Oncologic Emergency Research Articles

閉塞性大腸癌の治療：oncology emergencyへの対応を含めて

閉塞性大腸癌の治療：oncology emergencyへの対応を含めて

Guideline adherence for the management of emergency department patients with febrile neutropenia and no infection source: Is there room for improvement?

Febrile neutropenia is an oncologic emergency associated with significant morbidity and mortality. The objective of our study was to assess guideline adherence and clinical outcomes associated with the management of high- and low-risk febrile neutropenia patients presenting to the emergency department. A retrospective observational cohort study was conducted at a 60,000-visit emergency department at an academically-affiliated tertiary referral hospital. Patients were identified as low- or high-risk using the guideline-recommended Multinational Association for Supportive Care in Cancer score. The primary outcome was the proportion of cases in which the management was concordant with applicable febrile neutropenia guidelines. Guideline adherence was defined as hospital admission and intravenous antimicrobial therapy for high-risk patients and discharge home with oral antimicrobial therapy for low-risk patients. Secondary outcomes included appropriate vancomycin administration, hospital length of stay, rates of acute kidney injury, in-hospital Clostridium difficile infection rates, and 30-day mortality. Of the 237 patients included, 94 (39.7%) were low-risk patients and 143 (60.3%) were high-risk patients. Guideline adherence occurred in 96.8% of high-risk patients and 0.4% of low-risk patients. Mean hospital length of stay of the low-risk group was 5 ± 5.0 days compared to 7.2 ± 7.3 days in the high-risk group. Vancomycin was often inappropriately given in 69.5% of high-risk patients. Clostridium difficile occurred in 15 (10.3%) adherent and 4 (4.4%) non-adherent patients. By 30 days, 4 (4.3%) low-risk and 15 (10.7%) high-risk patients died. Adherence to the febrile neutropenia guidelines was low resulting in unnecessary hospital admissions of low-risk patients and frequent over-prescription of empirical vancomycin.

Sestrinske intervencije u tretmanu hitnih stanja u onkologiji

Emergencies in oncology are acute exacerbations of the patient's condition that can be fatal and are caused by a tumor process or antitumor treatment. Can affect different organs or organ systems, generally are classified as: obstructive syndromes, metabolic disorders, and hematological or immunological disorders. The nurse is an important member of the team involved in the treatment of cancer patients and their interventions can contribute to reducing the rate of mortality and successful treatment of emergencies. As she spends most of her time with the patient, the nurse must be educated to recognize the symptoms and signs of emergencies, in order to provide first aid in time and inform the doctor. Nurse interventions are aimed at performing diagnostic procedures in patients, applying appropriate therapeutic measures, monitoring patients and providing health care.

Tumor Lysis Syndrome.

1. Thomas B. Russell, MD* 2. David E. Kram, MD, MCR* 1. *Section of Pediatric Hematology/Oncology, Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC * AKI: : acute kidney injury ALL: : acute lymphoblastic leukemia HRD: : high-risk disease IRD: : intermediate-risk disease LRD: : low-risk disease TLS: : tumor lysis syndrome Along with knowledge of how to evaluate a pediatric patient with a suspected malignancy, general pediatricians must maintain a high level of suspicion of tumor lysis syndrome for initial management and timely patient referral. This syndrome is largely preventable, and certainly manageable, with prompt diagnosis and appropriate intervention. After completing this article, readers should be able to: 1. Define and diagnose tumor lysis syndrome (TLS). 2. Recognize the risk factors for TLS. 3. Stratify pediatric patients with cancer according to risk of developing TLS. 4. Identify interventions to prevent TLS. 5. Discuss management strategies for patients with TLS. Tumor lysis syndrome (TLS) is a life-threatening oncologic emergency that occurs when cancer cells break down, either spontaneously or after initiation of cytotoxic chemotherapy, and release their intracellular contents into the bloodstream. This massive release of uric acid, potassium, and phosphorous, which under normal physiologic conditions are excreted in the urine, can lead to hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia. These metabolic derangements increase the risk of severe complications, including acute kidney injury (AKI), cardiac arrhythmias, seizures, and even death. TLS is the most common oncologic emergency, and it occurs most frequently in children with acute leukemia and non-Hodgkin lymphoma. TLS is often preventable; clinicians must maintain a high index of suspicion and rely on effective prevention and treatment strategies. This review will serve to update the readership on TLS in pediatric oncology patients, including the definition, common risk factors, epidemiology, pathophysiology, and clinical consequences, as well as preventive and management measures for children with suspected or newly diagnosed cancers. TLS consists of a constellation of laboratory findings, including hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia and the consequential clinical …

