Oncologic Emergency Research Articles

The use of quasi-experimental design methods to evaluate and improve the impact of acute care centers on oncologic emergencies.

e13515 Background: Reducing avoidable hospital and emergency department (ED) use are national priorities in cancer care. Acute care centers (ACCs) that expand access for patients with oncologic emergencies are increasingly implemented as alternatives to inpatient and ED care. The impact of these ACCs is uncertain. Additionally, how to rigorously evaluate these interventions and to iteratively improve their effectiveness remains unclear as infrastructure interventions such as ACCs are not amenable to experimental manipulation. Methods: We are developing a novel quasi-experimental framework for evaluating and improving the effectiveness of an ACC intervention at the Simmons Comprehensive Cancer Center (SCCC) of the University of Texas Southwestern. SCCC covers one of the largest geographic regions of any academic medical center in the country, creating challenges addressing access to care. Drawing on the Andersen model for healthcare utilization we hypothesize that ACC effectiveness is mediated through enabling factors, particularly distance. Our initial evaluation framework draws on an untreated control group design with multiple pretest and post-test samples. The control group is comprised of patients living in zip codes farther away from the ACC. Additional analytic work will assess the feasibility of adding a matching cohort group structure based on factors such as onset of illness and matching individual patient episodes based on risk adjustment parameters. If the ACC is later expanded to other sites, the design can be further developed by adding a switching replications methodology to augment the quasi-experiment. Data collection draws on claims data provided through SCCC’s participation in Medicare’s Oncology Care Model (OCM). Results: Over OCM’s initial four performance periods (each six months long), all-cause risk adjusted hospitalization rates for SCCC patients ranged from 25.2% to 27.2%. All-cause risk adjusted OCM ED use ranged from 28.1 to 29.9%. Seeking to improve performance for both, SCCC leadership initially implemented a temporary urgent care clinic in August 2018. This initial prototype clinic was formalized into an operational ACC in August 2020. Evaluation of the impact of this ACC intervention is ongoing. Conclusions: ACCs represent potentially important means to reduce avoidable hospital and ED use. However, complex infrastructure interventions are not amenable to experimental evaluations assessing their impact, and it remains difficult to gain insights into how to tailor services through these interventions to support patients with oncologic urgencies and emergencies. Quasi-experimental approaches when integrated alongside ACC interventions represent promising mechanisms of evaluation and continuous quality improvement.

Risk factors for 30-day readmissions in patients with tumor lysis syndrome and solid malignancies: Analysis from the National Readmission Database.

e18863 Background: Tumor lysis syndrome (TLS) is a well-known potentially fatal complication of chemotherapy and an oncologic emergency. It is most prevalent in hematologic malignancies, but there are case reports and clinical series of occurrence after the treatment of solid tumors. Hospital readmissions are indicators of quality of care and cost control. We aim to look at the prevalence of readmissions after an initial episode of TLS in patients with solid malignancies and their financial burden on the United States healthcare system. Methods: We conducted a retrospective analysis of the 2017 National Readmission Database (NRD) of adult patients readmitted within 30 days after an initial “index” admission of TLS (ICD10 code E88.3) with a concomitant diagnosis of solid malignancy. We aimed to identify the 30-day readmission rate, mortality, healthcare-related utilization resources, and independent predictors of readmission by performing a COX regression analysis. Results: A total of 874 patients with solid tumors were admitted with TLS in 2017. The 30-day readmission rate was 20.4%. The main causes for readmission were sepsis, recurrent malignant lesions, metastasis to CNS, bleeding, acute kidney failure (AKI). Compared to initial admissions, readmitted patients were less likely to have acute kidney failure (AKI) (64.6% vs 30.8%; P < 0.01), less likely to require mechanical ventilation (17.9% vs 5.7%; P < 0.01), less likely to suffer shock (7.3% vs 2.3%; P = 0.03) and ileus (4.8% vs 0.7%; P = 0.04). Readmission was associated with higher in-hospital mortality rate (0.1% vs. 1.5%; P < 0.01), more likely to have private insurance (29.9% vs 36.1%; P < 0.01), and more likely to be discharged home (26.2% vs 36.8%; P < 0.01). The total health care in-hospital economic burden of readmission was $14.9 million in total charges to patients and $4 million in total costs for hospitals. Independent predictors of readmission were prolonged length of stay (during index admission), tobacco abuse, VTE, thrombocytopenia, and admission to an urban hospital. We identified the following preventive factors for readmission: radiation therapy, admission to a smaller hospital, total parenteral nutrition during the index admission and a primary gynecologic malignancy. Conclusions: Readmissions after TLS in patients with solid malignancy are associated with a higher in-hospital mortality rate and pose an increased health care burden. We identified risk factors that, if targeted, could lead to reducing readmissions, health care burden, and patient morbidity.

