urgent medical conditions
TRANSCRIPT
Microsoft PowerPoint - 3_Urgent_Medical_Conditions_D.
Rosielle_final.pptxUniversity of Minnesota School of Medicine
Minneapolis, MN
• I have no relevant disclosures.
• Many slides adapted from prior AAHPM board review courses by Drs Lauren Goodman, Earl Quijada, & Eric Widera
Objectives
URGENT MEDICAL CONDITIONS
• Spinal cord compression • Hypercalcemia • Increased intracranial pressure • Fractures • Seizures • Superior vena cava syndrome • Hemorrhage
ARS Question 1 A 48-year-old man with a previous history of lung cancer presents to the emergency department with upper back pain which has progressed over the last 3-4 days. His pain is localized to the upper thoracic spine and does not radiate. Over the past 24 hours he has noted left leg weakness. Prior to this event he continued to work as a bank loan officer. Severity is rated as 5-9/10. Examination shows point tenderness over the T4 vertebral process, 4/5 strength in the left knee extensors, and 3/5 weakness in the left ankle dorsiflexors. MRI of the cervical, thoracic, and lumbar spine shows a single metastatic lesion of T4 with early cord compression. Dexamethasone is started. He is evaluated by Radiation Oncology and Neurosurgery. Palliative Care is consulted for pain management.
ARS Question 1 Options
The patient’s short and long term functional status is likely to be optimized by:
A. Radiation therapy alone to the affected thoracic spine B. Open decompressive neurosurgery of the involved
thoracic spine followed by radiation therapy C. A course of radiation therapy followed by open
decompressive neurosurgery of the involved thoracic spine
D. Combined therapy with radiation therapy to the affected thoracic spine and kyphoplasty of the T4 vertebra.
URGENT MEDICAL CONDITIONS
Spinal Cord Compression
– Chronic disability
Key Concepts1
• 83-95% have back pain before diagnosis
• Ability to walk prior to treatment predicts preserved ambulation after treatment
• Best survival if ambulatory, 1 spinal metastasis, no visceral mets, radiosensitive, quick to start therapy
• Evaluation, treatment hinges on prognosis and goals of care
URGENT MEDICAL CONDITIONS
Pathophysiology1
• Vast majority are epidural or locally advanced metastases – 90% vertebral, 10% neural foramina – Intradural and leptomeningeal (dural) are rare
• Thecal sac compression leads to cord changes
– indentation → strangulation → infarction
Assessment1,2
• Pain can be local, referred, radicular or combination • Metastasis location often predicted by primary site:
– 60% thoracic (breast, lung cancers) – 30% lumbosacral (colon, pelvic cancers) – 10% cervical
• Can have radiculopathy, weakness, sensory changes, sphincter incontinence, autonomic dysfunction
• Cauda equina syndrome – Post-void residual has 90% sensitivity, 95% specificity
Diagnosis1
• MRI is gold standard – Sensitivity 93%, specificity 97%, pos. predictive value 95%
– If cannot MRI, CT spine with myelography has sensitivity 95%, specificity 95%, if CSF contrast flow not obstructed
• Image entire spine – 1/3 with cord compression have multiple metastatic sites
– May find unsuspected lesions, which alters surgical options and radiation therapy field
URGENT MEDICAL CONDITIONS
Pain and Symptoms2
• 60-90% of patients’ pain relieved with steroids + XRT
• Aggressive bowel regimen: – With sphincter control: stimulant; osmotic laxative
for stool every 1-2 days – Without sphincter control: polyethylene glycol +
stimulant suppository daily
• No evidence that very high doses (e.g., dexamethasone 96-100mg/day) improve outcomes; much evidence of side effects with such high doses
• Recommend moderate-dose dexamethasone: 10 mg IV bolus, then 4 mg IV/PO 4 times/day with 2 week taper – No standardized dosing, local culture/practice prevail! – Major point is that high dose is not necessary!
Radiation vs Surgery: Indications1,3
Radiation Alone Surgery (+/- post-operative RT)
No spinal compression or instability Spinal instability (e.g., spinal deformity, bony retropulsion into canal, pathologic fracture). This is why neurosurg needs to be consulted to determine this properly!
Prior radical spinal decompression Previous radiation therapy to area limiting further doses
Subclinical cord compression Disease progression despite radiation
Known radiosensitive tumor (typically breast, prostate, small cell, lymphoma, myeloma)
Radioresistant or unknown primary tumor
‘Poor surgical candidate’ (e.g., severe CAD, overall anticipated survival <3 mos); non- ambulatory at baseline
Good baseline performance status & lost ambulation for <48 hrs
Multiple areas of cord compression Single area of cord compression
URGENT MEDICAL CONDITIONS
Radiation Therapy: Outcomes1,3
• When initiated promptly (ideally within 24h of diagnosis) – Achieves pain relief in 40-80% – Retains sphincter control in 45-90% if initiated promptly – Of those without paralysis, 90% retain ambulation with RT alone – Of those with paralysis, <30% regain ambulation with RT alone
• Ideal schedule/dose remains unclear – 8Gy in 1-2 sessions is effective, may be preferable in patients with
short prognosis – Depending on dose/location, may be able to repeat in the future
Surgery: Outcomes4
For patients who are ‘reasonable surgical candidates’: • Surgery + RT, vs RT alone:6
– More regain ambulation if just lost it (62% vs 19%) • No short-term (1 month) survival difference;
small long-term survival benefit5,7
• There are mixed and unconvincing data about other outcomes (pain, retaining ambulation)
Prognosis5
– Shortest: multiple metastases, visceral or brain metastases, lung cancer
– Ambulatory status: • Patients who could walk after therapy (7-9 months) • Non-ambulatory pts after cord compression treatment (1-2
months)
URGENT MEDICAL CONDITIONS
Bottom Line – Cord Compression • Do image the entire spine with MRI if suspected –
physical exam is not sufficient to localize compression! • Do immediately start glucocorticoids • Do immediately & emergently consult radiation oncology
+ neurosurgery/spine surgery – Assuming surgical intervention is compatible with care goals
• For patients who have lost ambulation, surgery (followed by RT) is the only intervention with a realistic chance to restore ambulation
References: Spinal Cord Compression
1. McCurdy MT, Shanholtz CB. Oncologic emergencies. Crit Care Med. 2012 Jul;40(7):2212-22. doi: 10.1097/CCM.0b013e31824e1865. 2. Deyo RA, Rainville J Kent DL: What can the history and physical examination tell us about low back pain? JAMA 1992; 268:760–765. 3. George R, Jeba J, Ramkumar G, Chacko AG, Tharyan P. Interventions for the treatment of metastatic extradural spinal cord compression in adults. Cochrane Database Syst Rev. 2015 Sep 4;9:CD006716. doi: 10.1002/14651858.CD006716.pub3. 4. Akram H, Allibone J. Spinal surgery for palliation in malignant spinal cord compression. Clin Oncol (R Coll Radiol). 2010 Nov;22(9):792-800. doi: 10.1016/j.clon.2010.07.007. Epub 2010 Aug 10. 5. Abrahm JL, Banffy MB, Harris MB. Spinal cord compression in patients with advanced metastatic cancer: "all I care about is walking and living my life". JAMA. 2008 Feb 27;299(8):937-46. doi: 10.1001/jama.299.8.937. 6. Klimo Jr P, Thompson CJ, Kestle JR, Schmidt MH. A metaanalysis of surgery versus conventional radiotherapy for the treatment of metastatic spinal epidural disease. Neuro Oncol 2005;7(1):64e76. 7. Patchell RA, Tibbs PA, Regine WF, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet 2005;366(9486):643e648.
