Oncologic Emergency Research Articles

P2.16-009 Strategy for Oncologic Emergency in Thoracic Disease

No large series of oncologic emergencies in thoracic surgery has been reported. Such patients are usually in critical condition and need immediate intervention of various types. Here, we present the surgical interventions that have occurred in our experience with oncologic emergencies.

P2.01-067 Treatment of the Patients with Oncological Emergencies with Massive Pleural Effusion at the First Hospital Visit

P2.01-067 Treatment of the Patients with Oncological Emergencies with Massive Pleural Effusion at the First Hospital Visit

Oncology Emergency Department: A Nurse Practitioner Care Model

Oncology Emergency Department: A Nurse Practitioner Care Model

The Most Recent Oncologic Emergency: What Emergency Physicians Need to Know About the Potential Complications of Immune Checkpoint Inhibitors.

Immune checkpoint inhibitors targeting cytotoxic T-lymphocyte associated protein 4 (CTLA-4) and programmable cell death protein 1 (PD-1)/PD-L1 have shown antitumor activity in cancers such as melanoma, non-small cell lung cancer, renal cell carcinoma, and urothelial cancer. Certain checkpoint inhibitors have been approved for use in Canada, and are becoming a mainstay in the treatment of melanoma and other malignancies. These drugs have a unique side effect profile and are known to cause immune-related adverse events (irAEs). These adverse events often appear to originate from an infectious etiology, when in fact they result from the enhanced immune response caused by immune checkpoint therapy. IrAEs are primarily treated with corticosteroids, which suppress the overactive immune response that is secondary to the treatment. IrAEs can occur in any organ system, but adverse events in the skin, gastrointestinal, endocrine, and pulmonary systems are among the most common. As an emergency physician, one must be familiar with these drugs and their adverse events in order to identify patients presenting with irAE and treat them accordingly. This paper provides a brief introduction to immune checkpoint inhibitors, discusses the most common irAEs relevant to emergency physicians, and gives suggestions on how to manage patients presenting to the emergency department (ED) suffering from irAEs.

Myelosuppression, Bone Disease, and Acute Renal Failure: Evidence-Based Recommendations for Oncologic Emergencies

Oncologic emergencies associated with multiple myeloma include myelosuppression (anemia, neutropenia, and thrombocytopenia), bone-related emergencies, and acute renal failure. . This article reviews the pathophysiology of these multiple myeloma-associated oncology emergencies and provides a framework for assessment and effective intervention. . A comprehensive review of the levels of evidence, focusing on assessment, diagnosis, comorbidities, treatment, ongoing monitoring, and patient education, are presented to support the plan of care for at-risk patients. . Attention to signs and symptoms is the foundation for preventing these emergencies or managing additional escalation of symptoms.