Assessment of solid tumor oncology perception and knowledge gain in internal medicine (IM) residents through oncology video library: Educational intervention in progress.

e23000 Background: ACGME and internal surveys performed at the University of North Carolina (UNC) demonstrate that IM residents have historically been dissatisfied with their inpatient oncology experience. Other institutions have demonstrated that a resident oncology video library is feasible and effective in improving clinical knowledge, but formal protected time for module use limited engagement. We created an oncology video library targeted to the resident learner. To enhance impact, we incorporated dedicated time during elective rotations to access the modules. Methods: We performed a pre-survey using a Likert scale to assess resident knowledge perception of solid tumor cancers. We designed a curriculum based on the ABIM blueprint and those cancers frequently encountered on service. We filmed 21 videos of UNC oncologists discussing content they selected for the resident learner. To improve engagement, we provided a half-day of independent study during their outpatient oncology elective. As this study is ongoing, we plan to conduct a post-survey and post-test to evaluate long-term knowledge acquisition. Results: Twenty-seven of the 85 IM residents completed the pre-survey. Eleven (40.8%) reported feeling extremely or somewhat satisfied with inpatient oncology teaching; the remainder felt neutral (29.6%), somewhat (25.9%) or extremely dissatisfied (3.7%). Among oncologic emergencies, most residents felt comfortable managing hypercalcemia (88.9%) and cord compression (55.6%), but not SVC syndrome (29.6%). Prior to implementation of the videos, most reported little/no knowledge gain from their clinical rotations alone across nearly all 20 domains assessed. The only domain in which a majority (65.39%) reported some or significant knowledge gain was chemotherapy toxicities. These domains were selected as video lecture topics. In the five months since their release, each video has been viewed an average 21.5 times. The most viewed video (39 views) was on traditional chemotherapy pharmacology; the least viewed video (9 views) was on pancreas cancer. 28% of residents surveyed reported utilizing the videos, and for those who did access them, half (56.2%) felt that the time for the videos was sufficient, while the other half (43.8%) wished for more dedicated time. Conclusions: IM residents may benefit from an online video library to improve knowledge acquisition and perception of oncology rotations. However, to maximize impact, residents must be given adequate time separate from their service requirements to access the modules. This is a study in progress, and while initial data regarding video utilization appears promising, we await additional information to ascertain knowledge improvement.

Delays in time to antibiotics in inpatient oncologic neutropenic fever do not predict decreased overall survival.

e18765 Background: Neutropenic fever (NF) is relatively common oncologic emergency. Present expert consensus is that anti-pseudomonas gram-negative antibiotics should be administered within 60 minutes of detecting NF. To date studies investigating this relationship in neutropenic fever patients have been either limited in size, or have failed to reliably establish a relationship between time to antibiotics (TTA) and clinical outcomes.While some studies have shown an association between TTA and outcomes in NF patients admitted from the Emergency Department, such studies do not control for the time that patients may have been febrile in the community. To address these factors, we conducted a retrospective study on the effect of TTA on mortality in oncologic patients who developed NF as inpatients. Methods: We performed retrospective chart review of all cases of NF at an NCI designated Cancer Center between 7/1/2016 and 3/27/2019. NF was defined as temperature of 101˚ F on one occasion, or 100.4˚ F sustained over 60 minutes, with an absolute neutrophil count (ANC) less than 500. TTA and survival were calculated via chart abstraction; patients lost to follow up within 180 days were censored to the 180-day mortality group. Relationship between TTA and overall survival (OS) was analyzed via multivariable Cox regression. We excluded patients that had non-cancer related NF, were transferred from another institution with NF, were admitted from the ED with NF, or transitioned to hospice. Only the first instance of NF in any admission was analyzed. Results: A total of 187 eligible cases were identified during the study period, mean age was 57.6 +/- 13.6, 100 (53.5%) cases were in males, 114 (61.0%) cases in Caucasians, 53 (28.3%) in Black People. The 3 most common disease subtypes were acute leukemia (42.8%), plasma cell dyscrasias (27.8%), and lymphoma (16.6%). TTA showed no significant correlation with OS at any timeframe studied. Low Charlson Comorbidity Index ( < 3) correlated with increased survival through ̃360 days, however the effect was non-significant at longer timeframes. Immediate antibiotic treatment ( < 40 mins) correlated with poorer patient prognosis and significantly decreased OS (HR 3.08;CI: 1.30-7.28; p 0.010). Conclusions: TTA was not associated with OS in our study. For inpatients with NF, even hours long TTA may not be long enough to result in adverse clinical outcomes. Unlike NF patients presenting to the ED, where true TTA may often be many hours or even days prior to arrival, a few hours-long TTA in the hospital may not be sufficiently long enough to cause significant patient harm. Interestingly, in our cohort, those who received antibiotics quickly had adverse outcomes. It may be that in patients who were clinically unstable, TTA was shorter given the urgency of the situation. Ultimately, this study’s findings question the applicability of the 60-minute guideline when used in the inpatient setting.