ARS Question 2 Stem A 60-year-old woman with malignant melanoma and brain metastasis has just arrived to your PCU from the emergency department, having been admitted for increasing seizure activity over the past few days.
The seizures are manifested as acute confusion and then clonic activity in the right arm. The patient arrives from the emergency department with a seizure in progress that began on the elevator. The patient does not have IV access and has clear goals to avoid intravenous lines and phlebotomy. The seizure continues unabated throughout the transfer to the bed, and the patient’s partner and primary caregiver confirms that this seizure seems unusually persistent, as it has now been over 7 minutes. The finger-stick glucose reading from the emergency department was 150 mg/dL.
URGENT MEDICAL CONDITIONS
A. Diazepam 10 mg subcutaneous
B. Diazepam 1 mg buccal
C. Lorazepam 10 mg subcutaneous
D. Lorazepam 1 mg buccal
E. Midazolam 10 mg subcutaneous
F. Midazolam 1 mg intranasal
Seizures
• Risk of physical injury, aspiration • Emotionally distressing for caregivers • High mortality from status epilepticus • Panicked decisions may contradict established
goals of care
• HPM docs often manage seizures especially in hospice & PCU settings
URGENT MEDICAL CONDITIONS
• Seizure: temporary brain dysfunction due to abnormal electrical activity – Affects ~10% of individuals during their lives – 25% of seizures with clearly identifiable
cause • Status epilepticus: any seizure exceeding 5
minutes; or frequent seizures without return to baseline clinical state. – ~20% mortality with first episode in general
population
Patients at risk • Brain tumors • Stroke & TBI– hemorrhagic >> ischemic • Previous history of seizures • Dementia • Alcohol or drug abuse (withdrawal or intoxication) • Severe hypoglycemia, hypoxia • Other: electrolyte abnormalities, liver failure, renal
failure, infections, neurodegenerative diseases
– Collaboration with neurologist
– Staff education
– Home seizure kit for high-risk patients • Understand that prognosis, goals of care will drive
treatment and setting of care
• Choose anticonvulsant(s) of choice, based on pharmacology, side effects, cost
URGENT MEDICAL CONDITIONS
Review Prognosis, Goals of Care
o Does pt appear to have hours, days, weeks or months to live?
o Does pt and/or family want hospitalization?
o Did pt express a wish to die at home?
o How are the caregivers coping?
o Are advance directives in place?
o Consider continuous care at home, or inpatient hospice house, nursing home or hospital.
General Guideline for Seizure/Status10
• Give parenteral benzodiazepine (IV/SQ, Nasal, IM, or PR)
• Additional antiepileptic drug if status epilepticus
• Labs (chemistry, Hgb, WBC, toxicology)
• Additional antiepileptic dose/drug if refractory
• Consider urinary catheter, continuous EEG, CT
head, ECG, LP, MRI, ICP monitor
Benzodiazepines: Initial Drug of Choice10,12
• IV/SQ/Buccal/Intranasal (vial + mucosal atomizer device):
– Midazolam (fastest onset, short half-life) 0.1-0.3 mg/kg IV/SC;
– Intranasal midazolam (5mg puffs x2) is very popular in pediatrics
• IV/SQ/Buccal:
– Lorazepam (slower onset, longer half-life) 0.1 mg/kg IV/IM up to 4mg
– 2-4 mg is a common initial dose
• Rectal:
– Diazepam (slower onset, rapidly redistributes out of CNS) (0.2 mg/kg or 10-20mg)
– No longer the drug of choice
• Benzos less likely than placebo to cause respiratory depression in studies for generalized convulsive status
• Few studies of subcutaneous efficacy in epilepsy literature
URGENT MEDICAL CONDITIONS
• Second drug choice depends on organ functions, other medications taken, available routes for administration, available medications – IV options: phenytoin, levetiracetam, fosphenytoin,
valproate, midazolam (bolus or infusion), propofol (infusion), and phenobarbital
– Non-IV options: rectal diazepam, rectal phenobarbital (similar bioavailability to PO – no change in dosing), nasal midazolam, buccal lorazepam
Medication Issues • Many drug interactions • Many side effects,
including rare life- threatening effects
• Drug levels not always reliable
• Patients with multi- organ failure, low albumin
• Protein binding – Unbound fraction is
active - phenytoin, valproic acid
Status Epilepticus – Dosing10
phenytoin 20 mg/kg IV 4-5 mg/kg/day IV tid
fosphenytoin 20 mg/kg IV, IM 4-5 mg/kg/day IV, IM tid
phenobarbital 10 mg/kg IV, SC 1-3 mg/kg/day IV, SC
midazolam 0.2 mg/kg IV, SC, IM
Max 2mg/kg/hr infusion Titrate as needed for refractory Status
lorazepam 0.1 mg/kg IV, SC up to 2mg/min
URGENT MEDICAL CONDITIONS
Seizures – Bottom Line • Do have a protocol/plan for high risk patients in
hospice/PCU • Do test/treat for hypoglycemia • Bolus parenteral benzos (buccal, nasal) are
first line for a seizure – doses are higher than for most other uses!
• For status – treatment depends on goals; typically infusions of benzos or other AEDs
References: Seizures 8. DeLorenzo RJ, Pellock JM, Towne AR, Boggs JG. Epidemiology of status epilepticus. J Clin Neurophysiol. 1995 Jul;12(4):316-25.
9. Logroscino G, Hesdorffer DC, Cascino G, Hauser WA, Coeytaux A, Galobardes B, Morabia A, Jallon P. Mortality after a first episode of status epilepticus in the United States and Europe. Epilepsia. 2005;46 Suppl 11:46-8.
10. Brophy GM, Bell R, Claassen J, Alldredge B, Bleck TP, Glauser T, Laroche SM, Riviello JJ Jr, Shutter L, Sperling MR, Treiman DM, Vespa PM; Neurocritical Care Society Status Epilepticus Guideline Writing Committee. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care. 2012 Aug;17(1):3-23. doi: 10.1007/s12028-012-9695-z.
11. Arif H, Hirsch LJ. Treatment of status epilepticus. Semin Neurol. 2008 Jul;28(3):342-54. doi: 10.1055/s-2008-1079339. Epub 2008 Jul 24.
12. Krouwer HG, Pallagi JL, Graves NM. Management of seizures in brain tumor patients at the end of life. J Palliat Med. 2000 Winter;3(4):465-75.
