Clinical Problems in Oncology E-Book

Sing Yu Moorcraft

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 509

Veröffentlichungsjahr: 2014

Beschreibung

Clinical Problems in Oncology: A Practical Guide to Management is an easy-to-use, compact
reference with essential, practical information on managing oncological emergencies, as well as
the side effects and complications of cancer and its treatment. Because patient responses can vary
widely, depending on the type of treatment prescribed, this resource offers medical professionals
the specific information they need to improve the evaluation and treatment of cancer patients at
the point of care.

The compact format includes a wide range of clinical information, from the dose of drugs that would
typically be used, through guidance on the practical procedures that are frequently used
to treat oncology patients. Some of the book’s highlights include:

• Toxicity grading and management, including at-a-glance summaries of the most common toxicities associated with chemotherapy
• Prescribing guidelines, including how to write up electrolyte replacement properly
• Information on specialised oncology procedures (such as SIR spheres), and how to manage complications
• Types of vascular access lines and how to check their position, access them and troubleshoot problems

With an expert team of writers who have contributed materials in their areas of expertise, Clinical
Problems in Oncology is an ideal reference for oncologists in training, oncologists in non-training
positions, oncology registrars and general practitioners.

Leseprobe

CONTENTS

Cover

Title page

Copyright page

List of contributors

Preface

Acknowledgements

List of abbreviations

Chapter 1: Introduction to clinical problems in oncology

General approach to the management of oncology patients

References

Performance status

Tumour markers

References

Chapter 2: Oncological emergencies

Anaphylaxis and hypersensitivity reactions

References

Bleeding

References

Central airway obstruction and stridor

References

Extravasation

References

Febrile neutropenia

References

Hypercalcaemia

References

Non-neutropenic sepsis

References

Raised intracranial pressure and seizures

References

Spinal cord compression

References

Superior vena cava obstruction

References

Transfusion reactions

References

Tumour lysis syndrome

References

Chapter 3: Side effects and complications of cancer and its treatment

Overview of toxicity management

References

Abnormal liver function tests

References

Alopecia

References

Anaemia

References

Anorexia and nutrition

References

Ascites

References

Bone metastases and osteoporosis

References

Bowel obstruction

References

Breathlessness

References

Chest pain and other cardiac complications

References

Confusion and decreased conscious level

References

Constipation

References

Dental disorders

References

Diarrhoea

References

Dysphagia

References

Fatigue

References

Fertility and pregnancy

References

Haematuria

References

Hearing loss

References

Hiccups

References

Hyperglycaemia and hypoglycaemia

References

Hypertension and hypotension

References

Lymphoedema

References

Mucositis

References

Nausea and vomiting

References

Neuropathy

References

Neutropenia

References

Proteinuria

References

Pruritus

References

Psychiatric disorders

References

Rash

References

Renal failure and hydronephrosis

References

Sexual dysfunction

References

Thrombocytopenia

References

Thromboembolism

References

Vaccinations and immunoglobulin

References

Visual symptoms

References

Chapter 4: Introduction to radiotherapy

Introduction to radiotherapy

Methods of delivery of radiotherapy

References

Chapter 5: Radiotherapy side effects andtheir management

Overview of radiotherapy toxicity

Overview of radical radiotherapy treatment and side effect management by anatomical treatment site

Skin toxicities

Total body irradiation

References

Chapter 6: Endocrine therapy, immunotherapy and targeted therapies

Endocrine therapy

References

Immunotherapy

References

Targeted therapies

References

Chapter 7: Electrolyte abnormalities

Hypocalcaemia

References

Hyperkalaemia and hypokalaemia

References

Hypermagnesaemia and hypomagnesaemia

References

Hypernatraemia and hyponatraemia

References

Hyperphosphataemia and hypophosphataemia

References

Chapter 8: Palliative care and pain management

Pain management

End-of-life care

References

Chapter 9: Oncology procedures and their complications

Ascitic drains (paracentesis)

References

Biliary drains and stents

References

Central venous access devices

References

Chemoembolisation

References

Chest drains and pleurodesis

References

Enteral feeding tubes

Nephrostomies and ureteric stents

References

Oesophageal stents and dilatation

References

Radioembolisation (SIR-spheres®)

References

Radiofrequency ablation (RFA)

References

Chapter 10: Cancer drug development and funding

Clinical trials

References

Funding of cancer drugs

References

Personalised medicine

References

Appendices

Chemotherapy regimes

References

Drug toxicities

References

Useful resources

Supplemental Images

Index

End User License Agreement

List of Tables

Chapter 01

Table 1.1 Performance status.

