In this on-demand teaching session, expert Medical Oncologist Beatrice Preti, an Assistant Professor at Emory University, will guide participants through diagnosing and developing treatment plans for five major oncologic emergencies. These include spinal cord compression, febrile neutropenia, immunotherapy side effects, brain metastases, and tumour lysis syndrome. The session further covers the symptoms, diagnosis workup, treatment plans, and supportive care required for these oncologic emergencies. Real-life case questions will reinforce the learning outcomes, making the session highly practical for medical professionals involved with oncology patients. Research at Beatrice Preti's session to improve your ability to identify and overcome challenging scenarios in oncology.
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Oncologic Emergencies RD BEATRICE PRETI024Quick Intro Medical Oncologist beatrice.preti@emory.edu Assistant Professor (Emory University, Atlanta, GA, USA) Adjunct Professor (Western University, London, ON, Canada)Learning Objectives By the end of this session, participants should be able to: Diagnose five major oncologic emergencies Develop a preliminary treatment plan for five major oncologic emergencies Determine when (and who!) to call for help in five major oncologic emergenciesAre You READY????Spinal Cord CompressionDiagnosis: Symptoms Back pain Lower limb weakness Bowel Incontinence Urinary Retention Saddle Anaesthesia Numbness + Paraesthesias AtaxiaDiagnosis Associated with bony mets (breast, lung, prostate) but not always!Diagnosis Associated with bony mets (breast, lung, prostate) but not always! 10% cervical spine, 60-70% thoracic spine, 20-30% lumbosacral spine MUST IMAGINE WHOLE SPINEDiagnosis: Workup MRI SpineTreatment URGENT!!! Time = neurons!!! Ataxia > 48 hours = poor prognosisTreatment URGENT!!! Time = neurons!!! Ataxia > 48 hours = poor prognosis Treatment: Steroids ASAP: 10 mg IV, then 16 mg per day, divided Radiation: typically external beam radiotherapy Neurosurgery consultationCase Question Mrs L is a 55-year-old lady with metastatic breast cancer to the bone. She presents with a 3-day history of worsening lower back pain and lower limb weakness. CT scan of the spine reveals metastases to T12 and L1, with no clear sign of cord compression. What would you order next?Febrile NeutropaeniaDiagnosis: Symptoms Temperature > 38 C/100.4 F Sustained over 1 hour One-time > 38.3 C/101 F Symptoms of infection or feverDiagnosis: Workup Thorough history and examinationDiagnosis: Workup Thorough history and examination Full blood work: blood counts with differential, metabolic panel, liver, renal Neutropaenia: ANC < 1000 – 1500 cells/microL OR anticipated decrease Full cultures: blood x 2, urine, sputum Including two peripheral sites, or peripheral/central line Chest x-rayNote: Chest x-ray may appear “normal” in severe neutropaenia.Treatment Empiric antibiotics ASAP! Do you know what antibiotics would be recommended in your region (put in chat)?Treatment Empiric antibiotics ASAP! Decision on admission Other supportive care as needed Fluids Pain control Be cautious with acetaminophenCase Question Mr P is currently on FOLFIRINOX chemotherapy for metastatic pancreatic cancer. He presents six days after his last infusion with chills, nausea, and a temperature of 38.5C. Basic blood work shows a white cell count of 1.0 and an absolute neutrophil count of 0.4/400. Which of these next steps should be ordered FIRST?Immunotherapy Side EffectsDiagnosis: SymptomsDiagnosis: Symptoms Inflammation!!! Colitis Pembrolizumab Nivolumab Pneumonitis Encephalitis Durvalumab Ipilimumab Pericarditis Avelumab Hypophysitis Cemiplimab Thyroiditis/Pancreatitis AtezolizumabDiagnosis: Workup SUSPICION is key!!Diagnosis: Workup SUSPICION is key!! Consult med onc + appropriate service Full bloodwork, including CRP Relevant imaging Rule out infectious/other causesTreatment: Severe Cases Steroids! Steroids! Steroids! …additional immunosuppression in refractory casesCase Question Ms J is a 35-year-old female with metastatic melanoma, on nivolumab. She presents with 4 days of worsening diarrhoea. What should be done prior to considering steroids? Please write your answer in the chatBrain MetastasesDiagnosis: Symptoms Suspect in any patient with: Headache 40-50% patients Neurological symptoms/findings Seizures Altered level of consciousnessDiagnosis: Workup Contrast-enhanced MRI = gold standard Brain biopsy only if no other sites….Treatment Surgery Stereotactic Radiation Whole brain radiation …systemic therapiesTreatment Surgery One small lesion… Stereotactic Radiation Whole Brain Radiation Widespread/more anticipated …systemic therapiesCase Question Mr G has metastatic RCC. He presents with a seizure. CT scan of the head shows one metastatic deposit, with significant vasogenic oedema. Which of these would you do next?Tumour Lysis SyndromeDiagnosis: Symptoms Less common in solid tumours Small cell lung cancer, testicular cancer Extensive/bulky disease, abnormal labs at baseline Rapid cell deathDiagnosis: Workup Blood work Suspicion is key! And preparation!!!Prevention FLUIDS Urine 80-100 mL/hr Allopurinol in intermediate risk (i.e. solid tumour) Rasburicase Febuxostat: fancy new drug Urine alkalinisation is controversialTreatment Supportive: Fix electrolytes Rasburicase Dialysis if indicatedCase Question Tom is a 24-year-old male with metastatic testicular cancer. He has widespread disease with multiple bulky metasases. He is scheduled to start chemotherapy. Which of these would NOT be recommended for Tom?Bottom Line Ask for help Consult oncology Monitor closelyQuestions? Beatrice Preti Beatrice.Preti@emory.edu bpreti@qmed.ca