Hemorrhage
• HPM docs responsible for prevention; & management in hospice/PCU
• 6-14% of advanced cancer pts have significant bleeding • 3-12% of cancer pts have acute terminal hemorrhage • Patient at risk include those with
– Severe thrombocytopenia (<20k) – Cancers of head/neck, central lung/mediastinum, or
rectal/gynecologic structures – Refractory leukemia/myelodysplasia – Coagulopathy (liver disease/metastases, malnutrition, meds) – Surgery, Radiation, or other poorly healing wound – Visible arterial pulsation – Fungating tumors
Bleeding Sources14
40%
course in 20%; 3% fatal
• GI tract – Gastric, rectal or stromal – Chronic bleeding – Cirrhosis/portal HTN – Anticoagulation & AVMs
• Mucositis from Chemo/RT
HF02, bronchiectasis
wounds • Radiation for sentinel hemoptysis from lung
tumor • Endovascular stenting for high risk neck
cancer, especially after a sentinel bleed
URGENT MEDICAL CONDITIONS
Approach to Bleeding • Goals & place of care is hugely important
– Home vs Unit vs Hospital. What can hospice handle?
– Willing to be hospitalized for interventions, work-up?
– Ambulatory patient who is stable vs a patient who is rapidly deteriorating prior to bleeding from their terminal syndrome
Ongoing bleeding 13,14 • Local pressure, packing • Topical hemostatics like tranexemic acid or
aminocaproic acid (oral rinse, topical application to wound); thrombin powder
• Elevation (eg of head for oral bleeding) (meh) • More definitive diagnostics, interventions
– Endoscopy vs angiography for GIB – See below for carotid bleeding & hemoptysis
Reverse aggravators 13,14 • Anticoagulants or anti-platelet drugs, NSAIDs
• Vitamin K for patients on warfarin, cirrhosis – FFP for severe coagulopathy
• Platelets for active bleeding and Plt < 20k
• No clear role for systemic pro-coagulants like tranexemic acid
URGENT MEDICAL CONDITIONS
Preparing the care environment 15
• Bleeding can frighten everyone, so plan ahead • Dark towels in the room, basin, gloves/face
guard/gowns • Bleeding plan with caregivers, prepare them • Parenteral benzos available (nasal; IV or SC;
SL ok but may be tough if oral bleeding) • Patient/Family education on postural positioning
and reassurance
Medications in Terminal Hemorrhage?16
• Only one study in literature – semi-structured interviews of 11 nurses with experience managing massive terminal hemorrhages
• Generally, participants reported: – time from onset to death was so rapid, meds could not
always be given/take effect – “staying with and supporting the patient” while patient is
conscious, and camouflaging blood were “of more practical use”
• If it is not massive and patient is anxious, anxiolysis or sedation are reasonable
Carotid Blow-Out • Usually head & neck cancers directly eroding into
major arteries of neck. • Oncologist/ENT surgeons often know who is at
high risk – usually patients with progressive, end- stage disease not responding to active treatment
• Prior radiation, ulcerated, fistulated, or infected wounds are risk factors
• May be associated with a sentinel bleed which gives opportunity for prophylactic stenting
URGENT MEDICAL CONDITIONS
– Ok to transport, intervention manual pressure, ED, volume resuscitation/blood, angiography
• Surgical ligature was old treatment (high stroke rate) • Now: angiography with stenting is standard – (stroke <3%)
– No transport manual pressure if submassive; caring presence, reassurance, blood management, sedation (eg 5mg – 10 mg nasal midazolam)
Kozin E, et al. Fast Facts & Concepts #251. Carotid Blowout Management. https://www.mypcnow.org/blank-xv0o1
Large Volume Hemoptysis • Cancer, Cystic fibrosis/bronchiectasis > other causes • Disease modifying tx:
– IR therapies – bronchial artery embolization for massive hemoptysis
– Endobronchial therapies – laser resection of tumor or electrocautery for lower grade hemoptysis
– Palliative chest radiotherapy ? – No clear evidence base or protocols
• Symptomatic treatment same any other bleeding type
J Support Oncol 2012 doi:10.1016/j.suponc.2011.07.002
Hemorrhage – Bottom Line
• Prevent carotid blow-out with stenting
• Emergent angiography for carotid or massive hemoptysis when c/w care goals
• Calm, caring presence for massive terminal bleeding is more immediately important than parenteral sedation
URGENT MEDICAL CONDITIONS
References: Hemorrhage 13. Harris DG, Noble SI. Management of terminal hemorrhage in patients with advanced cancer: a systematic literature review. J Pain Symptom Manage. 2009 Dec;38 (6):913-27.
14. Prommer E. Management of bleeding in the terminally ill patient. Hematology. 2005 Jun;10(3):167-75.
15. Ubogagu E, Harris DG. Guideline for the management of terminal haemorrhage in palliative care patients with advanced cancer discharged home for end-of-life care. BMJ Support Palliat Care. 2012 Dec 1;2(4):294- 300.
16. Harris DG, Finlay IG, Flowers S, Noble SI. The use of crisis medication in the management of terminal haemorrhage due to incurable cancer: a qualitative study. Palliat Med. 2011 Oct;25(7):691-700.
A 68-year-old female followed by hospice for metastatic breast cancer was brought by her husband to the hospital for confusion. She is somnolent and mumbling. She is also thirsty and had complained of constipation and abdominal discomfort. Head CT in ED ‘negative.’ Her BUN and creatinine are mildly elevated, and her serum calcium is 12 mg/dL. Intravenous hydration is started.
ARS Question 3 Stem
ARS Question 3 Options Which of the following therapies will be most effective at controlling her symptoms long-term?
A. Tap water enemas
• Most common life-threatening metabolic disorder in cancer patients – 20-30% of patients during course of illness
• Causes delirium, renal failure, coma, death • 50% of patients die within 30 days • Treatment ideally gives time for anti-tumor
treatment, if available
Hodgkin & Non-Hodgkin
• Ionized calcium (best) or corrected total level
– Mild: 10.5-11.9 mg/dl
– Moderate: 12.0-12.9 mg/dl
– Severe: >14.0 mg/dl
• Age, co-morbidities influence symptom severity
Supportive MeasuresA
• Stop calcium supplements, lithium, vitamin D, thiazides
• Increase in weight-bearing mobility, if possible
• Replete phosphorus orally, if low
Pharmacologic TherapyA
• Primary treatment is volume resuscitation: e.g., normal saline 200-500 ml/hr, depending on cardiovascular and renal status
• Bisphosphonates – Response in 2-4 days, nadir in 4-7 days (60-90%
normalize); lasts 1-3 weeks – Pamidronate 60-90 mg IV over 2 hrs; cheaper – Zoledronic acid 4-8 mg IV over 5 min; more potent but
costly – Caution if serum creatinine >4.5 mg/dl; consider dialysis – Can cause jaw osteonecrosis, nephrotoxicity
URGENT MEDICAL CONDITIONS
Other Pharmacologic TherapyA
• Denosumab – For bisphosphonate refractory hypercalemia. – Much more expensive
• Calcitonin – Rapid onset but short duration of action – No longer recommended unless rapid reduction in
calcium level is required • Plicamycin (antineoplastic antibiotic)
– More side effects; less effective – No longer recommended
To treat or not to treat?B
• What is pt’s stage of illness, co-morbidities? • Are future anti-cancer treatments feasible? • How distressing are symptoms of
hypercalcemia? • Does pt have short-term goals to meet? • If refractory hypercalcemia & end-stage disease,
it is appropriate to not treat calcium level and provide symptomatic care if c/w care goals
Bottom Line - Hypercalcemia
• Goals of care
References: Hypercalcemia A. McCurdy MT, Shanholtz CB. Oncologic emergencies. Crit Care Med. 2012 Jul;40(7):2212-22. doi: 10.1097/CCM.0b013e31824e1865.
