Oncologic Emergency Research Articles

Prognostic Factors Predicting Poor Outcome in Cancer Patients with Febrile Neutropenia in the Emergency Department: Usefulness of qSOFA.

Background/Aims Febrile neutropenia is considered as one of the most important and potentially life-threatening oncologic emergencies, which requires prompt medical assessment and treatment with antibiotics. This was a single-center retrospective study that investigated the prognostic factors predicting poor outcome in patients with cancer who presented with febrile neutropenia at the emergency department (ED). Methods The medical records of patients diagnosed with febrile neutropenia in the ED from January 2014 to December 2017 were reviewed. Patients aged >18 years who were diagnosed with a malignancy were included in the analysis. Febrile neutropenia was defined as an absolute neutrophil count < 1,000/mm3 with a temperature greater than 38°C. Patients were divided into two groups: those who were admitted at the intensive care unit (ICU) or those who died in the hospital (case group) and those who were admitted at general wards and were discharged (control group). The two groups were compared to determine the factors associated with poor prognosis. Results We identified 104 patients (25 and 79 from the case and control groups, respectively) with cancer who presented with febrile neutropenia at the ED during the study period. Lower blood pressure, platelet count, and HCO3− level, higher CRP and creatinine level, and the presence of bacteremia were more commonly observed in the case group than in the control group. In the multiple logistic regression analysis, the following independent predictors significantly correlated with ICU admission and in-hospital mortality: quick sequential (sepsis-related) organ failure assessment (qSOFA) score (odds ratio [OR]: 4.62; 95% confidence interval [CI]: 1.17–18.22; p=0.285), hemoglobin level (OR: 0.51; 95% CI: 0.33–0.78; p=0.002), total bilirubin level (OR: 7.69; 95% CI: 1.29–45.8; p=0.025), and respiratory tract infection (OR: 29.65; 95% CI: 3.81–230.7; p=0.0012). Conclusions The qSOFA can be a useful bedside tool for patients with cancer who present with febrile neutropenia at the ED. Moreover, it can help emergency physicians in identifying patients at risk of poor prognosis and in initiating prompt empirical antimicrobial therapy. Further studies must be conducted to validate the efficacy of the qSOFA in these patients in the ED.

EL24 - Managements of oncologic emergency occurred in patients with advanced cancer

Various oncologic emergencies, such as severe infection due to myelosuppression, renal failure, tumor lysis syndrome, electrolytic abnormalities, neurologic disturbances, and so on, sometimes occur in patients with advanced cancer. In addition, since an introduction of many new molecularly targeted drugs including VEGF-pathway inhibitors and immune checkpoint inhibitors, cardiovascular adverse events and immune-related adverse events have recently attracted a greater attention in an area of oncology. Here, I introduce current topics about the management of the various oncologic emergencies observed in patients with cancer who receive cancer drug therapy.

Emergencias oncológicas torácicas del paciente con cáncer de pulmón

Patients with lung cancer are the type of cancer patient who are most often admitted to emergency departments due to disease-related complications. An oncologic emergency is defined as any acute event in a patient with cancer that develops directly or indirectly from the tumour and that threatens the patient's life. Oncologic emergencies are divided into metabolic, haematologic and structural emergencies. In this article, we address the main structural thoracic complications of patients with lung cancer, in which imaging tests play an essential role in their diagnosis. The main oncologic thoracic emergencies of lung cancer are airway obstruction, superior vena cava syndrome, acute pulmonary thromboembolism, pericardial tamponade, massive haemoptysis, spinal cord compression and pleural effusion. Oncologic emergencies are a significant cause of morbidity and mortality in patients with lung cancer. Emergency department physicians play a fundamental role in the early detection of these emergencies. The knowledge and correct identification of the main oncologic thoracic emergencies of patients with lung cancer therefore enable optimal diagnostic and therapeutic management.