Table 1.2 Common tumour markers.

Chapter 02

Table 2.1 CTCAE (V4.03) grading of tracheal obstruction.

Table 2.2 CTCAE (V4.03) grading of stridor.

Table 2.3 CTCAE (V4.03) grading of extravasation.

Table 2.4 Chemotherapeutic categories

Table 2.5 Chemotherapeutic agents that may cause a local reaction.

Table 2.6 CTCAE (V4.03) grading of neutropenic sepsis.

Table 2.7 CTCAE (V4.03) grading of hypercalcaemia.

Table 2.8 General overview of CTCAE (V4.03) grading of infection.

Table 2.9 Diagnostic criteria for sepsis.

Table 2.10 Clinical features at presentation.

Table 2.11 CTCAE (V4.03) grading of tumour lysis syndrome.

Table 2.12 Risk factors for developing tumour lysis syndrome.

Chapter 03

Table 3.1 CTCAE (V4.03) grading of abnormal liver function tests.

Table 3.2 CTCAE (V4.03) grading of alopecia.

Table 3.3 CTCAE (V4.03) grading of anaemia.

Table 3.4 CTCAE (V4.03) grading of anorexia.

Table 3.5 CTCAE (V4.03) grading of ascites.

Table 3.6 CTCAE (V4.03) grading of GI obstruction.

Table 3.7 CTCAE (V4.03) grading of dyspnoea.

Table 3.8 CTCAE (V4.03) grading of confusion.

Table 3.9 Abbreviated mental test.

Table 3.10 CTCAE (V4.03) grading of depressed level of consciousness.

Table 3.11 Glasgow Coma Scale (GCS).

Table 3.12 CTCAE (V4.03) grading of constipation.

Table 3.13 CTCAE (V4.03) grading of osteonecrosis.

Table 3.14 CTCAE (V4.03) grading of diarrhoea.

Table 3.15 CTCAE (V4.03) grading of dysphagia.

Table 3.16 CTCAE (V4.03) grading of fatigue.

Table 3.17 CTCAE (V4.03) grading of oligospermia.

Table 3.18 CTCAE (V4.03) grading of irregular menstruation.

Table 3.19 The impact of radiation therapy or systemic chemotherapy agents on spermatogenesis in patients with cancer.

Table 3.20 Risk of female gonadotoxicity of various antineoplastic agents.

Table 3.21 CTCAE (V4.03) grading of haematuria.

Table 3.22 CTCAE (V4.03) grading of hearing loss.

Table 3.23 CTCAE (V4.03) grading of hiccups.

Table 3.24 CTCAE (V4.03) grading of hyperglycaemia.

Table 3.25 CTCAE (V4.03) grading of hypoglycaemia.

Table 3.26 CTCAE (V4.03) grading of hypertension.

Table 3.27 CTCAE (V4.03) grading of hypotension.

Table 3.28 CTCAE (V4.03) grading of lymphoedema.

Table 3.29 CTCAE (V4.03) grading of mucositis.

Table 3.30 CTCAE (V4.03) grading of nausea.

Table 3.31 CTCAE (V4.03) grading of vomiting.

Table 3.32 Overview of commonly used anti-emetics.

Table 3.33 CTCAE (V4.03) grading of neuropathy.

Table 3.34 CTCAE (V4.03) grading of neutropenia.

Table 3.35 CTCAE (V4.03) grading of proteinuria.

Table 3.36 CTCAE (V4.03) grading of pruritus.

Table 3.37 CTCAE (V4.03) grading of anxiety.