B. Kovacs CS, MacDonald SM, Chik CL, Bruera E. Hypercalcemia of malignancy in the palliative care patient: a treatment strategy. J Pain Symptom Manage. 1995 Apr;10(3):224-32.
Superior Vena Cava Syndrome
Superior Vena Cava Syndrome • Up to 10% of SCLC, 4-5% NSCLC • Symptoms/Signs
– Neck swelling (100%) – Dyspnea ~80% – Swelling of face, UE ~40-70% – Plethora is rare ~13% – Dysphagia, confusion, hoarseness, chest pain
rarer
URGENT MEDICAL CONDITIONS
implies cerebral edema, AKI, or syncope) – Endovascular stenting + steroidsradiation
• Mainstay of treatment is radiotherapy + steroids – Stenting gives relief immediately and is reasonable
but less mandatory without emergent symptoms
– Symptom relief in 3-30 days
Straka et al. Springerplus. 2016. doi: 10.1186/s40064-016-1900-7
SVC Syndrome • Key is to consult radiation oncology
urgently, and consider IR with emergent symptoms or severe dyspnea, facial edema, syncope
• Poor prognosis – 5 months in lung cancer when a later complication (not small cell presenting with SVC)
Straka et al. Springerplus. 2016. doi: 10.1186/s40064-016-1900-7
Increased Intracranial Pressure
URGENT MEDICAL CONDITIONS
• Brain metastases are common – Lung cancer 50%
– Breast cancer 15-20%
• Prognosis poor, usually less than 8 months
• Symptoms of brain metastases include – Focal weakness, cognitive dysfunction, seizures,
or headache
• Psychosocial & spiritual care essential • Death from increasing pressure can be peaceful
Treatment Options for Brain MetsA,C
• Radiation • Neurosurgery
– No data compared to radiosurgery – Mass effect is one relative indication
• Chemotherapy – generally least effective
• Can sometimes taper to 2-4mg/day
• Side effects can include: • hyperglycemia, peripheral edema,
• myopathy, psychiatric disorders
References: Elevated ICP A. Loeffler, JS. Overview of the clinical manifestations, diagnosis, and management of patients with brain metastases. http://www.uptodate.com/contents/overview-of-the-clinical- manifestations-diagnosis-and-management-of-patients-with-brain-metastases Accessed May 3, 2016.
B. Drappatz, J. Management of vasogenic edema in patients with primary and metastatic brain tumors. http://www.uptodate.com/contents/management-of-vasogenic-edema-in- patients-with-primary-and-metastatic-brain-tumors?source=see_link Accessed May 3, 2016.
C. http://www.choosingwisely.org/clinician-lists/american-society-radiation-oncology-adjunct- whole-brain-radiation-therapy/ Accessed May 3, 2016.
D. Ryken TC, McDermott M, Robinson PD, Ammirati M, Andrews DW, Asher AL, Burri SH, Cobbs CS, Gaspar LE, Kondziolka D, Linskey ME, Loeffler JS, Mehta MP, Mikkelsen T, Olson JJ, Paleologos NA, Patchell RA, Kalkanis SN. The role of steroids in the management of brain metastases: a systematic review and evidence-based clinical practice guideline. J Neurooncol. 2010 Jan;96(1):103-14. doi: 10.1007/s11060-009-0057-4.
Epub 2009 Dec 3.
• Pathologic fractures can be extremely painful; avoid (prevent) if possible
Preventing Pathologic FracturesA
diagnosed (16% reduction w/PO, additional 17% reduction w/IV)
– Focal radiotherapy (Incidence of pathologic fracture after radiotherapy was 3% after one fraction or 1.6% after multiple fractions in one study)
• Surgical stabilization…
• Involvement of femur + lesser trochanter
• Diffuse involvement of long bone
• Prognosis > 4 weeks & surgical candidate
URGENT MEDICAL CONDITIONS
• Surgery indicated especially for – Femur (intramedullary nailing)
– Hip (standard total joint arthroplasty)
– Tibia
– Vertebrae
– Humerus • Results reported to be good - in one study 8%
complications and all patients walking and w/ less pain.
Newer Preventive Agent: DenosumabE
• Monoclonal antibody NF-kB receptor activator induces osteoclast differentiation/activation/survival
• Delays time to skeletal-related events (compression/pathologic fractures) in bone metastases from solid tumors – 2 of 3 trials: significantly more delay in SRE than zoledronic acid in patients with
bone metastases from breast cancer or castration-resistant prostate cancer – 3rd trial: noninferior to zoledronic acid in patients with bone metastases from
other solid tumor cancer types
• ASCO and NCCN recommend patients with bone metastases should have zoledronic acid, pamidronate, or denosumab plus calcium/vitamin D added to chemo regimen if adequate renal function and expected survival of 3 months or longer
Assessment & DecisionsF
• Prompt and complete assessment of the malignancy and its effects are essential.
• Treatment plans must consider: – Possible effects (or side effects) of active treatment on
patients overall condition and care, – Physical, psycho-social and spiritual aspects of the
condition and treatment effects, – Patient and family wishes.
• Sometimes surgery + RT +/- bisphosphonates is most effective combination
URGENT MEDICAL CONDITIONS
References: Pathologic Fracture A. Wu JS, Wong R, Johnston M, Bezjak A, Whelan T; Cancer Care Ontario Practice Guidelines Initiative Supportive Care Group. Meta-analysis of dose-fractionation radiotherapy trials for the palliation of painful bone metastases. Int J Radiat Oncol Biol Phys. 2003 Mar 1;55(3):594-605.
B. http://www.choosingwisely.org/clinician-lists/american-society-radiation-oncology-extended- fractionation-schemes-for-palliation-of-bone-metastases/ Accessed May 3, 2016.
C. Sze WM, Shelley M, Held I, Mason M. Palliation of metastatic bone pain: single fraction versus multifraction radiotherapy - a systematic review of the randomised trials. Cochrane Database Syst Rev. 2004;(2):CD004721.
D. Sarahrudi K, Hora K, Heinz T, Millington S, Vécsei V. Treatment results of pathological fractures of the long bones: a retrospective analysis of 88 patients. Int Orthop. 2006 Dec;30(6):519-24. Epub 2006 Aug 30.
E. Iranikhah M, Wilborn TW, Wensel TM, Ferrell JB. Denosumab for the prevention of skeletal-related events in patients with bone metastasis from solid tumor. Pharmacotherapy. 2012 Mar;32(3):274-84. doi: 10.1002/j.1875-9114.2011.01092.x. Epub 2012 Feb 13.
F. Wolanczyk MJ, Fakhrian K, Adamietz IA. Radiotherapy, Bisphosphonates and Surgical Stabilization of Complete or Impending Pathologic Fractures in Patients with Metastatic Bone Disease.