Nationwide content analysis of undergraduate obstetrics and gynaecology clinical curricula in Turkish medical schools

The aim was to perform a document content analysis of the subject titles in the undergraduate obstetrics and gynaecology (OG) curricula in Turkish medical schools regarding the National Core Curriculum revised in 2014 (NCC-2014). Two mini-focus group discussions with four voluntary OG faculty members in each session and one of the authors as the moderator were employed within a 1-week time frame to identify the primary (n = 36) and secondary (n = 15) NCC-2014 OG titles that were then compared for the alignment with the curricula of the various medical schools published on their website. The internet search and data analyses were each completed within 3 months. Overall, about 80% and 23% of primary and secondary OG topics were present in 54 medical schools, respectively. Teaching sessions on high-risk pregnancy and ovarian cancer were present in all of the curricula. Chromosomal disorders (11 schools), candidiasis/vaginal discharge (13 schools) and female sexual dysfunction (15 schools) were the least represented primary topics. None of the curricula had a title on neural tube defects or oncological emergencies. Obesity (one school), iron deficiency anaemia (four schools), genitourinary trauma (four schools) and domestic violence (four schools) were among the underrepresented secondary subject titles. This nationwide analysis revealed deficiencies in undergraduate OG core curricular content of the medical schools.

Pediatric Hematologic And Oncologic Emergencies

Hematologic and oncologic emergencies that afflict children and adolescents are important for emergency medicine physicians to recognize. Pediatric patients can present with a previous formal diagnosis and have a complication related to their disease or with new symptoms that suggest a hematologic or oncologic process. Oncologic treatments can also lead to life-threatening complications. Recognizing these emergencies is very important for emergency physicians to prevent further morbidity. This review covers common patient presentations, diagnosis, and treatments for hematologic and oncologic emergencies. This review contains 6 figures, 7 tables and 48 references Key words: hematology, hemophilia, immune thrombocytopenia, neutropenic fever, oncology, pediatric, sickle cell anemia, tumor lysis syndrome, von Willebrand disease

Pediatric Hematologic And Oncologic Emergencies

Hematologic and oncologic emergencies that afflict children and adolescents are important for emergency medicine physicians to recognize. Pediatric patients can present with a previous formal diagnosis and have a complication related to their disease or with new symptoms that suggest a hematologic or oncologic process. Oncologic treatments can also lead to life-threatening complications. Recognizing these emergencies is very important for emergency physicians to prevent further morbidity. This review covers common patient presentations, diagnosis, and treatments for hematologic and oncologic emergencies. This review contains 6 figures, 7 tables and 48 references Key words: hematology, hemophilia, immune thrombocytopenia, neutropenic fever, oncology, pediatric, sickle cell anemia, tumor lysis syndrome, von Willebrand disease

Spontaneous Tumor Lysis Syndrome: A Rare Presentation in Breast Cancer

Tumor lysis syndrome (TLS) is considered an oncologic emergency which requires early diagnosis and treatment to prevent mortality and morbidity. It refers to the constellation of metabolic disturbances manifested by acute renal failure associated with hyperuricemia, hyperkalemia, hypocalcemia and hyperphosphatemia. Diagnosis is made based on Cairo-Bishop clinical and laboratory criteria. Spontaneous TLS, occurring prior to the initiation of cancer therapy, has been reported in hematologic malignancies like high grade non-Hodgkin’s lymphoma (NHL) and acute leukemia, and rarely in solid tumors including colon cancer, hepatocellular carcinoma and in at least two cases of breast cancer. We present a case of spontaneous TLS in breast cancer patient which is rare but interesting disease manifestation. J Med Cases. 2019;10(1):24-26 doi: https://doi.org/10.14740/jmc3237

Oncological emergency surgery for metachronous large and small bowel metastases after pancreaticoduodenectomy for pancreatic cancer: a case report