Table 3.38 CTCAE (V4.03) grading of hand-foot syndrome/palmar plantar erythrodysesthesia (PPE)/acral erythema.

Table 3.39 CTCAE (V4.03) grading of acneiform rash.

Table 3.40 CTCAE (V4.03) grading of acute kidney injury.

Table 3.41 CTCAE (V4.03) grading of erectile dysfunction.

Table 3.42 CTCAE (V4.03) grading of vaginal dryness.

Table 3.43 CTCAE (V4.03) grading of vaginal stricture.

Table 3.44 CTCAE (V4.03) grading of thrombocytopenia.

Table 3.45 CTCAE (V4.03) grading of thromboembolic events.

Table 3.46 CTCAE (V4.03) grading of eye disorders.

Table 3.47 Ocular complications occurring with ≥ 20% probability on administration of chemotherapy.

Chapter 04

Table 4.1 Examples of palliative treatment regimes and treatment indications.

Chapter 05

Table 5.1 Side effects and management of radiotherapy to the brain.

Table 5.2 Side effects of head and neck radiotherapy.

Table 5.3 CTCAE (V4.03) grading of mucositis.

Table 5.4 CTCAE (V4.03) grading of respiratory toxicity.

Table 5.5 Side effects of radiotherapy to the thorax.

Table 5.6 CTCAE (V4.03) grading of dysphagia.

Table 5.7 Side effects of radiotherapy to the abdomen.

Table 5.8 Side effects of pelvic radiotherapy.

Table 5.9 CTCAE (V4.03) grading of lower GI side effects.

Table 5.10 CTCAE (V4.03) grading of genitourinary side effects.

Table 5.11 CTCAE (V4.03) grading of radiation dermatitis.

Table 5.12 Guidance on the management of early skin toxicity. Adapted from The Princess Royal Radiotherapy Review Team. Managing Radiotherapy Induced Skin Reactions – A Toolkit for Healthcare Professionals.

Chapter 07

Table 7.1 CTCAE (V4.03) grading of hypocalcaemia.

Table 7.2 CTCAE (V4.03) grading of hyperkalaemia.

Table 7.3 CTCAE (V4.03) grading of hypokalaemia.

Table 7.4 CTCAE (V4.03) grading of hypermagnesaemia.

Table 7.5 TCAE (V4.03) grading of hypomagnesaemia.

Table 7.6 CTCAE (V4.03) grading of hypernatraemia.

Table 7.7 CTCAE (V4.03) grading of hyponatraemia.

Table 7.8 CTCAE (V4.03) grading of hypophosphataemia.

Chapter 08

Table 8.1 ‘SOCRATES’: a common mnemonic acronym for assessing pain.

Table 8.2 A guide to conversions between opioids.

Table 8.3 Available fentanyl patches and breakthrough doses. Change patches every 72 hours (three days).

Table 8.4 Available buprenorphine patches (Transtec®) and breakthrough doses. Change patches every 96 hours (four days).

Table 8.5 Available buprenorphine patches (BuTrans®) and breakthrough doses. Change patches every seven days.

Table 8.6 Medications commonly used at the end of life.

Chapter 09

Table 9.1 Types of central venous access devices.

Appendices

Table 1 Commonly used abbreviations for chemotherapy regimes.

Table 2 Drug toxicities.

List of Illustrations

Chapter 02

Figure 2.1 Dermatomal distributions. There is individual variation in the distribution of dermatomes. This figure illustrates the likely distribution of dermatomes, but there is overlap between dermatomes areas of increased individual variability. Blank areas illustrate areas of greatest variability and overlap.

Chapter 03

Figure 3.1 Flowchart for the management of diabetes at the end of life.

Figure 3.2 Hand foot syndrome secondary to capecitabine.

Figure 3.3 Panitumumab-related rash.

Figure 3.4 Fissures of the fingertips in a patient treated with taxanes.

Figure 3.5 Paronychia in a patient treated with lapatinib.

Chapter 04

Figure 4.1 Flow diagram of radiotherapy treatment process.

Figure 4.2 Linear accelerator.

