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Ratnoff and Weisman Alyson Michener, PGY2 Internal Medicine University Hospitals Case Medical Center Logistics • • • • • Ratnoff Hem/onc attending 1 resident, 2 interns Intern cap is 8 Short, medium, long, happy Team room is Seidman 3 • • • • • Weisman Hem/onc attending or hospitalist 1 resident, 2 interns Intern cap is 8 Short, medium, long, happy Team room is Seidman 4 Common admissions • • • • • • • • • • • Sickle cell Pain control, nausea, vomiting Failure to thrive Cord compression Tumor lysis Malignancy workup Hypercalcemia SVC syndrome Constipation Neutropenic fever General medical problems Hints and tricks • • • • • E-mail your patient’s primary oncologist Review oncology notes in portal Know treatment history Ordering a peripheral smear Sickle cell care path, OARRS Ratnoff/Weisman Top 5 1. 2. 3. 4. 5. Neutropenic fever Sickle cell Cord compression Tumor lysis Pain management A 37-year-old woman is evaluated in the emergency department for fever and rigors of 4 hours’ duration. Medical history is significant for acute lymphoblastic leukemia for which she completed multiagent chemotherapy 10 days ago. Her medical history is otherwise noncontributory, and she takes no other medications. On physical examination, temperature is 38.8, blood pressure is 110/60 mm Hg, pulse rate is 100/min, and respiration rate is 16/min. On pulmonary examination, the lungs are clear. The remainder of the physical examination is unremarkable. Laboratory studies indicate a leukocyte count of 0.3µL with 0 neutrophils. The remaining laboratory studies are normal. A chest radiograph is normal. Blood and urine cultures are obtained. Which of the following is the most appropriate next step in management? A. Administer granulocyte-macrophate colony-stimulating factor B. Await culture results before starting antimicrobial therapy C. Begin piperacillin-tazobactam D. Begin vancomycin Neutropenic fever • Neutropenia: ANC <1500 cells/microL; Risk of infection rises with ANC <500 cells/microL • Infectious etiology identified in 20-30% of episodes • Common organisms: S. epidermidis, S. aureus, Pseudomonas and other gram negatives Neutropenic fever: Management • • • • • • • 2 sets of blood cultures Cultures from other sites if clinical suspicion CXR if respiratory sx Initial monotherapy with zosyn, cefepime, or meropenem Vancomycin for some indications Treatment is typically continued at least until ANC > 500 Adding antifungals AG Freifeld et al. Clinical practic guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of america. Clinical Infectious Diseases. 2011. 52(4): 56-93. Hematopoietic growth factors in neutropenic fever G-CSF and GM-CSF • Can be used prophylactically when risk of neutropenic fever is high • IDSA: not recommended for treatment • ASCO: can be considered in some instances TJ Smith et al. Recommendations for the use of wbc growth factors: american society of clinical oncology clinical practice guideline update. Journal of Clinical Oncology. 2015. 33:28 (3199-3212) A 29-year-old man is evaluated in the emergency department for dyspnea and diffuse severe pain in the arms, legs, back, and chest of 2 days’ duration. He has sickle cell anemia and experiences painful episodes one to two times per year. He also has a history of acute chest syndrome and has known erythrocyte alloantibiodies. In addition to increased fluid intake at home, he has been taking oral morphine sulfate, 30mg twice daily, with no relief. He also takes folic acid. On physical examination, temperature is 36.8, blood pressure is 153/65 mm Hg, pulse rate is 108/min, and respiration rate is 20/min. Oxygen saturation is 98% with the patient breathing ambient air. The patient is hunched over in pain, and he is diffusely tender to touch. Cardiopulmonary, abdominal, and neurologic examinations are normal. Laboratory studies show hemoglobin 7.2 g/dL, leukocyte count 11,900/µL with a normal differential, platelet count of 199,000/µL, reticulocyte count 5.4%, and lactate dehydrogenase of 420 units/L. The patient has alloantibodies to antigens C, E, and K on blood typing and screening. In addition to intravenous hydration and incentive spirometry, which of the following is the most appropriate initial treatment? A. B. C. D. Erythrocyte exchange transfusion Erythrocyte transfusion Intravenous meperidine Intravenous morphine Sickle cell complications • • • • • • • • • Pain crisis (vaso-occlusive crisis) Acute chest Stroke MI VTE Splenic sequestration Priapism