J Cancer. 2016 Jan 1;7(1):121-4. doi: 10.7150/jca.13377. eCollection 2016.
Thank You
[email protected]
Questions?
Minneapolis, MN
• I have no relevant disclosures.
• Many slides adapted from prior AAHPM board review courses by Drs Lauren Goodman, Earl Quijada, & Eric Widera
Objectives
URGENT MEDICAL CONDITIONS
• Spinal cord compression • Hypercalcemia • Increased intracranial pressure • Fractures • Seizures • Superior vena cava syndrome • Hemorrhage
ARS Question 1 A 48-year-old man with a previous history of lung cancer presents to the emergency department with upper back pain which has progressed over the last 3-4 days. His pain is localized to the upper thoracic spine and does not radiate. Over the past 24 hours he has noted left leg weakness. Prior to this event he continued to work as a bank loan officer. Severity is rated as 5-9/10. Examination shows point tenderness over the T4 vertebral process, 4/5 strength in the left knee extensors, and 3/5 weakness in the left ankle dorsiflexors. MRI of the cervical, thoracic, and lumbar spine shows a single metastatic lesion of T4 with early cord compression. Dexamethasone is started. He is evaluated by Radiation Oncology and Neurosurgery. Palliative Care is consulted for pain management.
ARS Question 1 Options
The patient’s short and long term functional status is likely to be optimized by:
A. Radiation therapy alone to the affected thoracic spine B. Open decompressive neurosurgery of the involved
thoracic spine followed by radiation therapy C. A course of radiation therapy followed by open
decompressive neurosurgery of the involved thoracic spine
D. Combined therapy with radiation therapy to the affected thoracic spine and kyphoplasty of the T4 vertebra.
URGENT MEDICAL CONDITIONS
Spinal Cord Compression
– Chronic disability
Key Concepts1
• 83-95% have back pain before diagnosis
• Ability to walk prior to treatment predicts preserved ambulation after treatment
• Best survival if ambulatory, 1 spinal metastasis, no visceral mets, radiosensitive, quick to start therapy
• Evaluation, treatment hinges on prognosis and goals of care
URGENT MEDICAL CONDITIONS
Pathophysiology1
• Vast majority are epidural or locally advanced metastases – 90% vertebral, 10% neural foramina – Intradural and leptomeningeal (dural) are rare
• Thecal sac compression leads to cord changes
– indentation → strangulation → infarction
Assessment1,2
• Pain can be local, referred, radicular or combination • Metastasis location often predicted by primary site:
– 60% thoracic (breast, lung cancers) – 30% lumbosacral (colon, pelvic cancers) – 10% cervical
• Can have radiculopathy, weakness, sensory changes, sphincter incontinence, autonomic dysfunction
• Cauda equina syndrome – Post-void residual has 90% sensitivity, 95% specificity
Diagnosis1
• MRI is gold standard – Sensitivity 93%, specificity 97%, pos. predictive value 95%
– If cannot MRI, CT spine with myelography has sensitivity 95%, specificity 95%, if CSF contrast flow not obstructed
• Image entire spine – 1/3 with cord compression have multiple metastatic sites
– May find unsuspected lesions, which alters surgical options and radiation therapy field
URGENT MEDICAL CONDITIONS
Pain and Symptoms2
• 60-90% of patients’ pain relieved with steroids + XRT
• Aggressive bowel regimen: – With sphincter control: stimulant; osmotic laxative
for stool every 1-2 days – Without sphincter control: polyethylene glycol +
stimulant suppository daily
• No evidence that very high doses (e.g., dexamethasone 96-100mg/day) improve outcomes; much evidence of side effects with such high doses
• Recommend moderate-dose dexamethasone: 10 mg IV bolus, then 4 mg IV/PO 4 times/day with 2 week taper – No standardized dosing, local culture/practice prevail! – Major point is that high dose is not necessary!
Radiation vs Surgery: Indications1,3
Radiation Alone Surgery (+/- post-operative RT)
No spinal compression or instability Spinal instability (e.g., spinal deformity, bony retropulsion into canal, pathologic fracture). This is why neurosurg needs to be consulted to determine this properly!
Prior radical spinal decompression Previous radiation therapy to area limiting further doses
Subclinical cord compression Disease progression despite radiation
Known radiosensitive tumor (typically breast, prostate, small cell, lymphoma, myeloma)
Radioresistant or unknown primary tumor
‘Poor surgical candidate’ (e.g., severe CAD, overall anticipated survival <3 mos); non- ambulatory at baseline
Good baseline performance status & lost ambulation for <48 hrs
Multiple areas of cord compression Single area of cord compression
URGENT MEDICAL CONDITIONS
Radiation Therapy: Outcomes1,3
• When initiated promptly (ideally within 24h of diagnosis) – Achieves pain relief in 40-80% – Retains sphincter control in 45-90% if initiated promptly – Of those without paralysis, 90% retain ambulation with RT alone – Of those with paralysis, <30% regain ambulation with RT alone
• Ideal schedule/dose remains unclear – 8Gy in 1-2 sessions is effective, may be preferable in patients with
short prognosis – Depending on dose/location, may be able to repeat in the future
Surgery: Outcomes4
For patients who are ‘reasonable surgical candidates’: • Surgery + RT, vs RT alone:6
– More regain ambulation if just lost it (62% vs 19%) • No short-term (1 month) survival difference;
small long-term survival benefit5,7
• There are mixed and unconvincing data about other outcomes (pain, retaining ambulation)
Prognosis5
– Shortest: multiple metastases, visceral or brain metastases, lung cancer
– Ambulatory status: • Patients who could walk after therapy (7-9 months) • Non-ambulatory pts after cord compression treatment (1-2
months)
URGENT MEDICAL CONDITIONS
Bottom Line – Cord Compression • Do image the entire spine with MRI if suspected –
physical exam is not sufficient to localize compression! • Do immediately start glucocorticoids • Do immediately & emergently consult radiation oncology
+ neurosurgery/spine surgery – Assuming surgical intervention is compatible with care goals
• For patients who have lost ambulation, surgery (followed by RT) is the only intervention with a realistic chance to restore ambulation
References: Spinal Cord Compression
1. McCurdy MT, Shanholtz CB. Oncologic emergencies. Crit Care Med. 2012 Jul;40(7):2212-22. doi: 10.1097/CCM.0b013e31824e1865. 2. Deyo RA, Rainville J Kent DL: What can the history and physical examination tell us about low back pain? JAMA 1992; 268:760–765. 3. George R, Jeba J, Ramkumar G, Chacko AG, Tharyan P. Interventions for the treatment of metastatic extradural spinal cord compression in adults. Cochrane Database Syst Rev. 2015 Sep 4;9:CD006716. doi: 10.1002/14651858.CD006716.pub3. 4. Akram H, Allibone J. Spinal surgery for palliation in malignant spinal cord compression. Clin Oncol (R Coll Radiol). 2010 Nov;22(9):792-800. doi: 10.1016/j.clon.2010.07.007. Epub 2010 Aug 10. 5. Abrahm JL, Banffy MB, Harris MB. Spinal cord compression in patients with advanced metastatic cancer: "all I care about is walking and living my life". JAMA. 2008 Feb 27;299(8):937-46. doi: 10.1001/jama.299.8.937. 6. Klimo Jr P, Thompson CJ, Kestle JR, Schmidt MH. A metaanalysis of surgery versus conventional radiotherapy for the treatment of metastatic spinal epidural disease. Neuro Oncol 2005;7(1):64e76. 7. Patchell RA, Tibbs PA, Regine WF, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet 2005;366(9486):643e648.