Chapter 05

Figure 5.1 Example of a perspex mask used in head and neck radiotherapy.

Figure 5.2 Example of acute radiotherapy skin reaction: CTCAE grade 3 confluent moist desquamation.

Chapter 08

Figure 8.1 Based on the World Health Organisation (WHO).

Figure 8.2 Examples of in-patient opioid prescriptions.

Chapter 09

Figure 9.1 Implantable port.

Figure 9.2 Ensuring the ideal position for the catheter tip for central venous access devices. The CXR shows a left-sided PICC line with its tip (white square) lying in the long axis of the superior vena cava (SVC) just above the carina. The boundaries of the safe zone are shown by the red dotted lines, lying 2 cm above and 2 cm below the carina respectively. To see a colour version of this figure, see Plate 9.2.

Figure 9.3 Flowchart for the investigation of occluded venous devices.

Supplemental Images

Plate 2.1 Dermatomal distributions. There is individual variation in the distribution of dermatomes. This figure illustrates the likely distribution of dermatomes, but there is overlap between dermatomes areas of increased individual variability. Blank areas illustrate areas of greatest variability and overlap.

Plate 3.2  Hand foot syndrome secondary to capecitabine.

Plate 3.3  Panitumumab-related rash.

Plate 3.4  Fissures of the fingertips in a patient treated with taxanes.

Plate 3.5  Paronychia in a patient treated with lapatinib.

Plate 4.2  Linear accelerator.

Plate 5.1  Example of a perspex mask used in head and neck radiotherapy.

Plate 5.2  Example of acute radiotherapy skin reaction: CTCAE grade 3 confluent moist desquamation.

Plate 9.2  Ensuring the ideal position for the catheter tip for central venous access devices. The CXR shows a left-sided PICC line with its tip (white square) lying in the long axis of the superior vena cava (SVC) just above the carina. The boundaries of the safe zone are shown by the red dotted lines, lying 2 cm above and 2 cm below the carina respectively.

Guide

Cover

Table of Contents

Begin Reading

Pages

iii

iv

ix

xi

xii

xiii

xiv

xv

xvi

xvii

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

25

26

27

28

29

30

31

32

33

34

35

36

24

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64

65

66

67

68

69

70

71

72

73

74

75

76

77

78

79

80

81

82

83

84

85

86

87

88

89

90

91

92

93

94

95

96

97

98

99

100

101

102

103

104

105

106

107

108

109

110

111

112

113

114

115

116

117

118

119

120

121

123

124

125

126

127

128

129

130

131

132

133

134

135

136

137

138

139

140

141

142

143

144

145

146

147

148

149

150

151

152

153

154

155

156

157

158

159

160

161

162

163

164

165

166

167

168

169

170

171

172

173

174

122

175

176

177

178

179

180

181

182

183

184

185

186

187

188

189

190

191

193

194

195

196

197

198

199

200

201

202

203

204

205

206

207

208

209

210

211

212

213

214

215

216

217

218

219

220

221

222

223

224

225

226

227

228

229

230

231

232

233

234

235

236

237

238

239

240

241

242

243

244

245

246

247

248

249

250

251

252

253

254

255

256

257

258

259

260

261

262

263

264

265

266

267

268

269

270

271

272

273

274

275

276

277

278

279

280

281

282

283

284

285

286

287

288

289

290

291

292

293

294

295

296

297

298

299

301

302

303

304

305

306

307

308

309

310

311

312

313

314

315

316

Clinical Problems in Oncology

A Practical Guide to Management

Edited by

Sing Yu Moorcraft, MB BCh, MRCP

Clinical Research Fellow in Medical Oncology

The Royal Marsden NHS Foundation Trust

London, UK

Daniel L.Y. Lee, MB BCh, MRCP

Specialist Registrar in Medical Oncology

St James’ Institute of Oncology

Leeds, UK

David Cunningham, MD, FRCP, FMedSci

Consultant Medical Oncologist

The Royal Marsden NHS Foundation Trust

London, UK

This edition first published 2014© 2014 by John Wiley & Sons, Ltd

Registered officeJohn Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex PO19 8SQ, UK

Editorial offices9600 Garsington Road, Oxford OX4 2DQ, UKThe Atrium, Southern Gate, Chichester, West Sussex PO19 8SQ, UK111 River Street, Hoboken, NJ 07030-5774, USA

For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell

The right of the author to be identified as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.

Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.

The contents of this work are intended to further general scientific research, understanding and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis or treatment by health science practitioners for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.

Library of Congress Cataloging-in-Publication Data

Clinical problems in oncology : a practical guide to management / edited by Sing Yu Moorcraft, Daniel L.Y. Lee, David Cunningham.p. ; cm.Includes bibliographical references and index.ISBN 978-1-118-67382-9I. Moorcraft, Sing Yu, editor of compilation. II. Lee, Daniel L. Y., editor of compilation. III. Cunningham, David, 1954 December 4– editor of compilation.[DNLM: 1. Neoplasms–Handbooks. 2. Clinical Medicine–methods–Handbooks. QZ 39]RC261616.99′4–dc23

2014001178

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

List of contributors

Emma Dugdale, MB ChB, MRCP, FRCRSpecialist Registrar in Clinical Oncology,St James's Institute of Oncology,Leeds, UK

Alexandra Gilbert, BSc, MBBS, MRCPNational Institute for Health Research Doctoral Research Fellow in Clinical Oncology,St James’ Institute of Oncology,Leeds, UK

Daniel L.Y. Lee, MB BCh, MRCPSpecialist Registrar in Medical Oncology,St James’ Institute of Oncology,Leeds, UK

Juanita Lopez, MB BChir, MRCP, PhDSpecialist Registrar in Medical Oncology,The Royal Marsden NHS Foundation Trust,London, UK

Sing Yu Moorcraft, MB BCh, MRCPClinical Research Fellow in Medical Oncology,The Royal Marsden NHS Foundation Trust,London, UK

Karen Neoh, MBChB, MRCPAcademic Clinical Fellow in Palliative Medicine,St Gemma’s Academic Unit of Palliative Care,Leeds, UK

Alexandra Pender, MB BCh, MRCPAcademic Clinical Fellow in Medical Oncology,The Royal Marsden NHS Foundation Trust,London, UK

Robin Prestwich, FRCR, PhDConsultant Clinical Oncologist,St James’ Institute of Oncology,Leeds, UK

Samantha Turnbull, MB ChB, MRCPSpecialist Registrar in Medical Oncology,St James’ Institute of Oncology,Leeds, UK

Preface

Clinical Problems in Oncology: A Practical Guide to Management was written by a group of trainees who found that there was no good source of information to guide them through the day-to-day management of patients with cancer.

The book, which is also available electronically, aims to provide a clear and yet concise description of how to deal with the day-to-day challenges of working within an oncology team. This includes essential background, such as the design and conduct of clinical trials, assessment of tumour response, evaluation of the performance status of patients and an overview of the concept of personalised medicine. There are also chapters outlining how to treat tumour-related symptoms and manage the side effects of conventional chemotherapy and the new class of targeted agents. The chapters on radiotherapy provide a grounding in this important aspect of cancer care, including practical solutions to assist clinicians looking after patients receiving this treatment, and there is also a detailed description of the management of oncological emergencies.

The objective of the authors was to provide a comprehensive source of information that would guide the trainee through their time on the ward, clinic and acute medical assessment unit. We have therefore included information that trainees will need to successfully function in these environments, ranging from the dose of drugs that would be typically used, through to guidance on the practical procedures that are frequently used to treat patients with cancer. We hope a copy of the book will find its way onto wards and clinics throughout the country and will become established as a reliable and comprehensive clinical guide to assist busy trainees.

Professor David Cunningham

Acknowledgements

We would like to thank Dr Kimberley Goldstein-Jackson and Niamh Cunningham for taking the time to read the manuscript and for their constructive comments. We would also like to thank Jane Ashton and Emily Wighton for reviewing the manuscript from a pharmacist’s perspective and Dr Liz O’Mahony for her comments on the Psychiatric disorders section. Finally, but by no means least, we are indebted to our families and friends, particularly John Moorcraft and Shaune Teasdale, for their support and patience during the preparation of this manuscript.