A Case of Congenital Mesoblastic Nephroma Rapidly Increasing in Size in Fetal Period and Causing an Oncologic Emergency After Birth

A Case of Congenital Mesoblastic Nephroma Rapidly Increasing in Size in Fetal Period and Causing an Oncologic Emergency After Birth

Current management of chemotherapy-induced neutropenia in adults: key points and new challenges: Committee of Neoplastic Supportive-Care (CONS), China Anti-Cancer Association Committee of Clinical Chemotherapy, China Anti-Cancer Association.

Chemotherapy-induced neutropenia (CIN) is a potentially fatal and common complication in myelosuppressive chemotherapy. The timing and grade of CIN may play prognostic and predictive roles in cancer therapy. CIN is associated with older age, poor functional and nutritional status, the presence of significant comorbidities, the type of cancer, previous chemotherapy cycles, the stage of the disease, specific chemotherapy regimens, and combined therapies. There are many key points and new challenges in the management of CIN in adults including: (1) Genetic risk factors to evaluate the patient’s risk for CIN remain unclear. However, these risk factors urgently need to be identified. (2) Febrile neutropenia (FN) remains one of the most common reasons for oncological emergency. No consensus nomogram for FN risk assessment has been established. (3) Different assessment tools [e.g., Multinational Association for Supportive Care in Cancer (MASCC), the Clinical Index of Stable Febrile Neutropenia (CISNE) score model, and other tools] have been suggested to help stratify the risk of complications in patients with FN. However, current tools have limitations. The CISNE score model is useful to support decision-making, especially for patients with stable FN. (4) There are still some challenges, including the benefits of granulocyte colony stimulating factor treatment and the optimal antibiotic regimen in emergency management of FN. In view of the current reports, our group discusses the key points, new challenges, and management of CIN.

Calling an Oncological Emergency Telephone to Seek Advice: An Interview Study.

Cancer treatment is increasingly provided on an outpatient basis, which may challenge patients and caregivers coping with illness and adverse effects at home. A telephone consultation is an accepted type of healthcare provision to support patients and prevent adverse outcomes when their capacity to self-manage is inadequate. Whether this option for help sufficiently supports patients needs further investigation. The aim of this study was to explore patients' and caregivers' experience of calling an oncological emergency telephone. The study applies a phenomenological hermeneutic approach with 12 semistructured interviews. Patients and caregivers who had called the oncological emergency telephone within the last 2 months were included. The interview texts were analyzed by content analysis. Patients and caregivers perceive the emergency telephone as a lifeline that they consider calling when the patient's condition changes from what they understand as normal to what they perceive as abnormal. They would rather call "one time too many than one time too few" if their resources are inadequate to ensure their safety. The tone, attitude, and professional competency of healthcare providers affect patients' experience of the call. The value of calling the oncological emergency telephone depends on the healthcare providers' professional competences and skills to establish a relationship that makes patients feeling accommodated and taken care of. Patients' and caregivers' perceptions of what constitutes a good telephone consultation represent significant knowledge that contributes to a more comprehensive and practice-based understanding of what is required to advise patients and caregivers in an oncological emergency telephone.

