Overview

•  Complications
  • Airway obstruction
  • PNA
  • Pleural effusion
  • Pericardial effusion
  • VTE
  • SVC syndrome
    • Symptoms: dyspnea (airway edema), chest fullness, blurred vision, headache (increased ICP)
  • Massive hemoptysis
    • Management: ETT (large-bore for bronschoscopy), affected side down
• Brain Metastases
  • Cancers: melanoma, lung, breast, colorectal
  • Management: dexamethasone 10mg IV load, elevated HOB, hypertonic saline or mannitol, prophylactic anti-eplipetics
• Meningitis
  • Pathogens: Listeria (ampicillin), Cryptococcus (amphotericin)
  • Evaluation: CSF sampling with cytology (diagnose leptomeningeal metastases)

Metabolic Disturbances

• Hypercalcemia
  • Cancers: MM, RCC, lymphoma, bone metastases (breast, lung, prostate)
  • Mechanism: metastatic destruction, PTH-RP, tumor calcitriol
  • Prognosis: 50% 30-day mortality
  • Symptoms
    • Chronic: anorexia, nausea/vomiting, constipation, fatigue, memory loss
    • Acute: CNS (lethargy, somnolence)
  • Findings
    • Calcium: >13.0mg/dL
    • ECG: QT shortening
  • Treatment
    • Mild: IVF
    • Severe: IVF, loop diuretics, bisophosphanate (pamidronate 90mg IV infused over 4 hours), consider calcitriol, consider hemodialysis if cannot tolerate fluids or unlikely to respond to diuretics
• Hyponatremia
  • Cancers: lung (small-cell), pancreatic, ovarian, lymphoma, thymoma, CNS
  • Mechanism: SIADH
  • Symptoms: muscle twitching, seizure, coma
  • Management: fluid restriction, if seizing administer 3% hypertonic saline at 100cc/hr until resolution
• Hypernatremia
  • Mechanism: decreased intake, increased GI losses from chemotherapy
  • Management: cautious fluid resuscitation
• Tumor Lysis Syndrome (TLS)
  • Cancers: hematologic, rapid-growth solid tumors
  • Mechanism: release of intracellular contents (uric acid, K, PO4, Ca)
  • Timing: 1-4 days after therapy (chemo, radiation)
  • Diagnosis
    • Uric acid >8mg/dL
    • Potassium >6mEq/L
    • Calcium <7mg/dL
    • PO4 >4.5mg/dL
    • Acute kidney injury
  • Management
    • IVF, allopurinol, rasburicase, urinary alkalinization
    • Consider hemodialysis if volume overloaded

Localized Complications

• Musculoskeletal Complications
  • Spinal cord compression
    • Cancers: prostate, breast, lung, RCC, non-Hodgkin lymphoma, MM (5-10% of all cancer patients)
    • Sites: thoracic (60%), lumbosacral (30%), cervical (10%)
    • Symptoms: pain (worse lying flat, cough/sneeze, heavy lifting)
    • Evaluation: MRI (se 93%, sp 97%)
    • Management: dexamethasone 10mg IV load, 4mg q6h, neurosurgical consultation, radiation oncology consultation
  • Pathologic fracture
    • Features: sudden onset, low-force mechanism
• Therapy Complications
  • Neutropenic fever
    • Definition: ANC <500 or ANC <1000 with expected nadir <500 (nadir typically occurs 5-10d after chemotherapy) with Tmax >38.3°C or >38.0°C for >1h
    • Examination: subtle signs of infection, thorough examination is critical (skin, catheter, perineum)
    • Treatment: carbapenem monotherapy, vancomycin if indwelling catheter, oncology consultation for colony stimulating factors
  • Chemotherapy-induced vomiting
    • Management: ondansetron with dexamethasone, consider NK-1 antagonist (aprepitant)

Hematologic Malignancies

• Acute leukemia
  • Signs/Symptoms: leukopenia (infection), anemia (weakness/fatigue), thrombocytopenia (bleeding)
  • Diagnosis: >5% blasts
• Thrombocytopenia
  • Management
    • No bleeding, goal >10,000
    • Fever, coagulopathy, hyperleukoctosis, goal >20,000
    • One unit of platelets increases count by 5,000
• Hyperleukocytosis
  • Definition: WBC > 50-100k
  • Complications: microvascular congestion (pulmonary, cerebral, coronary)
  • Symptoms
    • CNS: confusion, somnolence, coma
    • Pulmonary: dyspnea, respiratory alkalosis
  • Management: cytoreduction (induction chemotherapy, increased risk TLS)
• Hyperviscosity
  • Cancer: macroglobulinemia, MM
  • Symptoms: epistaxis, purpura, GIB, neuro deficits
  • Diagnosis: serum viscosity > 1.4-1.8
  • Management: emergent plasmapheresis
• Polycythemia
  • Diagnosis: Hb >17
  • Differential: dehydration, hypoxia, smoking, altitude
  • Symptoms: HA, vertigo, angina, claudication, pruritus (after showering)
  • Complications: thrombosis (stroke), bleeding
  • Management: emergent phlebotomy (500cc if otherwise healthy)
• Thrombocytosis
  • Diagnosis: platelet >1,000,000
  • Symptoms: vasomotor (HA, lightheadedness, syncope, chest pain, paresthesias)
  • Management: low-dose aspirin