List of abbreviations

5-FU

5-fluorouracil

A&E

accident and emergency

ABG

arterial blood gas

ACE

angiotensin converting enzyme

ADL

activities of daily living

ADT

androgen deprivation therapy

AE

adverse event

AF

atrial fibrillation

AFP

alpha-fetoprotein

ALK

anaplastic lymphoma kinase

ALP

alkaline phosphatase

ALT

alanine aminotransferase

AR

adverse reaction

AST

aspartate aminotransferase

ATE

arterial thromboembolism

BCG

Bacillus Calmette-Guérin

BD

bis di (twice daily)

BMI

body mass index

BNF

British National Formulary

BP

blood pressure

BRCA1

breast cancer gene 1

BRCA2

breast cancer gene 2

BTA

bladder tumour antigen

CA

carbohydrate antigen

CBD

common bile duct

CCF

congestive cardiac failure

CDF

Cancer Drugs Fund

CEA

carcinoembryonic antigen

CID

chemotherapy-induced diarrhoea

COPD

chronic obstructive pulmonary disease

CML

chronic myeloid leukaemia

CNS

central nervous system

CPAP

continuous positive airway pressure

CR

complete response

CRP

C-reactive protein

CRPC

castration-resistant prostate cancer

CSF

cerebrospinal fluid

CT

computerised tomography

CTCAE

Common Terminology Criteria for Adverse Events

CTPA

computed tomography pulmonary angiogram

CVC

central venous catheter

CXR

chest X-ray

dB

decibel

DIC

disseminated intravascular coagulation

DPD

dihydropyrimidine dehydrogenase

DNA

deoxyribonucleic acid

DVT

deep vein thrombosis

ECG

electrocardiogram

ECOG

Eastern Cooperative Oncology Group

EDTA

(51)Cr-ethylenediaminetetra acetic acid plasma clearance

EEG

electroencephalogram

EGFR

epidermal growth factor receptor

ENT

ear, nose and throat

ER

oestrogen receptor

ERCP

endoscopic retrograde cholangio-pancreatography

ESR

erythrocyte sedimentation rate

FBC

full blood count

FDA

Food and Drug Administration

FEV

1

forced expiratory volume in first second

FFP

fresh frozen plasma

FGFR

fibroblast growth factor receptor

FISH

fluorescence in situ hybridisation

FSH

follicle-stimulating hormone

FVC

forced vital capacity

g

gram

GBM

glioblastoma multiforme

GCP

Good Clinical Practice

GCS

Glasgow Coma Scale

GCSF

granulocyte colony-stimulating factor

GFR

glomerular filtration rate

GGT

gamma-glutamyltransferase

GI

gastrointestinal

GIST

gastrointestinal stromal tumour

GLP1

glucagon-like peptide-1

GnRH

gonadotrophin releasing hormone

GOJ

gastro-oesophageal junction

GP

general practitioner

Hb

haemoglobin

HCC

hepatocellular carcinoma

hCG

human chorionic gonadotrophin

HDU

High Dependency Unit

HER2

human epidermal growth factor receptor 2/aka

neu

HIV

human immunodeficiency virus

HRCT

high resolution computerised tomography

HRT

hormone replacement therapy

ICP

intracranial pressure

IFR

individual funding request

IG

immunoglobulin

IGF-1

insulin-like growth factor-1

IHC

immunohistochemistry

IM

intramuscular

IMRT

intensity-modulated radiation therapy

INR

international normalized ratio (prothrombin ratio)