Critical Care Nursing: Diagnosis and Management 8th edition

Critical Care Nursing: Diagnosis and Management 8th editionUrden LD, Stacy KM, Lough ME. St Louis, MO: Mosby; 2017. Paperback; 1112 pages. ISBN-13: 978-0323447522The textbook Critical Care Nursing: Diagnosis and Management is an excellent resource for any nurse on the continuum of novice to expert. The book is comprehensive, easy to read, and perfect as a fast reference tool. The level of detail about the how and why of disorders and their medical and nursing management makes complex concepts easy to understand.The book is set up in units that discuss topics in acute, progressive, and critical care nursing. Unit I, Foundations of Critical Care Nursing, takes a comprehensive look at concepts needed by all critical care nurses for practice. Topics include acute and critical care nursing practice; ethical, legal, and genetic issues; patient and family education; management of alterations in psychosocial and nutrition; pain and pain management; sedation, agitation, and delirium management; and end-of-life care.Units II to VII cover body system–specific issues such as cardiac, pulmonary, neurologic, kidney, gastrointestinal, and endocrine. Unit VIII covers multi-system alterations including trauma; shock, sepsis, and multiple organ dysfunction; burns; organ donation and transplantation; and hematologic and oncologic emergencies. Unit IX discusses the management of disorders that occur in patient populations such as obstetric, pediatric, older adult, and perianesthesia patients.These units include information on the epidemiology and etiology, pathophysiology, assessment and diagnosis, laboratory studies, and the medical, nursing, and collaborative management for each disorder. This concise, consistent organization makes the process of finding an answer to a specific question simple and quick. The units also have case studies with open-ended questions to stimulate critical thinking.Appendices provide nursing plans of care for implementing the interventions described. The appendices also provide the formulas for commonly encountered hemodynamic, pulmonary, neurologic, endocrine, and renal calculations for critical care. Critical care nurses manage a large amount of data; this comprehensive resource helps nurses understand how all those numbers are derived.Throughout the book there are tables and charts with detailed information on laboratory results, pharmacologic interventions, and assessments, providing an in-depth understanding of the concepts presented. The index makes finding topics easy. In addition, quality and safety issues for patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics are called out and easily identified by the Quality and Safety Education for Nurses icon.Purchase of this book also provides access to the Elsevier’s Evolve study resources, including study questions for CCRN, PCCN, and NCLEX; videos and animations; procedures from Elsevier Clinical Skills; and TEACH for Nurses lesson plans, with answers to the case studies in the book, a bank of test questions, and PowerPoint slides for classroom instruction.Critical Care Nursing: Diagnosis and Management is an excellent companion for any acute or critical care nurse who needs a great reference text or who is studying for licensing boards or specialty certification.

Diagnostic and Therapeutic Strategies for Patients with Malignant Epidural Spinal Cord Compression.

Malignant epidural spinal cord compression (MESCC) is an oncologic emergency with the potential for devastating consequences for patients if not promptly diagnosed and treated. MESCC is diagnosed by imaging. MRI is by far the most sensitive test, preferably with gadolinium. Once the diagnosis of MESCC is suspected, patients with neurologic deficits should receive prompt administration of dexamethasone with a 10-mg IV loading dose followed by 4mg every 6h. Quick taper is recommended once the definitive treatment is established. Consultation with medical oncology, radiation oncology, and neurosurgery is imperative in order to facilitate a multidisciplinary approach. Although spine surgery is the most effective method for relief of cord compression and is necessary if there is spinal instability, surgery is only used in selected patients because most patients have a poor overall condition and short life expectancy. Radiation therapy, therefore, is the most commonly used therapy for patients with MESCC after surgical decompression or in patients who are not surgical candidates. Conventional fractionated radiation alone can achieve modest neurologic outcomes in selected radiosensitive tumors. Radiosurgery techniques which deliver intense focal irradiation to a delimited area with imaging guidance and contoured radiation delivery to the shape of the tumor have recently emerged as increasing effective treatments in MESCC, especially in radioresistant tumors. Stereotactic radiosurgery and different radiation technologies have been studied in recent clinical trials.

Successful afatinib treatment through nasogastric tube in a ventilated patient with non-small cell lung cancer

<p class="BodyText1">The majority of lung cancer patients are discovered at advanced stages and some of them may often have complex medical problems in addition to the diagnosis of cancer, such as oncologic emergency requiring assistance in an intensive care unit (ICU). In the last decade, epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors have been recognized as key drugs for non-small cell lung cancer (NSCLC) harboring sensitive EGFR mutation. We report a case of stage IV NSCLC with EGFR mutation (exon 19 deletion). He was in a life-threatening stage due to a massive intrathoracic hemorrhage. After chest tube drainage and mechanical ventilation, afatinib was administered through nasogastric tube. Consequently, a dramatic response was obtained and he was able to be discharged from our hospital 11 weeks after the initiation of afatinib. This approach may be of benefit to rescue from life-threatening condition for selected patients.</p>

Modern approaches to the management of metastatic epidural spinal cord compression.