BackgroundA surgical case of metachronous metastases of pancreatic head cancer (PC) to the large and small bowel is extremely rare. Therefore, there are only a few reports about surgery for intestinal metastases from PC. An oncologic emergency is defined as an acute, potentially life-threatening condition in a cancer patient that developed directly or indirectly because of the malignant disease or cancer treatment.Case presentationA 63-year-old man with PC underwent pancreaticoduodenectomy after receiving neoadjuvant chemotherapy with gemcitabine and S-1. Histopathologically, the tumor was diagnosed as poorly differentiated, tubular adenocarcinoma, with pT2, N0, pStage IB according to the UICC classification, seventh edition. R0 was achieved. Three months after pancreatoduodenectomy, blood tests showed coagulation derangements with high C-reactive protein (CRP 11.30 mg/dl). Computed tomography (CT) scan revealed a 55-mm mass alongside the transverse colon. During 2 weeks of follow-up, the coagulation derangement and elevated CRP persisted. Repeat CT showed that the tumor enlarged to 65 mm, and an additional mass, 25 mm in diameter, was detected in the jejunum. He was hospitalized due to abdominal pain and diarrhea with persistent high fever and was inspected; however, there was no evidence for infections. With the understanding that his life-threatening symptoms were secondary to the underlying malignancy, extirpation of the tumors combined with partial resection of the transverse colon and the jejunum was performed on the eighth day of hospitalization, on an emergency basis.The lesions were identified as large and small bowel metastases from PC because histopathological examination revealed morphological features similar to the primary disease.Immediately after the emergency surgery, the fever resolved and the CRP level normalized. He was discharged and received nab-paclitaxel with gemcitabine chemotherapy for 2 months postoperatively. He selected for best supportive care after this. The patient died due to a relapse with mesenteric lymph node metastasis 7 months after the emergency surgery.ConclusionSurgery as an oncological emergency for selected patients could sometimes contribute to improving patient’s quality of life.

The outcomes of childhood acute lymphoblastic leukemia with hyperleukocytosis

Background Hyperleukocytosis in childhood acute lymphoblastic leukemia (ALL) is an emergency in oncology. This condition showed high mortality and relapse rates, as well as low survival rate. The outcomes of this group of patients are not yet well studied.&#x0D; Objective To evaluate the characteristics and outcomes of childhood acute lymphoblastic leukemia (ALL) with hyperleukocytosis.&#x0D; Methods This was a retrospective cohort study. The patients were children less than 18 year of age who were diagnosed as ALL in Dr. Sardjito Hospital, Yogyakarta, from January 1st 2010 to November, 30th 2016. Event-free survival rate and overall survival rate were estimated for group of patients with the white blood cell (WBC) groups 50-200x109/L and &gt;200x109/L using the Kaplan-Meier method.&#x0D; Results There were 705 children diagnosed as ALL during the study period, 129 (18%) with hyperleukocytosis and 111 of them met the inclusion criteria, consisted of 76 children in a group of WBC 50-200 x 109/L and 35 children in a group of WBC &gt;200 x 109/L. Presentation at diagnosis: median age were 7 years (range 1 month-18 years), male was 1.5 higher than female, 92% of cases with lymphoid infiltration, 5% with CNS involvement, 40% had bleeding tendency, and 10% had clinical tumor lysis syndrome (TLS). Median WBC was 122 (range 53.4-876) x 109/L; mean Hb was 8 (SD 3) g/dL; median platelet count was 30 (range 1-221) x 109/L. Immunophenotyping was done in 23 patients, 5/23 (8%) was T cell. The patients in lower WBC group showed lower death (26% vs. 34%, P=0,389), higher two-year event-free survival (EFS) 68% vs. 45%, P=0.003, and overall survival (77% vs. 68%, P= 0.16), compared to patients in higher WBC group. Univariate and multivariate Cox regression analyses revealed that none of the variables was a significant prognostic factor for 2 years EFS or overall survival.&#x0D; Conclusion The group of children with ALL and hyperleukocytosis with lower WBC at diagnoses showed better outcomes than the higher WBC.

Single 6-mg dose of rasburicase: The experience in a large academic medical center.