A Model Oncologic Emergency Medicine Curriculum for Residency Training.

Background Emergency medicine (EM) resident training in oncologic emergencies is limited, and significant gaps have been identified. Although 90% of emergency medicine residency program directors recognize the importance of residency training in oncologic emergencies, there is no standardized oncologic emergency curriculum. Objective We propose a focused oncologic EM curriculum that serves as a complement to existing EM didactics curriculums to prepare EM residents to recognize and manage the most common oncologic emergencies. It will also allow for familiarization with constantly evolving therapies, such as chimeric antigen receptor cellular therapy and immune checkpoint inhibitors.Discussion This curriculum consists of 10 hours of didactic instruction, which can be incorporated into an already existing didactic curriculum. The curriculum encompasses education on the recognition, rapid diagnosis, and management of oncologic emergencies, with the goal of improving the EM resident's understanding of cancer complications. The suggested topics can be delivered in a variety of methods, allowing for flexible integration in an already existing emergency education curriculum. The proposed curriculum should be introduced during the first postgraduate year and then in the second or third year of the residency to reinforce the learning points.Conclusions Our proposal of a focused, standardized 10 hour program curriculum aims to help to fill the gaps in knowledge of oncologic emergencies. To assist in wide dissemination and standardization of these curriculum topics, outlines for each module are given in the article and we also propose creation of open access online lectures and content to be shared for education purposes.

Deep learning for diagnosis of acute promyelocytic leukemia via recognition of genomically imprinted morphologic features

Acute promyelocytic leukemia (APL) is a subtype of acute myeloid leukemia (AML), classified by a translocation between chromosomes 15 and 17 [t(15;17)], that is considered a true oncologic emergency though appropriate therapy is considered curative. Therapy is often initiated on clinical suspicion, informed by both clinical presentation as well as direct visualization of the peripheral smear. We hypothesized that genomic imprinting of morphologic features learned by deep learning pattern recognition would have greater discriminatory power and consistency compared to humans, thereby facilitating identification of t(15;17) positive APL. By applying both cell-level and patient-level classification linked to t(15;17) PML/RARA ground-truth, we demonstrate that deep learning is capable of distinguishing APL in both discovery and prospective independent cohort of patients. Furthermore, we extract learned information from the trained network to identify previously undescribed morphological features of APL. The deep learning method we describe herein potentially allows a rapid, explainable, and accurate physician-aid for diagnosing APL at the time of presentation in any resource-poor or -rich medical setting given the universally available peripheral smear.

