Oncologic emergencies

23 Oncologic emergencies




Metastatic spinal cord compression







Management


The aim of treatment is to preserve or improve neurological function and achieve pain control. 70–100% patients who are ambulant at the beginning of treatment remain ambulant with prompt treatment, whereas only 30–50% patients who are non-ambulant regain the ability to walk and only 5–10% of paraplegic patients become ambulant. Hence it is important to have definitive treatment within 24 hours of presentation with suspected cord compression. Patients with MSCC secondary to a vascular event will not respond to treatment.




Specific measures


Definite treatment of MSCC depends on the histologic type and associated spinal stability. In patients with no prior history of cancer, surgical decompression with histologic confirmation is appropriate. If surgical decompression is not possible, a CT guided biopsy is needed.


Surgery may involve decompression, stabilization and or resection and reconstruction of the spinal canal. The patient’s overall prognosis and performance status should be taken into consideration and patients who have had no distal neurological function for >24 h should not be considered for surgery (Boxes 23.1 and 23.2).




Radiotherapy is the treatment most frequently used and is most effective for patients with radiosensitive tumours who are ambulatory at the beginning of treatment. For those without mechanical pain or structural instability, radiotherapy may significantly improve pain control and neurological function. The most commonly used regimes are 20 Gy in five fractions (more appropriate for patients with expected short survival) or 30 Gy in 10 fractions (Box 23.3). Some patients may deteriorate during radiotherapy when the steroid dose may be increased or they may be considered for surgery if appropriate. Patients with established paraplegia are treated with an 8 Gy single fraction for pain control.




The issue of whether surgery or radiotherapy or a combination of both gives best functional outcome is yet to be resolved. A randomized study compared radiotherapy (30 Gy in 10 fractions) started within 24 hours of onset of MSCC with surgery within 24 hours followed by radiotherapy within 2 weeks of surgery. Results showed that initial surgery followed by radiotherapy offers a longer period with ability to walk compared with those treated with radiotherapy alone (median, 126 days vs. 35 days, p = 0.006). This study showed that surgery permits most patients to remain ambulatory and continent for the remainder of their lives, while patients treated with radiation alone spend approximately two-thirds of their remaining time unable to walk and incontinent. However, results of this study may not be extended to all patients as the study was limited to patients with less radiosensitive tumours and with different tumour types and presentations.


Chemotherapy alone is not an option for treatment even in chemosensitive tumours as the response to treatment is often slow and unpredictable. Hence MSCC in chemosensitive tumours is treated with a combination of radiotherapy and chemotherapy.






Paediatric spinal cord compression


Paediatric MSCC differs from adult MSCC in that it is often caused by chemosensitive histological types not seen in adults such as neuroblastoma, Wilms’ tumour (p. 323). The usual pathogenesis is the direct invasion of tumour through neural foramina. The most common histologic type is neuroblastoma, which responds to chemotherapy. Decompressive surgery is offered when patients present with rapid progression or progress during chemotherapy. Radiotherapy is only offered when there is no response after chemotherapy and/or surgery and for those who require palliation after failure of multiple systemic regimens.





Encephalopathy





Management


Investigations include biochemical tests, infection screening, MRI brain, EEG and CSF examination and drug level estimation in selected cases.


In most cases of anti-neoplastic induced encephalopathy, the management is cessation of the drug and continuation supportive measures until recovery, and a re-challenge is seldom attempted. One exception is ifosfamide.


Ifosfamide encephalopathy can occur within minutes or hours of starting ifosfamide, or up to 24 hours after the completion of ifosfamide. The risk factors for ifosfamide encephalopathy are pelvic tumour, low albumin, impaired renal function, previous cisplatin, high dose of ifosfamide and CNS disease. In patients on ifosfamide, encephalopathy can be prevented by prophylactic dose of methylene blue (50 mg IV 4 times daily).


In patients with ifosfamide encephalopathy, treatment is based on the grade of the encephalopathy:






Visual loss





Febrile neutropenia



Introduction


Febrile neutropenia is defined as an oral or tympanic membrane temperature of ≥38°C on two occasions, at least one hour apart within a 12 h period or a single temperature of >38.5°C with an absolute neutrophil count of ≤0.5 × 109/l or ≤1.0 × 109/l with a predictable decline to ≤0.5 × 109/l in 24–48 h.


Febrile neutropenia is one of the most common complications of cancer treatment. 50–60% of patients with febrile neutropenia have an established or occult infection and 20% of patients with a neutrophil count ≤1.0 × 109/l have bacteraemia.


Susceptibility to infection increases as the neutrophil count drops below 1.0 × 109/l. The frequency and severity of infection are inversely proportional to the absolute neutrophil count, with the duration of neutropenia also contributing to overall risk. The timing of the neutrophil nadir depends on the type of chemotherapy and generally, it occurs 5–10 days after the last dose. Usually the neutrophil count recovers 5 days after the nadir.


In the majority of cases, bacterial pathogens are responsible for febrile neutropenic episodes with fungal (Figure 23.3), viral and protozoal infections occurring more commonly as secondary events. Currently, Gram-positive bacteria account for 60–70% of microbiologically detected infections, which may in part be due to the prevalent use of quinolones as prophylactic antibiotics. Other possible causes of this change in trend include widespread use of intravenous catheters, along with more profound and prolonged neutropenia due to intensive and recurrent treatment regimes.



Jun 18, 2016 | Posted by in ONCOLOGY | Comments Off on Oncologic emergencies

Full access? Get Clinical Tree

Get Clinical Tree app for offline access