Oncologic emergencies in abdominal surgery

Onkologische Notfalle in der Viszeralchirurgie stellen keine Seltenheit, jedoch eine erhebliche Herausforderung fur den behandelnden Chirurgen und den Patienten gleichermasen dar. Der Patient ist durch die Tumorerkrankung latent und durch die Notfallsituation akut gefahrdet. Der Chirurg muss daher nicht nur dem Notfall an sich, sondern auch der gesamtonkologische Situation bei seiner Entscheidungsfindung fur eine Therapie und wahrend dieser Phase Rechnung tragen. Hierbei sollten auch stets die individuellen Patientenwunsche und -vorstellungen beachtet und, wenn moglich, die Angehorigen in den Entscheidungsprozess eingebunden werden. Ein wesentlicher Punkt im Zuge der Bewertung des Notfalls ist neben der Indikationsstellung fur eine Operation die Unterscheidung zwischen einer palliativen und kurativen onkologischen Gesamtkonstellation. Dies erfordert daher neben der chirurgischen Erfahrung fur die Notfalloperation auch eine entsprechende onkologische Expertise des Chirurgen. Ziel war die Erstellung eines Uberblicks und Zusammenfassung der aktuellen chirurgischen und interventionellen Behandlungsmoglichkeiten onkologischer Notfalle in der Abdominalchirurgie. Es wurde eine selektive PubMed-basierte Literaturrecherche zum Thema chirurgischer und interventioneller Therapiemoglichkeiten onkologischer Notfalle in der Abdominalchirurgie, insbesondere im Hinblick auf Tumorblutung, -perforation und -obstruktion im Bereich des Gastrointestinaltrakts durchgefuhrt und deren Ergebnisse zusammengefasst und aufbereitet. Der Artikel bietet einen Uberblick uber den aktuellen Stand der Behandlungsmoglichkeiten onkologischer Notfalle im Bereich der Abdominalchirurgie.

Infections as oncologic emergencies

ZusammenfassungHintergrundPatienten mit onkologischen Erkrankungen, insbesondere mit hämatologischen Neoplasien, haben ein erhöhtes Risiko für allgemeine Infektionen und spezielle therapieassoziierte Komplikationen mit hoher Morbidität und Mortalität. Die jährliche Inzidenz und Prävalenz für Krebserkrankungen steigt in Deutschland. Moderne Therapieverfahren haben zu einem verbesserten Überleben geführt, jedoch erfordern steigendes Alter, Komorbiditäten und Gebrechlichkeit der Patienten multidisziplinäre Strategien zur Durchführung komplexer Therapiekonzepte und zur Behandlung von deren Komplikationen.MethodeEine selektive Literaturrecherche sowie die Leitlinien der European Society for Medical Oncology (ESMO), der Deutschen Gesellschaft für Hämatologie und Medizinische Onkologie (DGHO), der Arbeitsgemeinschaft Infektionen in der Hämatologie und Onkologie der DGHO (AGIHO) und der American Society of Clinical Oncology (ASCO) sind die Grundlage für den vorliegenden Artikel.SchlussfolgerungenDas Erkennen schwerer Infektionen bei Krebspatienten und deren Unterscheidung von therapieassoziierten Komplikationen stellt eine Herausforderung für den behandelnden Arzt dar. Neutropenisches Fieber ist der häufigste infektiologische Notfall in der Onkologie. Frühzeitige empirische Therapie mit Breitspektrumantibiotika und eskalierende diagnostische Maßnahmen sind notwendig für die erfolgreiche Therapie dieser Risikogruppe. In diesem Beitrag wird eine Reihe von lebensbedrohlichen Infektionen bei immunkompromittierten Patienten diskutiert.

Imaging in Oncologic Emergencies

Abstract With increase in number of oncological diagnoses and advances in cancer therapy there are a greater number of diagnosed oncological patients. This patient population is susceptible to disease processes and complications that can be a result of therapy, disease burden, or their hematological and immunological compromised status. The Radiologist must be aware of emergent diagnoses seen in these patients, promptly consider them in case consultation, and suggest further imaging and management. We review the imaging of oncological emergencies in the central nervous system, thorax, and abdomen. Common diagnoses and imaging findings are discussed by case example.

Creation and Pilot-testing of Virtual Patients for Learning Oncologic Emergency Management.