Metastatic epidural spinal cord compression (MESCC) is an oncologic emergency requiring prompt treatment to maximize neurologic function, ambulatory function and local control. Traditionally, options for MESCC included external beam radiation therapy with or without surgery. Surgery has usually been reserved for the patient with optimal performance status, single level MESCC or mechanical instability. Advances in external beam radiation therapy such as the development of stereotactic body radiation therapy have allowed for the delivery of high-dose radiation, allowing for both long-term pain and local control. Surgical advances, such as separation surgery, minimal access spine surgery and percutaneous instrumentation, have decreased surgical morbidity. This review summarizes the latest advances and evidence in MESCC to enable modern management.

The Spanish Adaptation of the Palliative Performance Scale (Version 2) Among Cancer Patients at the End of Life: Psychometric Properties

BackgroundPalliative Performance Scale (PPS) is a reliable tool to assess performance status in cancer patients receiving palliative care (PC). Spanish validated and culturally adapted tools are needed. ObjectivesThe objectives are to develop PPS translation and cross-cultural adaptation into Spanish and to assess its psychometric properties. DesignTranslation process with cross-cultural adaptation to produce Spanish Palliative Performance Scale (PPS-SPANISH). SettingsPC Team at one University hospital in Spain. ParticipantsFifteen advanced cancer patients (60 assessments) were included for PPS translation and validation and 250 patients for cross-sectional analysis. All participants were recruited at oncology ward, emergency area, and outpatient clinic by PC team professionals. Informed consent was given. Average age was 66.4 ± 13 years (60% men). MethodsThe process is designed in three steps. In Step 1, PPS translation and reverse translation into Spanish (three bilingual speakers) and linguistic complexity measurement were performed. In Step 2, readability and intelligibility assessment was carried out. In Step 3, a pilot study was conducted to assess test-retest reliability followed by a cross-sectional study to measure internal consistency. Inclusion criteria were the same for two samples. Demographic data were also analyzed by descriptive statistics. ResultsFollowing cultural, linguistic, and grammatical adaptation, PPS-SPANISH was readable and reliable. The analysis of the test-retest reliability after 48 hours showed intraclass correlations >0.60. Cronbach's alpha coefficient was 0.99 (0.988–0.992). There was high agreement with other functional assessment tools (Barthel Index and Karnofsky Performance Status Index). ConclusionsPPS-SPANISH showed reliability and validity, and it is suitable to assess performance status in cancer patients receiving PC.

Junior doctors' perspective on oncology placement

This article was migrated. The article was not marked as recommended. IntroductionThe incidence of cancer is increasing and cancer care is rapidly changing. Junior doctors have reported lack of confidence in managing patients with cancer. We sought feedback from junior doctors on placement within our centre to quantify the educational impact on their training.MethodsJunior doctors who undertook a placement between February 2015 and August 2016 were asked to complete an online survey covering quality of training, clinical support and future career aspirations prior to and following the rotation.Results47 of 81 (58%) responses were received.Median score for quality of clinical experience was 6/10 (interquartile range 5-8). 40(85%) preferred working on the assessment unit compared to inpatient wards.42(90%) trainees felt confident managing neutropenic sepsis and malignant spinal cord compression. 14(30%) felt confident managing acute radiotherapy toxicities and 19(40%) felt confident managing systemic anti-cancer agent toxicities. 35(75%) felt confident managing end of life care patients.29(61%) felt senior support to be good during regular hours and 24(52%) felt the same for out-of-hours working.24(51%) found oncology-specific departmental teaching useful.Prior to the rotation 10(21%) wished to train in oncology and this was maintained following the attachment.ConclusionJunior trainees were confident managing acute oncological emergencies and end of life care patients but were less certain managing radiotherapy/chemotherapy toxicities. There remains scope for development of oncology-specific teaching and improving clinical support.