Tumor lysis syndrome is an oncologic emergency due to the release of tumor cell contents, leading to metabolic derangements. Rasburicase, a recombinant urate oxidase, catabolizes uric acid. At our institution, we administer a single 6-mg dose of rasburicase to patients who are at risk for tumor lysis syndrome. We aimed to assess the efficacy of single 6-mg dose of rasburicase and explore risk factors associated with rasburicase failure. We report results in 92 adult patients who had a baseline uric acid greater than 7.5 mg/dL and received a single 6-mg dose of rasburicase for the management of tumor lysis syndrome. Responders were defined as those whose uric acid was less than or equal to 7.5 mg/dL within 24-36 h of rasburicase administration. The primary end point was response based on uric acid level. Secondary end points included response to rasburicase in association with lactate dehydrogenase, serum creatinine, calcium, phosphorus, blood pH, and oncologic diagnosis. Median age was 65 years and 70% were men. Most patients had leukemia (32%) or lymphoma (40%). Eighty-seven of 92 patients (95%), who received single 6-mg dose of rasburicase, achieved a uric acid less than 7.5 mg/dL within 24-36h of dosing. Body mass index was similar between responders and non-responders: 28.6 kg/m2 vs. 26.6 kg/m2, respectively, p = 0.6. Baseline lactate dehydrogenase levels were similar between the groups: 756 U/L vs. 892 U/L, respectively, p = 0.33. Blood pH values documented within 24 h of first dose of rasburicase were also similar between the two groups (n = 30; 7.33 vs. 7.34 respectively, p = 0.6). However, median baseline uric acid was lower in responders than non-responders: 12.3 mg/dL vs. 17.3 mg/dL, respectively, p = 0.012. Baseline serum creatinine and creatinine clearance were similar between responders and non-responders (2.2 mg/dL vs. 3.95 mg/dL; p = 0.12 and 29 mL/min vs. 16 mL/min; p = 0.11, respectively). Higher baseline uric acid levels were observed in patients who did not respond to the first rasburicase dose. In our study, uric acid levels normalized in 95% of patients after a single 6-mg dose of rasburicase indicating that a single 6-mg dose of rasburicase may be sufficient to manage tumor lysis syndrome, for most patients.

Leukemia Recurrence Exclusively in the Breast after Stem Cell Transplant

Introduction: Leukemic involvement of the breast is extremely rare but constitutes an oncologic emergency. Imaging findings of T-Cell acute lymphoblastic leukemia (T-ALL) recurrence in the breasts have not been previously described. Case Description: Patient is a 25 year old female who presented with symptoms of superior vena cava (SVC) obstruction secondary to a mediastinal mass status post biopsy demonstrating T-ALL, which was cluster of differentiation 3 (CD3) positive and B-cell lymphoma 2 (BCL-2), and 80% Ki-67 positive. She was treated with chemotherapy and post-treatment positron emission tomography/computed tomography (PET/CT) demonstrated resolution of mediastinal mass, with no evidence of distant disease. She underwent allogeneic hematopoietic stem cell transplant (HSCT) in first remission. Seven months post-HSCT, patient presented with a large area of tender swelling of both the breasts with biopsy demonstrating relapsed T-ALL. Radiologic findings showed bilateral breast masses on ultrasound and mammogram, which were hypermetabolic on PET/CT. Conclusions: Breast involvement in leukemia recurrence, a very rare entity, can present with palpable masses. Mammographic findings in leukemia can include masses or architectural distortion, they are typically hyperechoic on ultrasound, and can have marked uptake on PET/CT. Oncologists, primary care providers and radiologists should be aware of leukemia presentations in the breast for prompt referral for urgent management.

Prescribing Empiric Antibiotics for Febrile Neutropenia: Compliance with Institutional Febrile Neutropenia Guidelines.

Background: Febrile neutropenia (FN) is an oncologic emergency which should be treated immediately with empiric antibiotics. Different institutions observe different antibiograms and use different FN management guidelines. Our center implemented FN management guidelines for adult cancer patients in 2009. Hence, we decided to assess compliance with FN management guidelines and to describe the pattern of bacterial infections. Method: We conducted a cross-sectional study on all adult cancer patients admitted with FN. Data were collected from electronic medical records between January and December 2014. Results: One hundred FN episodes met the study inclusion criteria. The mean age of the patients was 41 ± 17 years; 52% (52 patients) were women. The most common diagnosis was lymphoma (33%). In terms of compliance to institutional FN guidelines, 55% of patients received guideline non-compliant treatment. The most common non-compliant treatment was incorrect amikacin dosing in 31% of patients, followed by incorrect vancomycin dosing in 20%, incorrect piperacillin/tazobactam dosing in 19%, inappropriate use of carbapenems in 18%, and non-compliant vancomycin use in 12% of patients. Bacterial isolates were only observed in 19% of the FN episodes. Among these 19 episodes of FN, Gram-negative pathogens were predominant and were identified in 74% of the episodes, followed by Gram-positive pathogens in 16% and polymicrobial pathogens in 10%. The mean time to defervescence was 2.21 ± 2 days. Conclusion: Our study concluded that there was a high percentage of non-compliance with our institutional FN management guidelines. We recommend following appropriate empiric antibiotic doses and indications as per institutional guidelines.