Purpose or objectiveManagement of oncologic emergencies becomes critical at the start of the second year of a radiation oncology residency. Considering the limited exposure to oncology in the medical school curriculum, this knowledge gap needs to be filled prior to managing real patients. The aim of this project was to create virtual patients (VPs) to ease this transition and improve learner readiness for independently managing oncologic emergencies on call.Material and methodsA curriculum mapping exercise was done to identify gaps. The main oncologic emergencies that needed to be addressed were selected for development of the modules. Review of the key concepts for management was elucidated and validated. These included history, physical examination, imaging interpretation, staging, as well as anatomy, epidemiology, pertinent literature, differential diagnosis, prognostication, radiation treatment planning, summarizing, and patient- and peer-communication skills. Clinical vignettes were then designed, in collaboration with a virtual patient education expert, to mimic the clinical presentation and evolution of a typical patient for three common oncologic emergencies: spinal cord compression, superior vena cava syndrome, and tumor-induced hemorrhage.ResultsThree virtual modules were developed: spinal cord compression, superior vena cava syndrome, and tumor-induced hemorrhage. Each case included 25 to 30 vignettes that participants progressed through, with a total estimated completion time of 30 to 45 minutes. Each node branched out to provide a detailed answer and explanation of the key concept. Figures were included to mimic real patients and to provide a more authentic learning experience. The modules also included quantitative pre- and post-testing assessments, including multiple-choice questions, true or false, fill in the blank, short answers, and text response. The cases were then transcribed onto a virtual patient simulation platform. Following completion of the module, a report was generated for each individual learner to track all responses and used as the assessment tool. The pilot test showed an increase of 28% in the pre-to-post-test results in a cohort of nine residents. The mean pre-test result of 58% increased to a mean post-test result of 86% (range: 70-100%) after completing the three modules.ConclusionVPs can be used for learning the management of oncologic emergencies and can be done on a simulation-based learning platform. The modules can be used as both, a learning and an assessment tool for junior residents. The results of the pilot test show a significant improvement in knowledge acquisition between pre- and post-test scores after completion of the three modules.

Acute Leukemia: Diagnosis and Treatment.

To provide an overview of acute leukemia, comparing incidence, presenting symptoms, diagnosis, prognosis, and treatment of the major subtypes. Review of articles dated 2010 to present in PubMed and CINAHL, and National Comprehensive Cancer Network Guidelines. The diagnosis of acute leukemia is comprised of a variety of hematopoietic neoplasms that are both complex and unique. Each subtype of acute leukemia has defining characteristics that affect prognosis and treatment. Nurses play an integral role in the care of the patient with acute leukemia during and beyond hospitalization. Therefore, baseline knowledge of these diseases is essential. Early symptom recognition is central in the management of oncologic emergencies.

The Impact of Diagnosis to Treatment Interval on the Outcome of Patients with Acute Myeloid Leukemia

Introduction: Acute myeloid leukemia (AML) has historically been considered an oncologic emergency, requiring immediate intervention and initiation of therapy. Although urgency to initiate treatment has been debated, no guidelines exist to address the impact of diagnosis to treatment interval (DTI) in patients with AML. Recent FDA approvals have added treatment options using targeted therapy as monotherapy in older patients (e.g. - ivosidenib), or in combination with chemotherapy in younger patients (e.g.- midostaurin) in the newly diagnosed setting with improved outcomes. Unfortunately, results of molecular mutation testing often return several days after the initial diagnosis of AML has been made. While immediate induction is important to control disease and to minimize disease-related morbidity and mortality (Sekkers et al), molecular testing is becoming increasingly important for treatment decisions, and there may be benefit in waiting for these results. In addition, in 'real world settings', several barriers (e.g., lack of resources, correct diagnostic testing) often delay time to diagnosis, and initiation of therapy. We conducted a retrospective study in two academic centers in a major metropolitan area in the United States to evaluate the impact of DTI on the outcomes of patients with AML. Methods: We collected data from 196 patients who presented to George Washington University Hospital (120 patients) between June 2010 and July 2018 and Georgetown University hospital (76 patients) between January 2014 and December 2018. All patients were older than 18 years. Patients with acute promyelocytic leukemia and those who decided to pursue treatment elsewhere were excluded. Patients characteristics including age, gender, race, smoking past medical history and disease characteristics (Cytogenetics, FISH and NGS when available) were collected using retrospective chart review. Type of treatment received (low intensity vs high intensity), and the time from diagnosis to initiation of therapy were collected. We recorded mortality at day 30 and day 90. Multivariable logistic regression models were used to evaluate the association of DTI with mortality independently from patient age. Chi-square test was used to examine the association of 30- and 90-day mortality with DTI. Results: A total of 140 patients were used in the analysis, 71% of whom were treated within 5 days of diagnosis (DTI <1-5 days), 16% in 6-10 days, and 12% in >10 days. Incidence of 30-day mortality was 15%, 14%, and 0% (p=.24), while 90-day mortality was 28% 18%, and 13% for <1-5, 6-10, and >10 days respectively (p=.33). Neither association was statistically significant, and adjusting for age and type of therapy did not change the findings. Conclusion: Our data does not support that shorter DTI is associated with improved mortality regardless of age or type of therapy. Although there was no statistical significance, there was a numerical trend of improved mortality in patients with delayed DTI (6-10 days) compared to those with a DTI of <1-5 days. Larger prospective studies need to be conducted to investigate DTI in AML patients based on patient's age, disease characteristics, and treatment type. In particular, given the growing importance of knowing molecular mutations at diagnosis, used for both prognosis and incorporation of potential targeted agents, it will be important to understand how long we can safely wait to treat patients without affecting outcomes. Disclosures Lai: Jazz Pharma: Membership on an entity's Board of Directors or advisory committees; Jazz Pharma: Speakers Bureau; Astellas: Speakers Bureau; Daiichi-Sankyo: Membership on an entity's Board of Directors or advisory committees; Agios: Membership on an entity's Board of Directors or advisory committees.