Neutropenic fever prophylaxis during induction therapy for acute myeloid leukemia.

e18531 Neutropenic Fever Prophylaxis During Induction Therapy for Acute Myeloid Leukemia Nassim Nabbout, MD, Salam Kadhem, MD, Rawaa Ebrahem, MD, Rossa Khalaf, MD, Baharat Malhotra, MD, K. James Kallail, PhD Background: Neutropenic fever is an oncological emergency [1] that occurs at a high rate in patients with acute myeloid leukemia (AML) undergoing induction chemotherapy. Oral antibiotics have been considered standard of care for prophylaxis for these patients once they develop neutropenia [2]. To determine the efficacy of this approach, we conducted a retrospective review of newly diagnosed AML patients. Methods: All adult patients who underwent induction treatment for newly diagnosed AML at one Wichita, Kansas medical center between January 1, 2011 and December 31, 2013 were identified. The medical records were reviewed and pre-specified variables were collected. Results: Thirty-eight patients were included and their charts were reviewed. Nineteen (50%) were males. Thirty-six patients (95%) were white. The average white blood count on day 1 of treatment was 34000 cell/mm3 and the range was 1300 - 305,000 cell/mm3. The average ANC was 3700 cell/mm3 with the range of 10 - 28288 cell/mm3. All patients received prophylactic oral antibiotics once they became neutropenic. In all, but one patient, this regimen consisted of combination of levofloxacin, acyclovir, and fluconazole. Thirty-four patients (89%) developed neutropenic fever while they were on oral prophylactic antibiotics. Two patients (5%) developed septic shock. Four patients (11%) died during the first 21 days of induction, all due to infections, and three (8%) went to hospice. Causative organisms were identified in 11 patients (29%). All patients were switched to intravenous vancomycin and cefepime once they became febrile. Conclusions: Eighty-nine percent of patients developed neutropenic fever despite prophylaxis with oral antibiotics. These dismal results suggest that the current standard of care for neutropenic fever prophylaxis is ineffective and highlight the need for a different approach. Future studies should consider changing the regimens of antibiotics and/or the route of administration toward more aggressive prophylactic strategies.

Characteristics and outcomes of oncology patients requiring admission to an Australian intensive care unit.

e21653 Background: Patients with advanced malignancies have historically been considered poor candidates for the intensive care unit (ICU), however survival and prognosis is continually improving and requirements for use of intensive care services is increasing. This study aimed to understand the characteristics and outcomes of oncology patients admitted to an Australian ICU and identify potential prognostic factors. Methods: A single-centre, retrospective, cohort study was conducted at Royal North Shore Hospital, a tertiary public hospital in Sydney, Australia with a 58-bed quaternary ICU. All patients aged > 18 years, admitted under the medical oncology team requiring ICU admission between June 2014 and June 2016 were evaluated. Data collected included basic demographics, cancer type and status, performance status (ECOG) and co-morbidities (ACE-27 score). Clinical outcomes were determined including ICU and hospital mortality, requirements (ventilation, dialysis, vasopressors, infection) and APACHE II scores. Results: There were 96 patients admitted to the ICU during the study period. Mean age was 61 years, 58% were male and 76% had metastatic disease. Most patients were receiving palliative treatment (89%), with recent chemotherapy (43%), immunotherapy (10%) and other therapies (5%). Of the 10 patients with recent immunotherapy, three (all melanoma) required ICU admission due to immunotoxicity with all three alive at time of data collection (mean 222 days follow-up). 13% were admitted due to an oncological emergency. Most common primary tumour site was thoracic (20%), genitourinary (11%), breast (10%) and melanoma (10%). Mean APACHE II score was 17 (SD 5.33), mean SOFA score was 4 (SD 2.70), ICU mortality was 5% and hospital mortality was 22%. For the 75 patients (78%) discharged from hospital, 42 (56%) were still alive at time of data collection (mean 321 days follow-up). Conclusions: Our patient population had good short-term outcomes for survival despite most receiving palliative treatment, although prognostic scores were also favourable. This suggests cancer patients can achieve positive outcomes after ICU admission with appropriate selection of patients crucial.