Rare Atypical Presentation of a Neuroblastoma of Posterior Mediastinum

Abstract Introduction Neuroblastoma is the third most common malignancy and one of the most common neurogenic tumors of posterior mediastinum in the pediatric age group. A posterior mediastinal tumor causing spinal cord compression is an important example of an oncologic emergency arising from a neurogenic tumor. We present a rare case of posterior mediastinum neuroblastoma, with exclusive lower limb weakness presenting at an unusually older age. Case Presentation A 6-year-old girl reported with upper back ache and sudden onset progressive bilateral lower limb weakness, with difficulty in urination for 10 days. The weakness had progressed to paraplegia on the day of presentation. On examination, the child was observed to have loss of tone and power in both lower limbs and bilateral extensor plantar reflex. Chest X-ray showed heterogeneous opacity involving most of the left lung. Contrast-enhanced MRI showed posterior mediastinal tumor, extending into spinal canal. Patient underwent D3 to D6 laminectomy with subtotal tumor excision and spinal decompression. Crush biopsy showed round cell tumor, and final histopathological examination revealed poorly differentiated neuroblastoma, which was strongly positive for neuron-specific enolase on immunohistochemistry. The surgery was followed by chemotherapy, and the patient remained symptom free on 2-year follow-up. Discussion The presenting symptoms in case of thoracic neuroblastoma may include airway obstruction and chronic cough. Sometimes, it may present with weakness, limping, paralysis, and bladder and bowel disturbances in case of spinal cord involvement. Posterior mediastinal neuroblastoma presenting with paraparesis is uncommon. In our case, the child presented with isolated lower limb flaccidity with no other classical symptoms. To the best of our knowledge and thorough study, only four cases of posterior mediastinum neuroblastoma presenting with lower limb paralysis has been published in the English literature to date. Conclusion Tumor usually presents with pressure symptoms, caused by the mass in the posterior mediastinum, but it’s almost exclusive occurrence in the pediatric population warrants a thorough investigation in patients presenting with not only a symptomatic mass but also exclusive lower limb neurological symptoms.

Effective Patient Selection for an Oncology-Dedicated Emergency Service: A Retrospective Study.

PURPOSE:Emergency cancer care constitutes a significant health care and patient burden. The purpose of this study was to identify characteristics of patients most fitting for treatment in an oncology-dedicated emergency department (OED).METHODS:Electronic files of patients with cancer seeking emergency services between April and June 2017 were retrospectively obtained from the hospital registry. Efficacy parameters were compared between patients treated in the OED and those treated in the general emergency department (GED). Using descriptive statistics and logistic regressions, patient- and treatment-related factors were correlated with effective care in the OED.RESULTS:More than half of the total 799 patients presented initially to the OED, of which 10.4% required GED referral. Treatment in the GED was associated with a higher rate of consultations, imaging, and hospitalization (P < .001), with the cost of imaging alone four times that of the OED ($23,263 US dollars difference). The relative proportion of patients with cancer visiting the GED was reduced after founding the OED. In the OED, patient diagnoses included lung (33%), GI, and breast cancer, of which 85% were metastatic. Frequent chief complaints were pain (45%), GI, malaise, and respiratory symptoms. Referral to the GED was significant in those with genitourinary cancer, back pain (P < .001), and neurologic symptoms, on biologic therapy, and with suspected oncological emergencies; conversely, disease symptoms (30% admissions) were well-controlled in the OED (P = .003).CONCLUSION:Using minimal resources, the OED provides efficacious, cancer-focused care, suitable for the majority of acute admissions. Careful triage is recommended, as high-risk patients should be referred to the GED, where advanced multidisciplinary management is more readily available.

Interprofessional clinical pathway program effects on patient outcomes in the setting of neutropenic fever: An integrative review.

Neutropenic fever (NF) is an oncologic emergency linked to substantial healthcare costs, treatment delays, and increased patient mortality. Clinical pathways have emerged as a coordinated, interprofessional approach to NF management. The aim of this review was to examine the research question: What is the effect of an interprofessional clinical pathway program on outcomes (time-to-antibiotic, mortality, cost, readmissions and length of stay) in patients presenting with NF? Using the integrative review method of Whittemore and Knafl, the databases PubMed, CINAHL and Scopus were searched for articles published in English between 1997 to present that met the following criteria: (1) reported clinical pathway implementation, and (2) reported outcome data on patients 18 years or older who were diagnosed with NF. Of the 17 included articles, 13 demonstrated improvement in reducing time-to-antibiotic following clinical pathway implementation. Three studies reported a reduction in mortality and two studies reported no change in patient mortality after NF clinical pathway integration. One study demonstrated a reduction in hospital readmissions, while three studies showed improvement in length of stay. None of the included studies reported data on cost reduction. Half of the articles articulated the different members of the interprofessional teams. The implementation of interprofessional clinical pathway programs for NF had positive effects on patient outcomes in this review. Measuring patient and institutional outcomes is necessary to evaluate the effectiveness of interprofessional clinical pathways in NF care. Future research should incorporate these measurements to improve the development and implementation of NF clinical pathways.

