LAS VEGAS—While structural and metabolic oncologic emergencies need to be recognized early to ensure the best possible patient care, symptoms are often subtle and require a high index of suspicion. That was the warning of speakers here at the Oncology Nursing Care conference, formerly called Critical Issues & Trends.
Signs of oncologic emergencies such as back pain, nausea, fatigue, and anorexia are very nonspecific, said Maura Polansky, MS, PA-C, of the Department of Gastrointestinal Medical Oncology at the University of Texas MD Anderson Cancer Center, where she is also Director of PA Education. “In medical oncology, virtually all of my patients have these symptoms.”
In an email correspondence, Theresa Brown, RN, an oncology nurse at the University of Pittsburgh Medical Center (UPMC) Shadyside Hospital, said that the early subtle signs of oncologic emergencies are “part of what makes oncology nursing difficult.” Subtle signs need to be noted, she said, adding that while the more benign explanation is usually the right one, the bigger concerns—for example, sepsis—“keep us on our toes.”
With structural oncologic emergencies, health care providers are addressing emergent life-threatening consequences of cancer metastases, said Deborah Boyle, RN, MSN, FAAN, of the Banner Good Samaritan Medical Center in Phoenix. These include spinal cord compression, superior vena cava syndrome, and cardiac tamponade.
Spinal Cord Compression
Spinal cord compression is the invasion of the epidural space by a local or metastatic tumor with consequent cord compression.
The thoracic spine is the most prominent site for this compression, followed by the lumbosacral and cervical spine, said Ms. Boyle, adding that patients may also have structural cord compression in multiple sites, The site will predict symptoms, although patients may be asymptomatic during the first phases of this process.
“The onset of symptoms is usually very gradual over days to weeks, she noted. Back pain may occur weeks to months before the development of neurological manifestations and usually occurs at the level of the spinal cord compression.
However, back pain is often a vague symptom because it can be caused by the hospitable bed or a prior injury, noted Ms. Brown, who was also a conference keynote speaker on survivorship and is a regular contributor to the New York Times, and author of Critical Care: A New Nurse Faces Death, Life, and Everything in Between (2010, HarperOne, ISBN 0061791555).
Ms. Boyle explained that patients may also experience autonomic dysfunction such as evacuation problems and sexual impairments, motor deficits, including weakness that starts in the feet and moves up the legs, and sensory deficits such as numbness that starts in the toes and works up in a stocking pattern.
Medical history helps to diagnose the condition, as does a physical exam that includes a comprehensive central nervous system exam and magnetic resonance imaging.
Ambulatory status is a predictor of survival—specifically, patients who are walking at presentation typically have a survival of about nine months compared with only about two months for nonambulatory patients (JAMA 2008;299:937-946).
“Treatment depends on the type of cancer, the location, the prognosis, the rate of symptom onset, the degree of involvement around the cord of the spine, the function before the symptoms occurred, and the degree of comorbidity,” she said.
Steroids are often given to reduce vasogenic edema in the cord and to help preserve neurologic function. Most patients will receive some degree of radiation therapy. Surgery is also a possibility for decompression and may be used in radioresistant tumors or if patients have already received their maximum radiation dose.
Surgery may also treat initial spinal cord compression when all signs point to a longer duration of survival and increased quality of life, she said.
Superior Vena Cave Syndrome
Superior vena cava syndrome occurs when an external mass or lymph node or internal clot occludes the superior vena cava vessel, impairing venous return to the heart from the head, neck, and upper extremities.
“It is almost always caused by a malignancy when we see it in clinical practice,” Ms. Boyle said. Primary malignancies are often of the lung and/or lymphoma, but may include breast, esophageal, and thyroid cancers, and pulmonary or lymph node metastases may also be involved.
Early symptoms include nonproductive cough, dyspnea, dysphagia, hoarseness, chest pain, facial, neck and arm swelling, and a feeling of fullness in the head—“something that is very hard to describe for many of our patients,” she said.
Other early symptoms include jugular vein distention, conjunctival redness, ruddy face and cheeks, and edemas of the face, arms, fingers, and neck.
Symptoms can be vague, Ms. Brown noted. For example, if a patient's face is swollen, it could also be due to an allergic reaction or “moon face” from steroids.
Later symptoms are more obvious, said Ms. Boyle, and include respiratory distress, facial or upper torso cyanosis, engorged conjunctivae, and mental status changes. Additionally, patients may experience tachypnea, orthopnea, stridor, stupor, coma, seizures, headache, visual disturbance, dizziness, syncope, lethargy, and irritability.
Patients are diagnosed with chest radiography, computed chest tomography, contrast venography, and MRI.
Treatment goals are early recognition and decompression, she said. If a tumor is caught early, therapy may include emergent surgery, stent placement, high-dose short-course radiation chemotherapy, steroids, and diuretics, she said. If the cause is due to thrombosis or a clot, practitioners may use fibrinolytic agents or anticoagulants.
Severe superior vena cava syndrome may require intubation, as well as ongoing assessment of the patient's mental status and keeping the head of the bed elevated.
Cardiac tamponade is a form of obstructive shock in which increased pericardial pressure from the accumulation of blood or fluid within the pericardial space results in impaired cardiac filling, decreased cardiac output, and hemodynamic compromise.
Although the condition is less common in cancer patients than superior vena cava syndrome and spinal cord compression, malignant disease is most often the cause, said Ms. Boyle. If cardiac tamponade goes untreated, it can lead to cardiovascular collapse, shock, or death.
