipseudomonal agent such as cefepime, piperacillin-tazobactam, meropenem, or imipenem.
  • For patients determined to be at low risk, outpatient therapy may be an option. Antibiotic regimen may include ciprofloxacin and amoxicillin/clavulanate. Include the patient’s oncologist in the discharge decision, as next-day follow up will be necessary.

Pearls

  • Corticosteroids are the first-line therapy for MSCC. In most cases, give dexamethasone 10 mg IV.
  • Initial therapy for TLS is IV fluids. Worsening kidney injury will require hemodialysis or continuous renal replacement therapy.
  • Patients with neutropenic fever require 2 sets of blood cultures. In addition, cultures need to be drawn from each lumen of any indwelling lines.
  • Neutropenic fever patients with abdominal pain and diarrhea need to be tested for Clostridium difficile, even in the absence of risk factors.

Table 1 Components of the Multinational Association of Supportive Care in Cancer (MASCC) Risk Index

Table 1. Components of the Multinational Association of Supportive Care in Cancer (MASCC) Risk Index

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Clinical Pathway for Emergency Department Management of Metastatic Spinal Cord Compression

Clinical Pathway for Emergency Department Management of Metastatic Spinal Cord Compression

Access the Clinical Pathway here

Clinical Pathway for Emergency Department Management of Tumor Lysis Syndrome

Clinical Pathway for Emergency Department Management of Tumor Lysis Syndrome

Access the Clinical Pathway here

Clinical Pathway for Emergency Department Management of Neutropenic Fever

Clinical Pathway for Emergency Department Management of Neutropenic Fever

Access the Clinical Pathway here

 

MDCalc
MDCalc Score Calculators
Absolute Neutrophil Count Calculator:
MASCC Risk Index for Febrile Neutropenia Calculator:
 
First Responders

What changes do you anticipate making in your practice as a result of this activity?

  • Watch for MSCC in patients complaining of back pain.
  • Give steroids for spinal cord compression.
  • Avoid giving IV calcium in hypocalcemia in TLS.
  • I'll use the MASCC risk index to assist in disposition decision for well-appearing febrile neutropenic patients.
  • I was unaware of the potential to discharge patients with neutropenia and fever; will start doing so on a case-by-case basis in consultation with the primary oncologist.
  • Cefepime without vancomycin is sufficient to treat stable patients with neutropenic fever without a source.
  • Use of the MDCalc calculators is very helpful.

Most Important References

  • McCurdy MT, Mitarai T, Perkins J. Oncologic emergen­cies, part I: spinal cord compression, superior vena cava syndrome, and pericardial effusion. Emerg Med Pract. 2010;12(2):1-20. (Review article) https://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=213
  • Loblaw DA, Mitera G, Ford M, et al. A 2011 updated system­atic review and clinical practice guideline for the management of malignant extradural spinal cord compression. Int J Radiat Oncol Biol Phys. 2012;84(2):312-317. (Review, clinical guide­line) DOI: http://dx.doi.org/10.1016/j.ijrobp.2012.01.014
  • Cairo MS, Coiffier B, Reiter A, et al. Recommendations for the evaluation of risk and prophylaxis of tumour lysis syn­drome (TLS) in adults and children with malignant diseases:  an expert TLS panel consensus. Br J Haematol. 2010;149(4):578-586. (Review, clinical guideline) DOI: http://dx.doi.org/10.1111/j.1365-2141.2010.08143.x
  • Coiffier B, Altman A, Pui CH, et al. Guidelines for the manage­ment of pediatric and adult tumor lysis syndrome: an evidence-based review. J Clin Oncol. 2008;26(16):2767-2778. (Review, clini­cal guidelines) DOI: http://dx.doi.org/10.1200/JCO.2007.15.0177
  • Freifeld AG, Bow EJ, Sepkowitz KA, et al. Clinical practice guide­line for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America. Clin Infect Dis. 2011;52(4):e56-e93. (Clinical guideline)  DOI: https://doi.org/10.1093/cid/cir073
  • Klastersky J, de Naurois J, Rolston K, et al. Management of febrile neutropaenia: ESMO Clinical Practice Guidelines. Ann Oncol. 2016;27 Suppl 5:v111-v118. (Clinical guideline)  DOI: https://doi.org/10.1093/annonc/mdw325
Publication Information
Authors

Michael T. McCurdy, MD; and David Wacker, MD

Peer Reviewed By

Karin Chase, MD; Natalie Kreitzer, MD

Publication Date

January 7, 2018

CME Expiration Date

February 1, 2021

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