Disseminated Intravascular Coagulation

This article describes the pathophysiology and causes of disseminated intravascular coagulation (DIC). Implications for nurses are also reviewed. Pee-reviewed articles and up-to-date references were used to check accuracy of the information and provide information for current management of this syndrome. DIC is an oncologic emergency in which bleeding and clotting occur simultaneously. In the cancer population, the syndrome is frequently associated with certain malignancies or sepsis. If not recognized and treated early, mortality can be high. This article describes the risk factors that contribute to DIC, clinical manifestations of DIC, and its treatment. Nurses need to consider the presenting diagnosis of the patient and understand laboratory abnormalities that signify DIC. The nurse plays a key role in early recognition of this syndrome as prompt treatment can reduce fatality.

The Unique Balancing Act of Managing Children With Cancer and COVID-19 Infection: A Single Center Experience From South India.

Children with cancer are vulnerable to severe infections. Balancing the intensive treatment of cancer, with the potential risk of coronavirus disease-2019 (COVID-19) related morbidity and mortality is a unique challenge. Children with cancer testing positive for severe acute respiratory syndrome coronavirus 2 virus by reverse-transcription polymerase chain reaction at our center were studied. Thirty-seven children tested positive for COVID-19 during the study period. The severity of the illness was mild, moderate, severe, and critical in 10 (27%), 13 (35%), 12 (32%), and 2 (5%) patients, respectively. Of the 14 patients with a severe/critical illness, 2 had oncological emergencies, 4 had dengue co-infection, and 1 had an inguinal bacterial abscess. All patients were discharged in a stable condition. Modification of the treatment protocol was performed in 11 (33%) of 33 patients who were on active treatment for cancer. There was a median delay of 32.5 days to administer the next cycle of chemotherapy in patients who acquired COVID-19 during cancer treatment. Six of 7 patients who were retested after 14 days remained positive by reverse-transcription polymerase chain reaction. Children with cancer with COVID-19 recover with good supportive care. Curative chemotherapy can be administered safely with appropriate modifications in children with cancer with COVID-19.

Types of cancer and outcomes in patients with cancer requiring admission from the emergency department: A nationwide, population-based study, 2016-2017.

Emergency department (ED) utilization and emergency admissions by patients with cancer have increased. The authors aimed to evaluate the characteristics of patients with cancer admitted through the ED and determine whether cancer types are related to in-hospital mortality. The National Emergency Department Information System database of patients visiting EDs in South Korea between 2016 and 2017 was analyzed. Among 6,179,088 adult patients who presented to an ED with nontraumatic medical illness, patients with cancer were identified. The primary outcome was in-hospital mortality. Patients with cancer accounted for 6.8% of ED visits, and 239,630 patients (57.0%) were admitted to the hospital (intensive care unit [ICU], 9.5%; others, 90.5%). The prevalent cancers requiring hospitalization were lung cancer (15.7%), liver cancer (14.2%), and colon cancer (11.6%). The commonest reasons for admission other than cancer-related medical problems (41.4%) were pneumonia (4.8%) and hepatobiliary infection (2.8%). Overall in-hospital mortality was 16.1% (ICU, 28.3%; general wards, 14.8%); lung cancer (22.9%), liver cancer (19.7%), and leukemia/multiple myeloma (17.8%) showed the highest mortality rates. The highest odds for mortality were for lung cancer (adjusted odds ratio [OR], 2.227; 95% confidence interval [CI], 2.124-2.335; P < .001) and liver cancer (adjusted OR, 1.839; 95% CI, 1.751-1.930; P < .001), which were referenced to genitourinary cancer by multivariable logistic regression analysis. More than half of the patients with cancer visiting EDs were admitted to the hospital with a mortality rate of 16.1%. Physicians treating patients with cancer and policymakers and planners designing health systems should understand the different prevalences and outcomes of oncological emergencies by cancer type to improve patient care.

Tumor Lysis Syndrome: Implications for Oncology Nursing Practice.