IPPV

intermittent positive pressure ventilation

ITU

Intensive Therapy Unit

IU

international unit

IV

intravenous

IVC

inferior vena cava

K

potassium

kg

kilogram

KRAS

v-Ki-ras2 Kirsten rat sarcoma viral oncogene homolog

KUB

kidneys, ureter, bladder

L

litre

LCP

Liverpool Care Pathway

LDH

lactate dehydrogenase

LFT

liver function test

LH

luteinising hormone

LHRH

luteinising hormone releasing hormone

LLN

lower limit of normal

LMWH

low molecular weight heparin

LP

lumbar puncture

LVEF

left ventricular ejection fraction

mane

in the morning

mcg

micrograms

MDT

multidisciplinary team meeting

MESNA

sodium-2-mercaptoethane

MHRA

Medicines and Healthcare products Regulatory Agency

µg

microgram

mg

milligram

MI

myocardial infarction

min(s)

minute(s)

ml

millilitre

mmHg

millimetres of mercury

MMR

mismatch repair (of DNA)

MMR

measles, mumps, rubella

MR

modified release

MR

magnetic resonance

MRA

magnetic resonance angiography

MRCP

magnetic resonance cholangio-pancreatography

MRI

magnetic resonance imaging

MSI

microsatellite instability

MSU

midstream urine

mTOR

mammalian target of rapamycin

MUGA

multi-gated acquisition scan

Na

sodium

NBM

nil by mouth

ng

nanogram

NG

nasogastric tube

NHL

non-Hodgkin's lymphoma

NHS

National Health Service

NICE

National Institute for Health and Care Excellence

nocte

at night

NSAID

non-steroidal anti-inflammatory drug

NSCLC

non-small-cell lung cancer

NSE

neuron-specific enolase

OD

omni di (once daily)

OGD

oesophageogastroduodenoscopy

OS

overall survival

OT

occupational therapist

PARP

poly (ADP-ribose) polymerase

PD

progressive disease

PDGFR

platelet derived growth factor receptor

PE

pulmonary embolism

PEFR

peak expiratory flow rate

PEG

percutaneous endoscopic gastrostomy

PET

positron-emission tomography

PFS

progression-free survival

PI3K

phosphatidylinositol 3-kinase

PICC

peripherally inserted central catheter

PO

per os (by mouth)

PPI

proton pump inhibitor

PR

partial response

PR

per rectum (by the rectum)

PR

progesterone receptor

PRLS

posterior reversible leukoencephalopathy syndrome

PRN

pro re nata

PS

performance status

PSA

prostate-specific antigen

PT

prothrombin time

PTC

percutaneous transhepatic cholangiography

PTEN

phosphatase and tensin homolog deleted on chromosome 10

PTH

parathyroid hormone

QDS

quater in die (four times a day)

RANK

receptor activator of NF-kB

RCC

renal cell carcinoma

RCT

randomised controlled trial

RECIST

Response Evaluation Criteria In Solid Tumours

RFA

radiofrequency ablation

RIG

radiologically inserted gastrostomy

RUQ

right upper quadrant

SAE

serious adverse event

SALT

speech and language therapy

SAR

serious adverse reaction

SC

subcutaneous

SCF

supraclavicular fossa

SCLC

small-cell lung cancer

SD

stable disease

SIGN

Scottish Intercollegiate Guidelines Network

SL

sublingual

SOB

short of breath

SOBOE

short of breath on exertion

SR

slow release

SSRI

selective serotonin reuptake inhibitors

SUSAR

suspected unexpected adverse reaction

SVC

superior vena cava

TACE

transarterial chemoembolisation

TDS

ter die sumendus (three times a day)

TFTs

thyroid function tests

TKI

tyrosine kinase inhibitor

TNM

tumour, lymph nodes, metastasis

TPN

total parenteral nutrition

TSH

thyroid-stimulating hormone

U

unit

U&E

urea and electrolytes

UK

United Kingdom

ULN

upper limit of normal

USA

United States of America

USS

ultrasound scan

UTI

urinary tract infection

VATS

video-assisted thoracic surgery

VEGF

vascular endothelial growth factor

VTE

venous thromboembolism

VZIG

varicella zoster immunoglobulin

WBC

white blood cell

WHO

World Health Organisation

Chapter 2Oncological emergencies

Daniel L.Y. Lee

St James’ Institute of Oncology, UK

CHAPTER MENU

Anaphylaxis and hypersensitivity reactions

Bleeding

Central airway obstruction and stridor

Extravasation

Febrile neutropenia

Hypercalcaemia

Non-neutropenic sepsis

Raised intracranial pressure and seizures

Spinal cord compression

Superior vena cava obstruction

Transfusion reactions

Tumour lysis syndrome

Anaphylaxis and hypersensitivity reactions

Definition

Hypersensitivity and anaphylaxis are immunologically triggered responses. Anaphylaxis can broadly be defined as a severe, life-threatening, generalised or systemic hypersensitivity reaction.

