Chemotherapy-related neutropenic septic shockin gynecological cancer

Ji Geun Yoo

Department of Obstetrics and Gynecology

Seoul St. Mary’s Hospital

The Catholic University of Korea

Introduction

• For patients with gynecologic cancer, adjuvant chemotherapy has played an important role.

• Chemotherapy induces myelosupression, resulting in neutropenia and sepsis which is a major toxicity.

• Febrile neutropenia– Morbidity : 20-30%– Overall in-hospital mortality : ~10%

• Septic shock : 40% mortality

Annals of Oncology 27 (Supplement 5): v111–v118, 2016

Introduction

Shock. 2018 Apr;49(4):371-384.

Crit Care. 2004 Oct;8(5):R291-8.

Introduction

• Taxane-platinum combination chemotherapy– Incidence of G3-4 neutropenia : 64% - 84%– Incidence of febrile neutropenia : 7% during primary treatment– Incidence of neutropenic septic shock : around 1%

• Incidence of septic shock during chemotherapy is not well known.

• We conducted a retrospective review, focusing on the incidence of septic shock according to cancer type, age, lines, and chemotherapeutic regimens

Methods

• Seoul St. Mary’s Hospital, 2009 – 2017• Patients diagnosed with gynecological cancers and received

chemotherapy • Concurrent chemoradiotherapy was not included• Definition of neutropenic septic shock group

– Patients with sepsis– Neutropenia <500/mcL or <1000/mcL with predicted decline to

500/ul within next 2 days– Vasopressor requirement to maintain a MAP of 65mmHg

despite adequate fluid resuscitation– Septic shock events during the course of chemotherapy

or within 4 weeks of the last cycle

Methods

• Patients who corresponding to sepsis, but hypotension is caused by other fatal co-morbidities were excluded(aspiration pneumonia, GI bleeding, biliary obstruction, …)

• Statistical analysis: IBM SPSS 20

– Fisher’s exact test– Mann-Whitney U test– Univariate and multivariate logistic regression

Results

• Total 1,009 patients received 10,246 chemotherapy cycles• 30 (3.0%) patients experienced 33 septic shock events• 12 events of death occured (mortality : 36.4%)

0.00%

1.00%

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6.00%

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~44 45~49 50-54 55-59 60-64 65-69 70-74 75~

Age at chemotherapy administration

Patients, n. Septic shock, %

0.00%

1.00%

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7.00%

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50

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~44 45~49 50-54 55-59 60-64 65-69 70-74 75~

Age at the first treatment

Patients, n. Septic shock, %

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

4.00%

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1st line 2nd line 3rd line 4th and over

Patients %

Discussion

• Definition of septic shock in neutropenic patients– The Third International Consensus Definitions for Sepsis

(SEPSIS-3, 2016)– Elevated lactate level is reflective of cellular dysfunction

with higher levels predictive of higher mortality• >2 mmol/L : 42.3% mortality• <2 mmol/L : 30.1% mortality

– Lactate level does not affect initial resuscitation of septic shock

• Incidence of septic shock was higher than previous studies– Ethnic differences in the toxicity of chemotherapy

• Japanese ovarian cancer patients : 70-80% grade 4 neutropenia• Breast, lung, renal cell carcinoma

Discussion

• Limitations– Retrospective settings– Small cases due to low incidence– Risk factors of septic shock did not identified

• BMI, performance status, stage, comorbidities, …– Septic shock events reported officially was counted

• Events treated in other hospitals were not identified• 20 patients had not visited since the last chemotherapy,

and 5 patients died within a month since the last chemotherapy• The true incidence is likely to be higher

Thank you for your attention!