To provide an overview of tumor lysis syndrome, which is one of the metabolic oncologic emergencies. A review and synthesis of empirical articles. One of the metabolic oncologic emergencies identified by the Oncology Nursing Society is tumor lysis syndrome. This condition is life-threatening and is characterized by metabolic derangements that can lead to acute kidney injury and multiple organ dysfunction. Normal intracellular components (potassium, phosphorus, and nucleic acids) spill into the bloodstream when cancer cells die. If the tumor is large and highly responsive to chemotherapy, the resulting cascade of dead tumor cells may overwhelm normal homeostatic mechanisms. The cells enter the bloodstream faster than they can be cleared by the kidneys. This results in hyperkalemia and hyperphosphatemia. Nucleic acids convert to uric acid in the liver with a resultant hyperuricemia. Excess uric acid in the kidneys can lead to uric acid nephropathy and renal insufficiency. Phosphorus binds with calcium, leading to hypocalcemia from the formation of calcium phosphate precipitate or crystals. These crystals can also lead to renal insufficiency or acute kidney injury, which can lead to a metabolic acidosis and exacerbation of the hyperkalemic state. These metabolic derangements define presence of tumor lysis syndrome. Multidisciplinary collaboration and communication is essential to identifying patients at risk prior to treatment. Meticulous nursing care in terms of prevention and treatment is critical to patient survival.

Nursing Care of Oncology Patients with Sepsis.

This article aims to update nurses on the incidence, diagnosis, and treatment of neutropenic sepsis and septic shock. A search of electronic databases, including PubMed and CINAHL, and e-books was performed, as was a search of clinically focused and point-of-care resources from the National Cancer Institute and UpToDate until December 2020. Neutropenic sepsis and septic shock are oncological emergencies and can be fatal for patients undergoing anticancer treatment. Prompt and targeted treatment based on clinical signs is necessary to minimize further sequela, including morbidity and mortality. The oncology nurse must possess an understanding of the risk factors, presenting signs, and initial management of a neutropenic fever, sepsis, and septic shock. Early identification and initiation of treatments in patients in sepsis and septic shock will allow the oncology nurse to intervene with speed, skill, and confidence while working within the multidisciplinary team to provide the best outcome based on current evidence.

Tumor Lysis Syndrome: Introduction of a Cutaneous Variant and a New Classification System.

Tumor lysis syndrome, an oncological emergency, is characterized by laboratory parameters such as hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia, as well as renal injury with an elevated creatinine. Tumor lysis syndrome is seen in patients with aggressive malignancies and high tumor burden. More frequently, it occurs in individuals with hematologic malignancies such as high-grade lymphomas (such as Burkitt lymphoma) and leukemia (such as acute lymphocytic leukemia). It also, albeit less commonly, can be seen in patients with widespread solid tumors that are rapidly proliferating and are markedly sensitivity to antineoplastic therapy. Tumor lysis syndrome is usually preceded by cancer-directed therapy; however, the syndrome can present spontaneously prior to the individual receiving malignancy-directed treatment. We reported a man with metastatic salivary duct carcinoma who had cutaneous metastases that presented as carcinoma hemorrhagiectoides. Microscopic examination demonstrated that the metastatic tumor cells had infiltrated and replaced the entire dermis. After the patient received his first dose of antineoplastic therapy, he had an excellent response and the cutaneous metastases developed into ulcers; we hypothesize that most of the dermis, which had been replaced by tumor cells, disappeared as a result of the therapeutic response, and the overlying epidermis became necrotic and shed, leaving an ulcer. His dramatic response to treatment prompted us to propose a new classification of tumor lysis syndrome, which should include the systemic form of the condition as well as the new variant: cutaneous tumor lysis syndrome. We anticipate that, with improvement in targeted therapies, there may be an increase in therapy-associated cutaneous tumor lysis syndrome.

Cancer related emergencies with the chief complaint of pain: Incidence, ED recognition, and quality of care

BackgroundPain is the most common reason for cancer-related emergency department (ED) visits and a precursor of the urgency of oncological emergencies. PurposeTo identify the incidence of oncological emergencies with the chief complaint of pain and evaluate ED recognition and quality of care in managing the associated emergency. MethodsThis was a retrospective observational study of cancer patients presented to three EDs during the four-year study period. ResultsThe study's sample consisted of 252 patients admitted with oncological emergencies with a chief complaint of pain. Some oncological emergencies were more likely to be prioritized appropriately, such as febrile neutropenia and increased intracranial pressure. However, most patients with spinal cord compression and cardiac tamponade were more likely to be triaged to less urgent triage categories. Timeliness of ED care was suboptimal for most patients, particularly among those assigned to less urgent triage categories. Indicators for the low quality of care extended beyond ED with multiple adverse events in the hospital. ConclusionTriage nurses are expected to use the oncological emergencies' prevalent symptoms to allocate the patients to high triage urgency accurately. Patient waiting to be seen expected to be reassessed periodically to ensure waiting remain safe. Hospitals can adopt or establish pathways, protocols, or standardized order sets to fast-track patients with oncological emergencies. The health information system should be available to monitor and improve the delivered care continuously.