Primary tumors are usually associated with mesothelioma, malignant fibrous histiocytoma, rhabdomyosarcoma, or angiosarcomas, she said. Metastatic spread to the heart “is really quite rare,” she added.
“Early symptoms are vague and most frequently overlooked.” Dyspnea, retrosternal chest pain—relieved by leaning forward and worsening when supine—cough, hoarseness, hiccups, and muffled heart sounds are all signs.
Later signs of cardiac tamponade are generally the worsening of earlier symptoms, she added. For example, dyspnea may compromise speech or the patient may experience the Beck Triad—i.e., elevated central venous pressure, hypotension, and distant heart sounds.
The condition is diagnosed with two-dimensional echocardiogram, computed tomography scan, and magnetic resonance imaging. Treatment includes pericardiocentesis to “remove fluid and restore stability.” Additionally, Ms. Boyle said, a post-procedure catheter may promote adhesion formation or scarring, while pericardial sclerosis can prevent fluid reaccumulation. Patients may also receive systemic chemotherapy.
Cancer treatment, however, may be postponed while the patient is being stabilized.
Ms. Polansky explained that metabolic emergencies require early identification because patients may become ill quite quickly. These emergencies include hypercalcemia, sepsis, and disseminated intravascular coagulation.
“Hypercalcemia is fairly common in our patients,” she said, adding that it is typically caused by parathyroid hormone-related peptide or osteolysis and is the most common paraneoplastic endocrine syndrome.
Associated malignancies are non-small cell lung cancer, renal cancer, head and neck cancer, and bladder cancer. “I primarily see GI cancer patients, and it's not common, but I do see it from time to time, so it should be on our radar with all of our cancer patients,” she said.
Symptoms of hypercalcemia often start out as nonspecific and include nausea, vomiting, constipation, and lethargy. As the problem progresses, patients may also experience confusion, hyporeflexia, and dysrythmias; and coma and death are also possible.
Treatment includes increasing urinary calcium through hydration. “It's a very effective short-term quick fix,” Ms. Polansky explained. Loop diuretics can also be helpful, but should not be administered until patients are well hydrated. “Ultimately, bisphosphonates are the backbone of treatment,” she noted.
Finally, health care providers will also treat the underlying malignancy “when effective treatment is available,” she said.
The terms sepsis, systemic inflammatory response syndrome (SIRS), sepsis shock, and bactermia are often used interchangeably, said Ms. Polansky.
Sepsis or SIRS refer to an inflammatory condition that releases cytokines, and while it is typically an infectious condition it does not have to have an infectious etiology.
Septic shock is when patients with sepsis subsequently experience either hypotension or evidence of organ hypoperfusion. Bactermia is the presence of bacteria of the blood documented by blood culture.
Common causes of sepsis are bacteremia, CNS infection, intra-abdominal infection, pneumonia, osteomyelitis, and urinary tract infection, especially if patients are immunocompromised. Symptoms include hyperthermia or hypothermia, shortness of breath, tachycardia, and elevated white count.
Treatment depends on prompt recognition of the condition and administration of broad spectrum antibiotics, in addition to examining the sources of infection and providing aggressive supportive care, said Ms. Polansky.
The longer it takes for patients to be evaluated, the higher their mortality rate.
The Surviving Sepsis Campaign suggests several approaches to care although not all are always indicated. These include obtaining blood cultures prior to antibiotics, improving the time to broad-spectrum antibiotics, administering low-dose steroids or recombinant activated protein C (RHAPC), maintaining adequate central venous oxygen saturation, central venous pressure and glycemic control, preventing excessive inspiratory plateau pressures, measuring serum lactate, and treating hypotension and elevated lactate with fluids.
Disseminated Intravascular Coagulation(DIC)
Disseminated intravascular coagulation is an acquired pathologic syndrome associated with many medical, surgical, and obstetric diseases, said Ms. Polansky.
Precipitating factors include endothelial, tissue, and platelet and red cell injury. The condition results in excess thrombin release and activation of a coagulation cascade, and may be acute or chronic.
Cancer patients may develop DIC due to infections, intravascular hemolysis, and less often, advanced malignancies, she noted.
Symptoms include abnormal bleeding and clotting. “The bleeding is what often gets people's attention, but it's the clotting that can be life threatening,” and can result in renal impairment, pulmonary compromise, and stroke or microvascular CNS involvement.
The diagnosis is dependent on clinical suspicion based on evidence of abnormal bleeding or clotting. Ms. Polansky said that health care providers need to check prolonged partial thromboplastin time (PTT) and prothrombin time (PT), decreased platelet count, and elevated d-dimer and fibrin degradation productions to get a full panel of clotting indicators— “Those are not without controversy, and sometimes they’re nonspecific,” she said, adding that diagnostic criteria, including those of the International Society on Thrombosis and Haemostatsis, can be useful.
Management of DIC involves prompt recognition and treatment of underlying causes. Supportive care such as mechanical ventilation, dialysis, and transfusion may also be needed.
“Heparin is also used judiciously,” she said. “This is where the management of these patients can be very complicated and very difficult. On the one hand they’re bleeding; on the other hand, these clotting syndromes can result in death.”
In addition, said Ms. Brown, patients experiencing DIC may need to be stabilized before any cancer treatment continues.