Retinopathy Infections Managing a vaso-occlusive crisis • • • • • Labs: CBC, retic, LDH, CMP, CRP, UA, T&S Check for carepath Fluids Pain medication Incentive spirometry A 21-year-old woman is admitted to the hospital with a sickle cell pain crisis. Over the next 48 hours, she develops worsening dyspnea, chest pain, and fever. She takes daily folic acid supplementation and morphine delivered by a patient-controlled analgesia device with bolus and demand infusions. On physical exam, temperature is 38, blood pressure is 123/65 mm Hg, pulse rate is 118/min, and respiration rate is 22/min and labored. There is no jugular venous distension. Cardiopulmonary exam discloses decreased bilateral breath sound at the lung bases, but no crackles or S3. There is no peripheral edema. Laboratory studies show hemoglobin 6.2 g/dL, leukocyte count 6900/µL with a normal differential, MCV 84 fL, platelet count 179,000/µL and reticulocyte count 4.4%. Oxygen saturation is 86% with the patient breathing oxygen, 3 L/min by nasal cannula. Chest radiograph shows multilobar infiltrates not present on admission chest radiograph. An electrocardiogram demonstrates sinus tachycardia with no ST changes. Broad spectrum antibiotics are begun, incentive spirometry is initiated, and morphine is continued. Which of the following is the most appropriate additional treatment? A. Erythrocyte transfusion B. Fluid bolus C. Furosemide D. Hydroxyurea Acute chest • Fever, chest pain, hypoxemia, wheezing, cough, or respiratory distress with a new pulmonary infiltrate on CXR • May see drop in hemoglobin • Management o o o o o o Analgesia Oxygen Incentive spirometry Antibiotics Simple transfusion Urgent exchange transfusion Evidence-based management of sickle cell disease. Expert panel report, 2014. http://www.nhlbi.nih.gov/sites/www.nhlbi.nih.gov/files/sickle-cell-disease- Pain management • Pain affects 70-80% of patients with advanced malignancy • Pain is often undertreated • Can be related to the malignancy or the treatment A Caraceni et al. Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. The Lancet: Clinical Oncology. 2012. 13:2 (58-68). Assessment of pain • • • • • • History Pain syndrome Pathophysiology and etiology of pain Extent of malignancy and plan for further treatment Goals of care Related symptoms Cancer pain syndromes • • • • • • • Hemorrhage Pathologic fracture Obstruction/perforation Mucositis Neuropathy from chemotherapy Post radiation Tumor invasion Treatment of cancer pain • • • • • Can include disease-modifying therapies and symptomatic treatment Opioid analgesics Non-opioid analgesics Adjuvant analgesics Non-pharmacologic treatment Opioid analgesia • Start with short acting o Tramadol o Oxycodone o Hydromorphone • Patient controlled analgesia • Transition to a long acting agent • Palliative care consult Other issues in pain management • Adjuvant therapy o Anticonvulsants (gabapentin) o Antidepressants (desipramine and nortriptyline) o Corticosteroids • Opiate side-effects o Constipation o Nausea o Itching E Bruera and HN Kim. Cancer Pain. JAMA. 2003. 290:18 (2476-2479). A 78-year-old man is hospitalized for a 1-week history of progressive and severe back pain and weakness in both legs. He describes a sense of “heaviness” in his legs and has had an increasing difficulty climbing stairs and getting out of a chair. Medical history is significant for asymptomatic multiple myeloma that his been followed with periodic examinations and laboratory studies; his last assessment was 3 months ago and was stable. On physical exam, vital signs are normal. He has point tenderness over the T10 and T11 vertebral bodies, decreased lower extremity muscle strength (3+/5), increased reflexes isolated to both lower extremities, and bilateral extensor plantar responses. The remainder of the physical examination is unremarkable. Laboratory studies are significant for a serum hemoglobin level of 6.5 g/dL and a serum calcium level of 13mg/dL. MRI of the thoracic and lumbar spine shows a vertebral body mass and extension into the epidural space at T12 and compression of the spinal cord. Which of the following is the most appropriate initial step in treatment? A. Biopsy of the epidural mass B. Decompressive surgery C. IV glucocorticoids D. Multiagent chemotherapy E. Radiation therapy Malignant spinal cord compression Compression of the dural sac and its contents (spinal cord and/or cauda equina) by an extradural tumor mass • ~3% of hospitalized cancer patients per year • Most commonly seen in lung cancer, breast cancer, prostate, multiple myeloma • 20% initial presentation of malignancy • Outcome is dependent on pretreatment neurologic status DA Loblaw, J Perry, A Chambers, and NJ Laperriere. Systematic review of the diagnosis and management of malignant extradural spinal cord compression: the cancer care ontario practice guidelines initiative’s neuro-oncology disease site group. Journal of Clinical Oncology. 