P09.15 Severity of Lung Cancer Disease in Hospitalized Patients During COVID-19

Covid-19 pandemic has drastically changed the management of patients with cancer; however, there is still limited data regarding the real impact of Covid-19 on patient’s outcomes due to delayed diagnosis and treatment of clinical complications. We aimed to assess the prevalence, severity and mortality of clinical complications and oncology emergencies in hospitalized patients in our institution during the Covid19 period vs. the same period of 2019. We conducted a retrospective study of patients with small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC) who were admitted to the Department of Medical Oncology during Jan-Jun 2019 (before-Covid) and Jan-Jun 2020 (Covid-19 period). Clinical, pathological and biological data were collected. We assessed the clinical severity in both periods including: PS at admission, progression disease (PD), oncologic emergencies (%), start of a systemic therapy or switch to other therapy line. We also analyzed the differences on the 30-day mortality rate since hospitalization between both periods. 229 admissions, 133 during and 93 before Covid-19 pandemic (N=180 patients) were enrolled; the median duration of the hospitalization was 9 days (4-16). Median age was 66 years, 35% were female, 88% with PS≥2, 27% were current smokers; 83% had NSCLC histology. Most of them (82%) had advanced disease at admission; 69% were under systemic therapy (chemotherapy 39%, immunotherapy 17%, targeted therapies 11%). Nine patients (4%) were active covid-19 cases (9 NSCLC, 0 SCLC). The table 1 summarized the most common clinical conditions by histology, in both periods. In NSCLC population, during-Covid, lower rate of admissions were observed (4 cases less per month), with no increase of oncologic emergencies. The PD during hospitalization was slightly higher during vs. before-Covid, but no differences were observed in 30-days mortality rate. In SCLC population, during-Covid, the rate of admissions was doubled (2 cases more per month), with more cases progressing during the hospitalization. (46% during vs. 34% before-Covid). In contrast to NSCLC, the 30-days mortality rate was higher during-Covid (38%) vs. before-Covid (20%). Updated data will be presented in the meeting.Tabled 1NSCLC (N= 190)SCLC (N= 39)During-Covid (2020) N=83 (44%)Before-Covid (2019) N=107 (52%)During-Covid (2020) N=13 (33%)Before-Covid (2019) N=26 (67%)Baseline characteristicsMain reason of hospitalization Dyspnea Fever Pain Neurological symptoms Others27 (33%) 20 (24%) 9 (11%) 11 (13%) 16 (19%)26 (24%) 22 (21%) 16 (15%) 20 (17%) 23 (23%)3 (23%) 3 (23%) 1 (8%) 4 (30%) 2 (16%)11 (42%) 2 (8%) 1 (4%) 6 (23%) 6 (23%)PS at admission 0-1 ≥21 (1%) 82 (99%)22 (21%) 82 (79%)0 (0%) 13 (100%)3 (12%) 23 (88%)Stage at admission Locally Locally advanced Advanced7 (8%) 7 (8%) 69 (84%)7 (7%) 9 (8%) 90 (85%)0 (0%) 4 (30%) 9 (70%)2 (8%) 4 (15%) 20 (77%)N# mets. Sites at admission ≤2 >255 (67%) 28 (33%)64 (60%) 43 (40%)8 (62%) 5 (38%)14 (54%) 12 (46%)Line of therapy (only advanced disease) 0-1 ≥255 (65%) 28 (35%)69 (64%) 38 (36%)10 (76%) 3 (23%)21 (81%) 5 (19%)Disease severityN# AdmissionsN= 83 (14 per month)N=107 (18 per month)N=26 (4 per month)N=13 (2 per month)N# Readmissions21 (25%)22 (21%)1 (8%)5 (19%)Median duration of hospitalization (range)8(1;47)10(1;104)8(1;22)9(1;67)Oncology Emergencies Yes No8 (10%) 75 (90%)22 (20%) 85 (80%)1 (8%) 12 (92%)7 (27%) 19 (73%)Progression during hospitalization Yes No32 (39%) 51 (61%)35 (32%) 72 (68%)6 (46%) 7 (54%)9 (34%) 17 (66%)Early death (30-days mortality rate) Yes No20 (24%) 63 (76%)22 (21%) 84 (79%)5 (38%) 8 (62%)5 (20%) 20 (80%) Open table in a new tab We preliminary observed more aggressive disease with worse outcomes in patients with SCLC hospitalized during-Covid compared to the same period in 2019. No differences were observed in NSCLC. The final outcomes will be assessed in a larger and mature cohort still ongoing.