Management of oncological emergencies on the acute take.

In 2008, recommendations from the National Confidential Enquiry into Patient Outcome and Death identified large variations in the quality and safety of delivery of systemic anti-cancer therapy. In 49% of cases it was felt there was room for improvement and in 27% of cases treatment actually caused or hastened death. Every hospital with an emergency department and/or specialist oncology beds should therefore have a fully functioning acute oncology service to align acute oncology with urgent care. Many patients will still present via the acute take and therefore acute physicians need to be aware of the role of the acute oncology teams and management of oncology emergencies. This article discusses the role of the acute oncology team, management of acute oncology emergencies, namely neutropenic sepsis, metastatic spinal cord compression and superior vena cava obstruction, and important points for acute teams to consider.

Emergency admissions and subsequent inpatient care through an emergency oncology service at a tertiary cancer centre: service users' experiences and views.

Avoiding unnecessary emergency admissions and managing those that are admitted more effectively is a major concern for both patients and health services. To generate evidence useful for improving services for direct patient benefit, this study explores service users' views and experiences of emergency admissions and subsequent inpatient care. Participants were recruited during a cancer-related emergency admission from a tertiary cancer centre with an emergency oncology service and emergency department. Semi-structured interviews were conducted with 15 patients and 12 carers post hospital discharge. Interview transcripts were analyzed using framework analysis. Twenty patients experienced 43 emergency admissions over 6months. Most admissions (35/43) followed patients presenting acutely or as emergencies with cancer treatment side effects. Most admissions (35/43) were directly to an oncology ward following specialist advice, review and triage, and thus unavoidable. Participants experienced outstanding inpatient care because of the following: prompt and effective symptom control and stabilization of acute conditions; continuity of cancer care and coordination between acute and long-term treatment; satisfactory professional-patient communication and information sharing; responsive, motivated and competent staff; and less restrictive visiting times. Gaps in care were identified. Many emergency admissions are necessary for people with cancer. Future work should focus on improving easy access to specialist advice and triage, and the process of admission; providing rapid palliation of symptoms and prompt stabilization of acute conditions, and satisfactory inpatient care; closing the circle of care for patients by actively involving primary care and palliative/end-of-life care services to address the complex needs of patients and carers.

Replace “Have to” With “Want to”

Replace “Have to” With “Want to”

Oncology education for Canadian internal medicine residents: the value of participating in a medical oncology elective rotation.

Despite the high incidence and burden of cancer in Canadians, medical oncology (mo) rotations are not mandatory in most Canadian internal medicine (im) residency training programs. All im residents scheduled for a mo rotation at 4 Canadian teaching cancer centres between 1 January 2013 and 31 December 2015 were invited to complete an online survey before and after their rotation. The survey was designed to evaluate perceptions of oncology, comfort in managing cancer patients, and basic oncology knowledge. The survey was completed by 68 im residents pre-rotation and by 48 (71%) post-rotation. Cancer-related learning was acquired mostly from mo physicians in clinic (35%). Self-directed learning, didactic teaching, and resident or fellow teaching accounted for 31%, 26%, and 10% respectively of learning acquisition. Comfort level in dealing with cancer patients and patients at end of life improved to 4.0/5 from 3.2/5 (p < 0.001) and to 4.0/5 from 3.6/5 (p = 0.003) respectively. Mean knowledge assessment score improved to 83% post-rotation from 76% pre-rotation (p = 0.003), with the greatest increase observed in general knowledge of common malignancies. The 3 topics ranked as most important to learn during a mo rotation were oncologic emergencies, common complications of treatment, and approach to diagnosis of cancer. A rotation in mo improves the perceptions of im residents about oncology and their comfort level in dealing with cancer patients and patients at end of life. Overall cancer knowledge is also improved. Given those benefits, im residency programs should encourage most of their residents to complete a mo rotation.