ARS Question 2 Stem A 60-year-old woman with malignant melanoma and brain metastasis has just arrived to your PCU from the emergency department, having been admitted for increasing seizure activity over the past few days.
The seizures are manifested as acute confusion and then clonic activity in the right arm. The patient arrives from the emergency department with a seizure in progress that began on the elevator. The patient does not have IV access and has clear goals to avoid intravenous lines and phlebotomy. The seizure continues unabated throughout the transfer to the bed, and the patient’s partner and primary caregiver confirms that this seizure seems unusually persistent, as it has now been over 7 minutes. The finger-stick glucose reading from the emergency department was 150 mg/dL.
URGENT MEDICAL CONDITIONS
A. Diazepam 10 mg subcutaneous
B. Diazepam 1 mg buccal
C. Lorazepam 10 mg subcutaneous
D. Lorazepam 1 mg buccal
E. Midazolam 10 mg subcutaneous
F. Midazolam 1 mg intranasal
Seizures
• Risk of physical injury, aspiration • Emotionally distressing for caregivers • High mortality from status epilepticus • Panicked decisions may contradict established
goals of care
• HPM docs often manage seizures especially in hospice & PCU settings
URGENT MEDICAL CONDITIONS
• Seizure: temporary brain dysfunction due to abnormal electrical activity – Affects ~10% of individuals during their lives – 25% of seizures with clearly identifiable
cause • Status epilepticus: any seizure exceeding 5
minutes; or frequent seizures without return to baseline clinical state. – ~20% mortality with first episode in general
population
Patients at risk • Brain tumors • Stroke & TBI– hemorrhagic >> ischemic • Previous history of seizures • Dementia • Alcohol or drug abuse (withdrawal or intoxication) • Severe hypoglycemia, hypoxia • Other: electrolyte abnormalities, liver failure, renal
failure, infections, neurodegenerative diseases
– Collaboration with neurologist
– Staff education
– Home seizure kit for high-risk patients • Understand that prognosis, goals of care will drive
treatment and setting of care
• Choose anticonvulsant(s) of choice, based on pharmacology, side effects, cost
URGENT MEDICAL CONDITIONS
Review Prognosis, Goals of Care
o Does pt appear to have hours, days, weeks or months to live?
o Does pt and/or family want hospitalization?
o Did pt express a wish to die at home?
o How are the caregivers coping?
o Are advance directives in place?
o Consider continuous care at home, or inpatient hospice house, nursing home or hospital.
General Guideline for Seizure/Status10
• Give parenteral benzodiazepine (IV/SQ, Nasal, IM, or PR)
• Additional antiepileptic drug if status epilepticus
• Labs (chemistry, Hgb, WBC, toxicology)
• Additional antiepileptic dose/drug if refractory
• Consider urinary catheter, continuous EEG, CT
head, ECG, LP, MRI, ICP monitor
Benzodiazepines: Initial Drug of Choice10,12
• IV/SQ/Buccal/Intranasal (vial + mucosal atomizer device):
– Midazolam (fastest onset, short half-life) 0.1-0.3 mg/kg IV/SC;
– Intranasal midazolam (5mg puffs x2) is very popular in pediatrics
• IV/SQ/Buccal:
– Lorazepam (slower onset, longer half-life) 0.1 mg/kg IV/IM up to 4mg
– 2-4 mg is a common initial dose
• Rectal:
– Diazepam (slower onset, rapidly redistributes out of CNS) (0.2 mg/kg or 10-20mg)
– No longer the drug of choice
• Benzos less likely than placebo to cause respiratory depression in studies for generalized convulsive status
• Few studies of subcutaneous efficacy in epilepsy literature
URGENT MEDICAL CONDITIONS
• Second drug choice depends on organ functions, other medications taken, available routes for administration, available medications – IV options: phenytoin, levetiracetam, fosphenytoin,
valproate, midazolam (bolus or infusion), propofol (infusion), and phenobarbital
– Non-IV options: rectal diazepam, rectal phenobarbital (similar bioavailability to PO – no change in dosing), nasal midazolam, buccal lorazepam
Medication Issues • Many drug interactions • Many side effects,
including rare life- threatening effects
• Drug levels not always reliable
• Patients with multi- organ failure, low albumin
• Protein binding – Unbound fraction is
active - phenytoin, valproic acid
Status Epilepticus – Dosing10
phenytoin 20 mg/kg IV 4-5 mg/kg/day IV tid
fosphenytoin 20 mg/kg IV, IM 4-5 mg/kg/day IV, IM tid
phenobarbital 10 mg/kg IV, SC 1-3 mg/kg/day IV, SC
midazolam 0.2 mg/kg IV, SC, IM
Max 2mg/kg/hr infusion Titrate as needed for refractory Status
lorazepam 0.1 mg/kg IV, SC up to 2mg/min
URGENT MEDICAL CONDITIONS
Seizures – Bottom Line • Do have a protocol/plan for high risk patients in
hospice/PCU • Do test/treat for hypoglycemia • Bolus parenteral benzos (buccal, nasal) are
first line for a seizure – doses are higher than for most other uses!
• For status – treatment depends on goals; typically infusions of benzos or other AEDs
References: Seizures 8. DeLorenzo RJ, Pellock JM, Towne AR, Boggs JG. Epidemiology of status epilepticus. J Clin Neurophysiol. 1995 Jul;12(4):316-25.
9. Logroscino G, Hesdorffer DC, Cascino G, Hauser WA, Coeytaux A, Galobardes B, Morabia A, Jallon P. Mortality after a first episode of status epilepticus in the United States and Europe. Epilepsia. 2005;46 Suppl 11:46-8.
10. Brophy GM, Bell R, Claassen J, Alldredge B, Bleck TP, Glauser T, Laroche SM, Riviello JJ Jr, Shutter L, Sperling MR, Treiman DM, Vespa PM; Neurocritical Care Society Status Epilepticus Guideline Writing Committee. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care. 2012 Aug;17(1):3-23. doi: 10.1007/s12028-012-9695-z.
11. Arif H, Hirsch LJ. Treatment of status epilepticus. Semin Neurol. 2008 Jul;28(3):342-54. doi: 10.1055/s-2008-1079339. Epub 2008 Jul 24.
12. Krouwer HG, Pallagi JL, Graves NM. Management of seizures in brain tumor patients at the end of life. J Palliat Med. 2000 Winter;3(4):465-75.