Carotid blowout syndrome: An oncological emergency less discussed.

Carotid blowout syndrome: An oncological emergency less discussed.

Gaps in Radiation Therapy Awareness: Results From an Educational Multi-institutional Survey of US Internal Medicine Residents

Internists and primary care providers play a growing role in cancer care. We therefore evaluated the awareness of radiation therapy in general and specifically the clinical utility of stereotactic body radiation therapy (SBRT) for early-stage non-small cell lung cancer (NSCLC) among current US internal medicine residents. A web-based institutional review board-approved multi-institutional survey was distributed to US internal medicine residency programs. The survey evaluated trainee demographic characteristics, baseline radiation oncology awareness, knowledge of the role of SBRT for early-stage NSCLC, and whether the survey successfully improved awareness. Thirty US internal medicine programs participated, with an overall participant response rate of 46% (1177 of 2551). Of the trainees, 93% (n=1076) reported no radiation oncology education in their residency, 39% (n=452) reported confidence in knowing when to consult radiation oncology in an oncologic emergency, and 26% (n=293) reported confidence in knowing when to consult radiation oncology in the setting of a newly diagnosed cancer. Of the participants, 76% (n=850) correctly identified that surgical resection is the standard treatment in operable early-stage NSCLC, but only 50% (n=559) of participants would recommend SBRT to a medically inoperable patient, followed by 31% of participants (n=347) who were unsure of the most appropriate treatment, and 10% (n=117) who recommended waiting to offer palliative therapy. Ninety percent of participants (n=1029) agreed that they would benefit from further training on when to consult radiation oncology. Overall, 96% (n=1072) indicated that the survey increased their knowledge and awareness of the role of SBRT. The majority of participating trainees received no education in radiation oncology in their residency, reported a lack of confidence regarding when to consult radiation oncology, and overwhelmingly agreed that they would benefit from further training. These findings should serve as a call to increase the educational collaboration between internal medicine and radiation oncology departments to ensure optimal cancer care.

Cohort study of oncologic emergencies in patients with head and neck cancer.

Treatments for head and neck squamous cell carcinoma (HNSCC) are associated with toxicities that lead to emergency department presentation. We utilized data from an ongoing prospective cohort of newly diagnosed, previously untreated patients (N = 298) with HNSCC to evaluate the association between clinical and epidemiologic factors and risk for and frequency of emergency department presentation. Time to event was calculated from the date of treatment initiation to emergency department presentation, date of death, or current date. Frequency of emergency department presentation was the sum of emergency department visits during the follow-up time. History of hypertension, normal/underweight body mass index (BMI), and probable depression predicted increased risk for emergency department presentation. BMI and severe pain were associated with higher frequency of emergency department presentations. Clinical and epidemiologic factors can help predict patients with HNSCC who will present to the emergency department. Such knowledge may improve treatment-related patient outcomes and quality of life. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1195-1204, 2017.

Tumor lysis syndrome in an extraskeletal osteosarcoma: a case report and review of the literature

BackgroundThis case report describes a spontaneous tumor lysis syndrome due to a rare solid tumor.Case presentationA 65-year-old white woman had tumor lysis syndrome, which represent a dangerous oncological emergency. This syndrome occurs usually with a hematological tumor, but in this case our patient had a solid tumor, which was a rare extraskeletal osteosarcoma, localized in her pelvic region. She also had lung metastases and bilateral hydronephrosis.After spontaneous tumor lysis syndrome, she had acute renal insufficiency, which was treated with hemodialysis and successively with rasburicase, Kayexalate (sodium polystyrene sulfonate), and febuxostat.ConclusionTumor lysis syndrome represents an oncological emergency, which must be suspected and treated as soon as possible.