Pediatric Central Nervous System Tumor Diagnosis, Complications, and Emergencies

Central nervous system tumors are the most common solid malignancy in childhood and the leading cause of cancer-related mortality in children. With an average of 13 new patients being diagnosed daily with a central nervous system tumor, many of these patients will present to the emergency department for evaluation and management. Furthermore, many children experience complications and/or adverse effects directly from the tumor itself, from multimodality treatment (ie, surgery, radiation therapy, and/or chemotherapy), and/or as long-term survivors. Oncologic emergencies include increased intracranial pressure, spinal cord compression, seizures/status epilepticus, central diabetes insipidus, and adrenal insufficiency. Evaluation and management by emergency medicine practitioners are critically important for these patients in all phases of their diagnosis and treatment and can contribute significantly to an improved prognosis.

Cancer pain in the emergency department: A multicenter study of the Comprehensive Oncologic Emergencies Research Network.

6541Background: Despite initiatives to improve cancer analgesia, patients with cancer frequently present to the emergency department (ED) with pain related issues. To our knowledge, no previous stu...

Hypercalcemia of Malignancy: Drug Therapy Pearls

•Hypercalcemia of malignancy is an oncologic emergency requiring prompt treatment. •There are several different treatment options, all used in different scenarios. •Certain patients may be easily treated with intravenous fluids and diuretics. •Other patients may need bisphosphonates, started early on because of long onset. •There are many patient-specific considerations for each treatment. Rachel J. Bubik, PharmD, is a pharmacy resident at Mayo Clinic in Rochester, MN, and can be reached at . Nathan J. Dahl, PharmD, BCOP, is a hematology/oncology clinical pharmacist at Mayo Clinic in Rochester. Timothy Nguyen, PharmD, BCPS, CCP, FASCP, is an associate professor of pharmacy practice at the Arnold & Marie Schwartz College of Pharmacy and Health Sciences at the Long Island University College of Pharmacy in Brooklyn, NY, and department editor for Prescription Pad. Timothy would like to hear your ideas for future columns and can be reached at .

Extended Versus Intermittent Infusions of Cefepime for the Treatment of Febrile Neutropenia

Background Neutropenic fever is an oncologic emergency treated with β-lactam antibiotics. Previous literature suggests that extended infusions of β-lactam antibiotics may improve clinical outcomes. Currently, there is only 1 previous study investigating the use of extended infusions in this population, which demonstrated a lack of benefit. Objective The objective of this study was to determine the effectiveness of extended infusions of cefepime compared with intermittent infusions in patients with febrile neutropenia. Methods A retrospective chart review was completed comparing extended infusions with intermittent infusions of cefepime for febrile neutropenia. Adult patients admitted to a community teaching hospital who incurred febrile neutropenia were included. Results A total of 166 patients receiving cefepime were included, of which 28 received extended infusions and 138 received intermittent infusions. Overall, baseline characteristics were similar between groups besides receipt of prior chemotherapy, duration of neutropenia, optimal renal dosing, and presence of documented mucositis. In the extended infusion arm, defervescence at 24 hours was more frequent (82% vs 51%, P = 0.002) and median time to defervescence was decreased by 14 hours (10 vs 24 hours, P = 0.02). Furthermore, extended infusions increased the odds of defervescence at 24 hours by 4.28 (95% confidence interval, 1.43–12.75; P = 0.009) and doubled the likelihood of defervescence at any time (hazard ratio, 2.02; 95% confidence interval, 1.23–3.32, P = 0.005). Conclusions Contrary to prior literature, extended infusions of cefepime significantly decreased the time to defervescence and increased the proportion with defervescence at 24 hours. This suggests that extended infusions of cefepime may be superior to intermittent infusions, but future prospective studies are needed to confirm these findings.