The Domino Effect-Treatment of Superior Vena Cava Obstruction Triggering Tumor Lysis Syndrome: A Case Report

Oncological emergencies present in a multitude of manners-structural, metabolic, hematologic, etc. affecting multiple systems, often. Urgent institution of therapy is often required for a successful outcome. Occasionally, the treatment of one emergency can initiate a related or unrelated emergency, necessitating management of all the complications simultaneously. Superior vena cava obstruction (SVCO) is a medical emergency and most often manifests in patients with a malignant disease process requiring immediate diagnostic evaluation and therapy due to its’ life threatening presentation. The management of the SVCO is usually with chemotherapy, radiotherapy or intervention. In cases of large tumor burden, management of SVCO can trigger other complications. Tumor lysis syndrome is an oncologic emergency, which is characterized by a massive release of intracellular potassium, phosphate, and nucleic acid metabolites into the systemic circulation, which can be life-threatening. We present the case of a T-cell acute lymphoblastic leukemia with superior vena cava syndrome, developing tumor lysis syndrome on instituting definitive chemotherapy in a young patient. Doi: 10.28991/SciMedJ-2021-0301-6 Full Text: PDF

An oncologic emergency case of massive dedifferentiated liposarcoma of the small bowel mesentery

We report the case of a 71-year-old man who complained of abdominal distension, pedal edema, respiratory discomfort, and weight gain. Computed tomography revealed a giant, poorly enhancing tumor occupying the entire abdomen, with abdominal ascites. The tumor was causing hydronephrosis, compression of the inferior vena cava, and elevation of the diaphragm. The patient exhibited deterioration of performance status (PS3 on the ECOG scale) and required oxygen; therefore, emergency surgery was performed. Operative findings included bloody abdominal ascites and peritoneal dissemination. The large tumor arose from the small bowel mesentery, and infiltrated into the cecum and sigmoid colon. Tumor excision with ileocecal resection and sigmoidectomy was performed. Histopathological examination revealed dedifferentiated liposarcoma. The patient was discharged on postoperative day 22, but pre-discharge CT revealed a recurrent liposarcoma in the retroperitoneum. Therefore, chemotherapy was initiated and the treatment has been continued for over 6months after surgery. Due to the rarity of this disease, there is no consensus regarding treatment strategies for DDLPS with peritoneal dissemination or in patients with a poor general condition, especially in the setting of oncologic emergency. In this case, multimodal treatment was used to successfully manage this life-threatening state and obtain satisfactory therapeutic results.

Cancer pain management in the emergency department: a multicenter prospective observational trial of the Comprehensive Oncologic Emergencies Research Network (CONCERN)

Many patients with cancer seek care for pain in the emergency department (ED). Prospective research on cancer pain in this setting has historically been insufficient. We conducted this study to describe the reported pain among cancer patients presenting to the ED, how pain is managed, and how pain may be associated with clinical outcomes. We conducted a multicenter cohort study on adult patients with active cancer presenting to 18 EDs in the USA. We reported pain scores, response to medication, and analgesic utilization. We estimated the associations between pain severity, medication utilization, and the following outcomes: 30-day mortality, 30-day hospital readmission, and ED disposition. The study population included 1075 participants. Those who received an opioid in the ED were more likely to be admitted to the hospital and were more likely to be readmitted within 30days (OR 1.4 (95% CI: 1.11, 1.88) and OR 1.56 (95% CI: 1.17, 2.07)), respectively. Severe pain at ED presentation was associated with increased 30-day mortality (OR 2.30, 95% CI: 1.05, 5.02), though this risk was attenuated when adjusting for clinical factors (most notably functional status). Patients with severe pain had a higher risk of mortality, which was attenuated when correcting for clinical characteristics. Those patients who required opioid analgesics in the ED were more likely to require admission and were more at risk of 30-day hospital readmission. Future efforts should focus on these at-risk groups, who may benefit from additional services including palliative care, hospice, or home-health services.