Factors Affecting the Morbidity and Mortality of Malignancy Patients Admitted to the Emergency Department

Objectives: The objective of this study is to identify the clinical characteristics and the factors affecting the morbidity and mortality of the patients with malignancy and to increase the quality of care and raise awareness of rapid targeted-therapy in the emergency department. Materials and Methods: In our study, cancer patients 18 years of age and older who presented to the emergency department of a university hospital were evaluated prospectively. Patients' demographics, vital signs, characteristics associated with malignancy, examinations performed, and their results, treatments, and length of stay were evaluated. Results: A total of 1283 patients and 1522 presentations were recorded. 51.99% of the patients were male, and 48.01% were female. The overall mean age was 63.05±14.08. The most prevalent symptom was dyspnea (17.94%), and the most common type of cancer was lung cancer (16.23%). In male patients, the most prevalent complaint was fever, and the most common type of cancer was lung cancer (34.63%). In female patients, the most prevalent complaint was dyspnea, and the most common type of cancer was breast cancer (35.25%). The influence of MAP, pulse, Hb levels, uremia, and hypoalbuminemia on mortality and ICU admission was significant. Overall, 41.46% of the patients were hospitalized, and 1.05% of the patients died. The average length of stay was 4.64±6.73 days. Conclusion: Patients with malignancy constitute a significant portion of emergency department admissions. Promoting the emergency physicians' insight into and experience on oncological emergencies would contribute to decreasing the mortality and morbidity of these patients.

Development and implementation of “advanced cancer shared care letters” to improve shared care between oncologists and family physicians.

37 Background: Optimal care of patients living with advanced cancer requires a collaborative approach between oncologists and family physicians (FPs), starting early in the disease trajectory. We developed and implemented “advanced cancer shared care letters” to improve communication, collaboration and role clarity amongst providers. Methods: A physician-to-physician standardized “advanced cancer shared care letter” for colorectal cancer was created at a Canadian tertiary cancer center with input across stakeholders. The letter is ordered by the oncologist when they determine a patient to have advanced (i.e. incurable) cancer. The letter outlines components of shared care, division of responsibilities, monitoring for complications, responding to oncological emergencies, and consultation services such as palliative care. A cover sheet is provided for FPs to return to confirm their involvement, indicate their comfort level with providing a palliative approach to care (e.g. advance care planning, managing symptoms) and ask questions. Letters were piloted in two gastrointestinal (GI) oncology outpatient clinics for two months, and then implemented in the seven remaining GI clinics over two months. Metrics were collected for five months to evaluate implementation. Results: Over 5 months, 76 shared care letters were ordered; in 5 cases, no FP was identifiable. Cover sheets were returned by 39/71 FPs (55%). Content returned included prognosis questions, goals of care conversations, supportive services available in their practice and those in use by the patient, capacity to manage symptoms (e.g. opioid prescribing), and requests to engage palliative care services. Implementation challenges included frequent change in clerical staff and management, electronic chart challenges and variable adoption. Conclusions: The shared care letter provides a useful mechanism for FPs and oncologists to share information. It increases communication and care coordination between typically siloed providers, to enhance patient experience. A similar letter is provided to patients and we are now developing a shared care letter that is generalizable for any type of advanced cancer.