Spontaneous tumor lysis syndrome in a patient with metastatic prostate cancer.

Tumor lysis syndrome (TLS) is a life-threatening oncological emergency, with most cases occurring in hematological malignancies following the initiation of treatment. However, on rare occasions, TLS may occur in solid tumors as well. In the present case study, the case is reported of a 56-year-old African-American man who presented with a recent diagnosis of prostate cancer, abdominal pain, elevated transaminases, renal insufficiency, hyperkalemia, and hyperuricemia, consistent with spontaneous TLS in the setting of metastatic prostate cancer. A computed tomography scan of the patient's abdomen demonstrated diffuse metastatic tumor burden. Following treatment with allopurinol, rasburicase, and initiation of anti-androgen therapy for the prostate cancer, the patient's TLS laboratory results normalized, however, his renal functions continued to decline. TLS is rare in solid tumors, and particularly rare in prostate cancer, with only six other case reports of the syndrome occurring to the best of our knowledge. This case report highlights the need for early recognition of TLS, even in cases that are not typically associated with the syndrome, as prompt diagnosis will affect early management and may be able to prevent or minimize complications.

Implementation of a Pathway for the Treatment of Fever and Neutropenia in Pediatric Patients With Cancer.

Fever and neutropenia is an oncologic emergency. Time-to-antibiotics (TTA) refers to the amount of time from initial provider evaluation for fever and neutropenia to intravenous antibiotic administration. Research supports that rapid time-to-antibiotics (RTTA) is associated with improved patient outcomes. This quality improvement project evaluated the success of implementing an RTTA pathway in pediatric oncology patients with fever and neutropenia. The setting was an advanced practice nurse-managed pediatric ambulatory infusion center where patients with fever and neutropenia were often evaluated and treated. In order to improve TTA, a multidisciplinary pathway was implemented with a goal of TTA that was less than 60 minutes from initial provider evaluation. Implementation of the RTTA pathway included discussion of shared expectations with the pharmacy and education departments and discussion of shared expectations with the bedside nurses and advanced practice nurses staffing the unit. Additionally, a preliminary lab test was utilized. Success of the implementation was evaluated through 2 measures: TTA and nurses' knowledge of fever and neutropenia and the importance of RTTA. The aims of this project were to improve TTA as well as nurses' knowledge of fever and neutropenia and the importance of RTTA, and both these aims were successfully attained.

Epidemiological and clinical patterns of presentation of surgical oncological emergencies of abdomen at a tertiary institution

Background: Oncological surgical emergencies of abdomen pose a typical problem for surgeons with respect to the choice of curative and palliative treatments and procedures in absence of opportunity for proper evaluation and support of multidisciplinary approach. For appropriate management, it is important to understand the epidemiological and clinical profile of this disease complex.Methods: A prospective analysis of abdominal emergencies encountered in emergency surgery department was done over a period of two years at a single institution and the malignancies were studied with respect to the pattern of clinical presentation and epidemiological characteristics.Results: At our centre, the incidence of intraabdominal oncological emergencies requiring surgery was found to be 6.56% of total emergent presentations excluding abdominal trauma cases. The overall mortality for study duration was 29% and the perioperative mortality within 30 days was 24%. Colonic malignancies (62%) and gastric malignancies (28%) were the most common to present as emergency. It was noted that small bowel (5%) and ovarian malignancy (5%) were not common. Perforation peritonitis was the only presentation as acute emergency in carcinoma stomach. In colonic malignancies, obstruction was the most common emergency presentation (92.5%) and perforation was an uncommon mode of presentation (7.5%).Conclusions: Surgical intervention appears to be unavoidable in the situation of a malignancy presenting as an emergency case, despite the awareness that most of these patients are going to have a limited life expectancy. A high rate of perioperative mortality is observed in emergent presentations of oncological abdominal emergencies.