Hemorrhage
• HPM docs responsible for prevention; & management in hospice/PCU
• 6-14% of advanced cancer pts have significant bleeding • 3-12% of cancer pts have acute terminal hemorrhage • Patient at risk include those with
– Severe thrombocytopenia (<20k) – Cancers of head/neck, central lung/mediastinum, or
rectal/gynecologic structures – Refractory leukemia/myelodysplasia – Coagulopathy (liver disease/metastases, malnutrition, meds) – Surgery, Radiation, or other poorly healing wound – Visible arterial pulsation – Fungating tumors
Bleeding Sources14
40%
course in 20%; 3% fatal
• GI tract – Gastric, rectal or stromal – Chronic bleeding – Cirrhosis/portal HTN – Anticoagulation & AVMs
• Mucositis from Chemo/RT
HF02, bronchiectasis
wounds • Radiation for sentinel hemoptysis from lung
tumor • Endovascular stenting for high risk neck
cancer, especially after a sentinel bleed
URGENT MEDICAL CONDITIONS
Approach to Bleeding • Goals & place of care is hugely important
– Home vs Unit vs Hospital. What can hospice handle?
– Willing to be hospitalized for interventions, work-up?
– Ambulatory patient who is stable vs a patient who is rapidly deteriorating prior to bleeding from their terminal syndrome
Ongoing bleeding 13,14 • Local pressure, packing • Topical hemostatics like tranexemic acid or
aminocaproic acid (oral rinse, topical application to wound); thrombin powder
• Elevation (eg of head for oral bleeding) (meh) • More definitive diagnostics, interventions
– Endoscopy vs angiography for GIB – See below for carotid bleeding & hemoptysis
Reverse aggravators 13,14 • Anticoagulants or anti-platelet drugs, NSAIDs
• Vitamin K for patients on warfarin, cirrhosis – FFP for severe coagulopathy
• Platelets for active bleeding and Plt < 20k
• No clear role for systemic pro-coagulants like tranexemic acid
URGENT MEDICAL CONDITIONS
Preparing the care environment 15
• Bleeding can frighten everyone, so plan ahead • Dark towels in the room, basin, gloves/face
guard/gowns • Bleeding plan with caregivers, prepare them • Parenteral benzos available (nasal; IV or SC;
SL ok but may be tough if oral bleeding) • Patient/Family education on postural positioning
and reassurance
Medications in Terminal Hemorrhage?16
• Only one study in literature – semi-structured interviews of 11 nurses with experience managing massive terminal hemorrhages
• Generally, participants reported: – time from onset to death was so rapid, meds could not
always be given/take effect – “staying with and supporting the patient” while patient is
conscious, and camouflaging blood were “of more practical use”
• If it is not massive and patient is anxious, anxiolysis or sedation are reasonable
Carotid Blow-Out • Usually head & neck cancers directly eroding into
major arteries of neck. • Oncologist/ENT surgeons often know who is at
high risk – usually patients with progressive, end- stage disease not responding to active treatment
• Prior radiation, ulcerated, fistulated, or infected wounds are risk factors
• May be associated with a sentinel bleed which gives opportunity for prophylactic stenting
URGENT MEDICAL CONDITIONS
– Ok to transport, intervention manual pressure, ED, volume resuscitation/blood, angiography
• Surgical ligature was old treatment (high stroke rate) • Now: angiography with stenting is standard – (stroke <3%)
– No transport manual pressure if submassive; caring presence, reassurance, blood management, sedation (eg 5mg – 10 mg nasal midazolam)
Kozin E, et al. Fast Facts & Concepts #251. Carotid Blowout Management. https://www.mypcnow.org/blank-xv0o1
Large Volume Hemoptysis • Cancer, Cystic fibrosis/bronchiectasis > other causes • Disease modifying tx:
– IR therapies – bronchial artery embolization for massive hemoptysis
– Endobronchial therapies – laser resection of tumor or electrocautery for lower grade hemoptysis
– Palliative chest radiotherapy ? – No clear evidence base or protocols
• Symptomatic treatment same any other bleeding type
J Support Oncol 2012 doi:10.1016/j.suponc.2011.07.002
Hemorrhage – Bottom Line
• Prevent carotid blow-out with stenting
• Emergent angiography for carotid or massive hemoptysis when c/w care goals
• Calm, caring presence for massive terminal bleeding is more immediately important than parenteral sedation
URGENT MEDICAL CONDITIONS
References: Hemorrhage 13. Harris DG, Noble SI. Management of terminal hemorrhage in patients with advanced cancer: a systematic literature review. J Pain Symptom Manage. 2009 Dec;38 (6):913-27.
14. Prommer E. Management of bleeding in the terminally ill patient. Hematology. 2005 Jun;10(3):167-75.
15. Ubogagu E, Harris DG. Guideline for the management of terminal haemorrhage in palliative care patients with advanced cancer discharged home for end-of-life care. BMJ Support Palliat Care. 2012 Dec 1;2(4):294- 300.
16. Harris DG, Finlay IG, Flowers S, Noble SI. The use of crisis medication in the management of terminal haemorrhage due to incurable cancer: a qualitative study. Palliat Med. 2011 Oct;25(7):691-700.
A 68-year-old female followed by hospice for metastatic breast cancer was brought by her husband to the hospital for confusion. She is somnolent and mumbling. She is also thirsty and had complained of constipation and abdominal discomfort. Head CT in ED ‘negative.’ Her BUN and creatinine are mildly elevated, and her serum calcium is 12 mg/dL. Intravenous hydration is started.
ARS Question 3 Stem
ARS Question 3 Options Which of the following therapies will be most effective at controlling her symptoms long-term?
A. Tap water enemas
• Most common life-threatening metabolic disorder in cancer patients – 20-30% of patients during course of illness
• Causes delirium, renal failure, coma, death • 50% of patients die within 30 days • Treatment ideally gives time for anti-tumor
treatment, if available
Hodgkin & Non-Hodgkin
• Ionized calcium (best) or corrected total level
– Mild: 10.5-11.9 mg/dl
– Moderate: 12.0-12.9 mg/dl
– Severe: >14.0 mg/dl
• Age, co-morbidities influence symptom severity
Supportive MeasuresA
• Stop calcium supplements, lithium, vitamin D, thiazides
• Increase in weight-bearing mobility, if possible
• Replete phosphorus orally, if low
Pharmacologic TherapyA
• Primary treatment is volume resuscitation: e.g., normal saline 200-500 ml/hr, depending on cardiovascular and renal status
• Bisphosphonates – Response in 2-4 days, nadir in 4-7 days (60-90%
normalize); lasts 1-3 weeks – Pamidronate 60-90 mg IV over 2 hrs; cheaper – Zoledronic acid 4-8 mg IV over 5 min; more potent but
costly – Caution if serum creatinine >4.5 mg/dl; consider dialysis – Can cause jaw osteonecrosis, nephrotoxicity
URGENT MEDICAL CONDITIONS
Other Pharmacologic TherapyA
• Denosumab – For bisphosphonate refractory hypercalemia. – Much more expensive
• Calcitonin – Rapid onset but short duration of action – No longer recommended unless rapid reduction in
calcium level is required • Plicamycin (antineoplastic antibiotic)
– More side effects; less effective – No longer recommended
To treat or not to treat?B
• What is pt’s stage of illness, co-morbidities? • Are future anti-cancer treatments feasible? • How distressing are symptoms of
hypercalcemia? • Does pt have short-term goals to meet? • If refractory hypercalcemia & end-stage disease,
it is appropriate to not treat calcium level and provide symptomatic care if c/w care goals
Bottom Line - Hypercalcemia
• Goals of care
References: Hypercalcemia A. McCurdy MT, Shanholtz CB. Oncologic emergencies. Crit Care Med. 2012 Jul;40(7):2212-22. doi: 10.1097/CCM.0b013e31824e1865.