2677. Infection-Related Outcomes in Patients With Malignancy-Related Febrile Neutropenia: A National Perspective

BackgroundFebrile neutropenia (FBN) is a life-threatening oncological emergency requiring hospitalization and early treatment with broad-spectrum antibiotics. We aimed to study differences in infection-related outcomes for febrile neutropenia in various malignancies.MethodsThe National Inpatient Sample (NIS) data set was queried from 2007 to 2014 to identify all patients with a diagnosis of neutropenic fever (ICD-9: 780.6x and 288.5x or 288.0x or 284.1x). Diagnoses for various cancers were determined via their respective Clinical Classification Software (CCS) codes. Diagnoses of pneumonia (481.x, 482x), bacterial meningitis (320.x), Clostridium difficile (008.45), infectious colitis due to neoplastic agents (009.x), urinary tract infection (599.0x), pyelonephritis (590.1x, 590.80), skin and soft-tissue infection (682.x, 684.x, 686.8x, 686.9x), mucositis (528.01), influenza (CCS 487), sepsis (995.91), severe sepsis (995.92), septic shock (785.52), E. coli septicemia (038.42), Pseudomonas septicemia (038.43), MRSA septicemia (038.12) and Streptococcal septicemia (038.0) were identified using their respective ICD/CCS codes. Variables were analyzed via multivariate analysis using the program SAS.ResultsWe studied 381,043 patients with FBN. Leukemia was the most common malignancy associated with FBN (140,190, patients, 36.8%). Meningitis was found to be significantly associated with brain cancer, while other infections were associated with a range of malignancies. (Table.1) Methicillin-resistant Staphylococcus aureus was associated with cancers of the bone, breast, uterus and non- hodgkins lymphoma, while other microorganisms varied across different malignancies (Table 2). Septic Shock was associated with cancer of the pancreas, lung, bone, breast, leukemia, bladder, kidney, thyroid, myeloma, prostate, testis, cervix, brain, melanoma, non-hodgkins lymphoma, compared with other malignancies (Table 3).ConclusionPathogen-specific and targeted antibiotic therapy is the cornerstone of treatment in FBN. Our study provides evidence of specific presentations and organisms causing infections in various malignancies. We hope that further outcomes-based research will provide objective evidence of certain high-risk infections, improving patient outcomes and minimizing redundant testing. Disclosures All authors: No reported disclosures.

Oncologic Emergencies: The Fever With Too Few Neutrophils.

Cancer is associated with a variety of complications, including neutropenic fever, which can result in severe morbidity and mortality. This oncologic emergency requires ED management. This narrative review provides focused updates for emergency clinicians regarding neutropenic fever. Neutropenic fever is defined by fever with oral temperature >38.3°C or temperature >38.0°C for 1 hour with an absolute neutrophil count (ANC) < 1000 cells/microL. Patients who have received chemotherapy within 6 weeks of presentation are at high risk for neutropenia. While most patients with neutropenic fever do not have an identifiable bacterial source of fever, clinicians should treat patients for bacterial infection. Rapid assessment and management are vital to improving outcomes in patients with suspected or confirmed neutropenic fever. History and examination should focus on the most common sites of infection: the gastrointestinal tract, blood, skin, lung, and urinary tract. However, physical examination and laboratory or imaging assessment may not display classic signs of infection. Blood cultures should be obtained, and broad-spectrum antibiotics are recommended. Oncology consultation is an integral component in the care of these patients. Several risk scores can assist in stratifying patients who may be appropriate for discharge home and follow-up. Neutropenic fever is an oncologic emergency. Rapid diagnosis and care of patients with neutropenic fever can improve outcomes, along with oncology consultation.

Oncologic Emergencies: Too Much Clotting-Venous Thromboembolism in Malignancy.