2005. vol 23 no 9 (2028-2037). Assessment • • • • • Back pain Weakness Difficulty walking Increased deep tendon reflexes Bladder and bowel incontinence Management • • • • • • MRI entire spine High dose dexamethasone (10 mg IV stat followed by 4mg Q6) Call spine (ortho or neurosurgery) Call radiation oncology Pain control Urinary catheterization Metastatic spinal cord compression: diagnosis and management of patients at risk of or with metastatic spinal cord compression. NICE clinical guidelines, No. 75. 2008. A 27-year-old man is evaluated in the emergency department for a 1-week history of bruising and gingival bleeding with flossing. He has no significant medical history and takes no medications. On physical exam, temperature is 37.5, blood pressure is 110/80 mm Hg, pulse rate is 80/min, and respiration rate is 14/min. Scattered ecchymoses and cutaneous petechiae are present. There is no lymphadenopathy or splenomegaly. Laboratory studies Leukocyte count 150,000/µL Platelet count 20,000/µL Creatinine 4 mg/dL Fibrinogen Normal Phosphorus 8 mg/dL Peripheral blood smear shows 70% myeloblasts. Urate 12circulating mg/dL Which of the following is the most appropriate treatment? A. Fresh frozen plasma B. High-volume normal saline hydration and rasburicase C. Multiagent chemotherapy D. Platelet transfusion Tumor lysis syndrome • Metabolic derangements from abrupt release of cellular components after rapid lysis of malignant cells • Most common with hematologic malignancies • Findings o o o o o o Hyperuricemia Hyperkalemia Hyperphosphatemia Hypocalecemia Uremia Acute renal failure Tumor lysis syndrome diagnosis • CTLS: LTLS + renal insufficiency, arrhthmias/sudden death, seizures Electrolyte derangements • • • • Hyperphosphatemia – nausea, vomiting, diarrhea, lethargy, seizures Hypocalcemia – cardiac arrhythmia, hypotension, tetany, cramps Hyperkalemia – arrhythmias, fibrillation, cardiac arrest Uremia Management of TLS • • • • • • Fluids, fluids, fluids Treat hyperkalemia and electrolyte derangements Alkalinization? Allopurinol Rasburicase (recombinant urate oxidase) Dialysis B Coiffier, A Altman, C Pui, A Younes, and MS Cairo. Guidelines for the management of pediatric and adult tumor lysis syndrome: an evidence-based review. Journal of Clinical Oncology. 2008. 26(16): 2767-2778. Rasburicase • Contraindicated in patient’s with G6PD deficiency • 0.1-0.2 mg/kg daily for 1-7 days • Length of therapy based on uric acid levels • Check uric acid levels 4 hours after administration B Coiffier, A Altman, C Pui, A Younes, and MS Cairo. Guidelines for the management of pediatric and adult tumor lysis syndrome: an evidencebased review. Journal of Clinical Oncology. 2008. 26(16): 2767-2778. References • • • • • • • • A Caraceni et al. Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. The Lancet: Clinical Oncology. 2012. 13:2 (58-68). AG Freifeld et al. Clinical practic guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of america. Clinical Infectious Diseases. 2011. 52(4): 56-93. B Coiffier, A Altman, C Pui, A Younes, and MS Cairo. Guidelines for the management of pediatric and adult tumor lysis syndrome: an evidence-based review. Journal of Clinical Oncology. 2008. 26(16): 2767-2778. DA Loblaw, J Perry, A Chambers, and NJ Laperriere. Systematic review of the diagnosis and management of malignant extradural spinal cord compression: the cancer care ontario practice guidelines initiative’s neuro-oncology disease site group. Journal of Clinical Oncology. 2005. vol 23 no 9 (2028-2037). E Bruera and HN Kim. Cancer Pain. JAMA. 2003. 290:18 (2476-2479). Evidence-based management of sickle cell disease. Expert panel report, 2014. http://www.nhlbi.nih.gov/sites/www.nhlbi.nih.gov/files/sickle-cell-disease-report%20020816.pdf Metastatic spinal cord compression: diagnosis and management of patients at risk of or with metastatic spinal cord compression. NICE clinical guidelines, No. 75. 2008. TJ Smith et al. Recommendations for the use of wbc growth factors: american society of clinical oncology clinical practice guideline update. Journal of Clinical Oncology. 2015. 33:28 (3199-3212)