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