Malignancy predisposes patients to higher risk of venous thromboembolism (VTE), which is the second leading cause of death in patients with cancer. This narrative review evaluates VTE in malignancy and the emergency medicine investigation and management of this patient population. Patients with malignancy are at higher risk of VTE, including deep venous thrombosis (DVT) and pulmonary embolism (PE). Risk factors include the underlying cancer, other hematologic disorders, cancer therapies, and underlying comorbidities. While patients with malignancy and VTE can present similarly to those without malignancy, incidental VTE is more common in cancer patients. Existing scores such as the Wells and Revised Geneva score can assist in risk stratification in patients with malignancy. A negative D-dimer result in the appropriately risk-stratified patient can be used to exclude VTE, though D-dimer is more commonly elevated at baseline in patients with malignancy. Several scoring systems may be useful to predict recurrent risk of VTE, including the Khorana and Ottawa scores. Treatment includes anticoagulation with direct oral anticoagulants (DOACs) or low molecular weight heparin (LMWH). Outpatient therapy may be appropriate in select patients. This narrative review provides key updates in the assessment and management of cancer patients with VTE.

P1.16-39 Oncology Emergencies in Patients with Lung Cancer: Experience of One Hospital

Oncological emergencies (OE) are common conditions associated with significant morbidity and mortality. Individuals with malignancy may present with a cancer-related emergency; for many, this will be their initial manifestation of cancer (about 23%). Patients with lung cancer are the type of cancer patient who are most often admitted to emergency departments due to OE. The aim of this study was to characterize the OE like superior vena cava syndrome and metastatic spinal cord compression (MSCC) in patients with lung cancer, at our hospital. a retrospective review was undertaken to assess the number and the outcomes of patients admitted from 2015 to 2018 with lung cancer who had superior vena cava syndrome and MSCC. in this 4-year period there were 455 new patients with the diagnosis of lung cancer, and 31 had an OE: n= 15 (48%) had superior vena cava syndrome and n = 16 (52%) had MSCC. The median age was 66 years old and 90% were man. The histological diagnostics was adenocarcinoma in 48% (n=14), small cell lung cancer in 34% (n=10) and squamous cell carcinoma in 18% (n=4). In 61% (n=19) of the patients the OE was the first manifestation of cancer, and lead to the diagnosis. In the others, the median time between the diagnosis and the emergency was 6 months (0-56 month). Of this, 36% (n=4) were in the first-line chemotherapy, 36% (n=4) in the second-line chemotherapy and 18% (n=2) in the third-line chemotherapy. MSCC was the most frequent OE with 46% (n=16) of the patients, followed by superior vena cava syndrome (43%; n=15). 63% of the patients with MSCC, when the diagnosis was performed had lost the ability to walk; 50% had paraparesis, 25% paraplegia and only one presented with sphincter incontinence. 69% (n=11) of the patients with MSCC were treated with radiotherapy; 44% (n=7) underwent surgery and/or radiotherapy; 13% (n=2) were treated with steroids in combination with radiotherapy. 14 patients who were presented with superior vena cava syndrome (93%) were treated with radiotherapy. After the OE only 13 patients (37%; n=8 (62%) in superior vena cava syndrome and n=5 (38%) in MSCC) initiated or restarted systemic treatment for lung cancer. In this group disease progression was observed in a median time of 2 month after OE (0-31 months). Only 2 patients with MSCC who had lost the ability to walk regain it. 71% (n=21) of patients were dead 3 months after the OE. Only 4 patients (25%) with MSCC and 6 (40%) with superior vena cava syndrome were alive after 3 months of OE. OE causes severe morbidity and compromised survival and can be the initial manifestation of lung cancer. We need to be aware of this situation because the OE have the potential to progress rapidly; therefore, prompt, accurate diagnosis and institution of appropriate treatment are essential to achieve favorable outcomes.

108 Oncologic Emergencies in the Emergency Medicine Residency Curriculum: A National Survey

Cancer is the second leading cause of death in the United States (US). Malignancy-related complaints contribute significantly to emergency department (ED) visits and frequently require prompt diagnosis and management, especially with the emergence of immune therapy and its adverse events. Novel cancer therapies are increasingly used due to their effectiveness and more frequently in outpatient settings. Emergency physicians are now expected to encounter more patients with complications of these new treatments.