B. Kovacs CS, MacDonald SM, Chik CL, Bruera E. Hypercalcemia of malignancy in the palliative care patient: a treatment strategy. J Pain Symptom Manage. 1995 Apr;10(3):224-32.
Superior Vena Cava Syndrome
Superior Vena Cava Syndrome • Up to 10% of SCLC, 4-5% NSCLC • Symptoms/Signs
– Neck swelling (100%) – Dyspnea ~80% – Swelling of face, UE ~40-70% – Plethora is rare ~13% – Dysphagia, confusion, hoarseness, chest pain
rarer
URGENT MEDICAL CONDITIONS
implies cerebral edema, AKI, or syncope) – Endovascular stenting + steroidsradiation
• Mainstay of treatment is radiotherapy + steroids – Stenting gives relief immediately and is reasonable
but less mandatory without emergent symptoms
– Symptom relief in 3-30 days
Straka et al. Springerplus. 2016. doi: 10.1186/s40064-016-1900-7
SVC Syndrome • Key is to consult radiation oncology
urgently, and consider IR with emergent symptoms or severe dyspnea, facial edema, syncope
• Poor prognosis – 5 months in lung cancer when a later complication (not small cell presenting with SVC)
Straka et al. Springerplus. 2016. doi: 10.1186/s40064-016-1900-7
Increased Intracranial Pressure
URGENT MEDICAL CONDITIONS
• Brain metastases are common – Lung cancer 50%
– Breast cancer 15-20%
• Prognosis poor, usually less than 8 months
• Symptoms of brain metastases include – Focal weakness, cognitive dysfunction, seizures,
or headache
• Psychosocial & spiritual care essential • Death from increasing pressure can be peaceful
Treatment Options for Brain MetsA,C
• Radiation • Neurosurgery
– No data compared to radiosurgery – Mass effect is one relative indication
• Chemotherapy – generally least effective
• Can sometimes taper to 2-4mg/day
• Side effects can include: • hyperglycemia, peripheral edema,
• myopathy, psychiatric disorders
References: Elevated ICP A. Loeffler, JS. Overview of the clinical manifestations, diagnosis, and management of patients with brain metastases. http://www.uptodate.com/contents/overview-of-the-clinical- manifestations-diagnosis-and-management-of-patients-with-brain-metastases Accessed May 3, 2016.
B. Drappatz, J. Management of vasogenic edema in patients with primary and metastatic brain tumors. http://www.uptodate.com/contents/management-of-vasogenic-edema-in- patients-with-primary-and-metastatic-brain-tumors?source=see_link Accessed May 3, 2016.
C. http://www.choosingwisely.org/clinician-lists/american-society-radiation-oncology-adjunct- whole-brain-radiation-therapy/ Accessed May 3, 2016.
D. Ryken TC, McDermott M, Robinson PD, Ammirati M, Andrews DW, Asher AL, Burri SH, Cobbs CS, Gaspar LE, Kondziolka D, Linskey ME, Loeffler JS, Mehta MP, Mikkelsen T, Olson JJ, Paleologos NA, Patchell RA, Kalkanis SN. The role of steroids in the management of brain metastases: a systematic review and evidence-based clinical practice guideline. J Neurooncol. 2010 Jan;96(1):103-14. doi: 10.1007/s11060-009-0057-4.
Epub 2009 Dec 3.
• Pathologic fractures can be extremely painful; avoid (prevent) if possible
Preventing Pathologic FracturesA
diagnosed (16% reduction w/PO, additional 17% reduction w/IV)
– Focal radiotherapy (Incidence of pathologic fracture after radiotherapy was 3% after one fraction or 1.6% after multiple fractions in one study)
• Surgical stabilization…
• Involvement of femur + lesser trochanter
• Diffuse involvement of long bone
• Prognosis > 4 weeks & surgical candidate
URGENT MEDICAL CONDITIONS
• Surgery indicated especially for – Femur (intramedullary nailing)
– Hip (standard total joint arthroplasty)
– Tibia
– Vertebrae
– Humerus • Results reported to be good - in one study 8%
complications and all patients walking and w/ less pain.
Newer Preventive Agent: DenosumabE
• Monoclonal antibody NF-kB receptor activator induces osteoclast differentiation/activation/survival
• Delays time to skeletal-related events (compression/pathologic fractures) in bone metastases from solid tumors – 2 of 3 trials: significantly more delay in SRE than zoledronic acid in patients with
bone metastases from breast cancer or castration-resistant prostate cancer – 3rd trial: noninferior to zoledronic acid in patients with bone metastases from
other solid tumor cancer types
• ASCO and NCCN recommend patients with bone metastases should have zoledronic acid, pamidronate, or denosumab plus calcium/vitamin D added to chemo regimen if adequate renal function and expected survival of 3 months or longer
Assessment & DecisionsF
• Prompt and complete assessment of the malignancy and its effects are essential.
• Treatment plans must consider: – Possible effects (or side effects) of active treatment on
patients overall condition and care, – Physical, psycho-social and spiritual aspects of the
condition and treatment effects, – Patient and family wishes.
• Sometimes surgery + RT +/- bisphosphonates is most effective combination
URGENT MEDICAL CONDITIONS
References: Pathologic Fracture A. Wu JS, Wong R, Johnston M, Bezjak A, Whelan T; Cancer Care Ontario Practice Guidelines Initiative Supportive Care Group. Meta-analysis of dose-fractionation radiotherapy trials for the palliation of painful bone metastases. Int J Radiat Oncol Biol Phys. 2003 Mar 1;55(3):594-605.
B. http://www.choosingwisely.org/clinician-lists/american-society-radiation-oncology-extended- fractionation-schemes-for-palliation-of-bone-metastases/ Accessed May 3, 2016.
C. Sze WM, Shelley M, Held I, Mason M. Palliation of metastatic bone pain: single fraction versus multifraction radiotherapy - a systematic review of the randomised trials. Cochrane Database Syst Rev. 2004;(2):CD004721.
D. Sarahrudi K, Hora K, Heinz T, Millington S, Vécsei V. Treatment results of pathological fractures of the long bones: a retrospective analysis of 88 patients. Int Orthop. 2006 Dec;30(6):519-24. Epub 2006 Aug 30.
E. Iranikhah M, Wilborn TW, Wensel TM, Ferrell JB. Denosumab for the prevention of skeletal-related events in patients with bone metastasis from solid tumor. Pharmacotherapy. 2012 Mar;32(3):274-84. doi: 10.1002/j.1875-9114.2011.01092.x. Epub 2012 Feb 13.
F. Wolanczyk MJ, Fakhrian K, Adamietz IA. Radiotherapy, Bisphosphonates and Surgical Stabilization of Complete or Impending Pathologic Fractures in Patients with Metastatic Bone Disease.
J Cancer. 2016 Jan 1;7(1):121-4. doi: 10.7150/jca.13377. eCollection 2016.
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