There are two types of reaction, one is IgE mediated and the other is not. There has recently been a move away from these distinct diagnoses, that of anaphylaxis and anaphylactoid reactions respectively, to sub-categorisation within an overarching diagnosis of anaphylaxis.

Causes

All intravenous infusions are at some risk of a hypersensitivity reaction or anaphylaxis. The overall incidence is around 5%; however, some are much more high risk.

High risk infusions include

: platinum and taxane chemotherapies (e.g. cisplatin, carboplatin, paclitaxel, docetaxel), some monoclonal antibody therapies (e.g. rituximab).

Other causes include

: antibiotics, NSAIDs, vaccines, contrast media, foods, insect stings, skin preparations and latex.

Symptoms and signs

Patient education is paramount, and early symptoms may be as vague as feeling ‘unwell’ or ‘not normal’.

Early diagnosis improves outcomes and shortens the possible effects, so vigilance of the treating team is important.

Acute reactions can occur within seconds of exposure and can progress rapidly, slowly or in a biphasic manner. Rarely, reactions can occur after a few hours or persist for more than 24 hours.

Beta-blockers may increase the severity of the reaction and antagonise the effect of adrenaline. Adrenaline can cause severe hypertension and bradycardia in patients taking non-cardioselective beta-blockers.

Symptoms can range in severity and are most commonly divided into two groups:

Mild symptoms only, without any respiratory symptoms.

Clinical signs of shock with possible respiratory distress, stridor, wheeze or laryngeal oedema.

Management

Specific treatment will depend on the severity of the reaction and the drug which is being infused. Each department should have guidance on the local protocol, but general guidance is given below.

Localised hypersensitivity reaction

Assess symptoms and observations.

Consider antihistamine and/or corticosteroid use (see anaphylaxis treatment section below for doses).

Repeat observations every 15 minutes for one hour.

Anaphylaxis

Stop the IV infusion and keep the IV access.

Call for help and prepare resuscitation trolley for use.

Assess airway, breathing and circulation, along with consciousness (GCS).

Lay the patient flat or in the Trendelenberg position (i.e. feet elevated).

Oxygen – 15 litres/minute via a non-rebreath mask.

Adrenaline

:

Intramuscular injection (1 mg/ml, 1:1000 dilution) into antero-lateral thigh, 0.5 mg every five minutes (treatment of choice).

Intravenous 50 mcg (0.5 ml, 1:10,000 dilution) boluses according to response – if repeated boluses required, start an adrenaline infusion. This is usually only given in specialist units (e.g. HDU, ITU or theatres) for patients with profound shock that is immediately life threatening.

Fluids

: start with a fluid challenge of 500–1000 ml of crystalloid. Over two litres of fluid may extravasate within the first five minutes, so large volumes may be needed.

Corticosteroids

: 200 mg hydrocortisone stat IM or slow IV.

Anti-histamines

: 10 mg chlorpheniramine stat IM or slow IV.

Monitor pulse oximetry, blood pressure and perform an ECG.

Consider admission to a high-level bed if vasopressor or ventilatory support is needed.

Other drugs

:

Glucagon may be useful in the treatment of anaphylaxis in patients on beta-blockers.

Atropine may be useful for bradycardia.

Bronchodilators (e.g. salbutamol, ipratropium) may be useful if a patient has asthmatic symptoms.

Investigations

: mast cell tryptase – at least one sample after the onset of symptoms (do not delay resuscitation to take the sample). Ideally, also take another sample 1–2 hours after the start of symptoms and a third sample at convalescence or at 24 hours. This can help to confirm the diagnosis of anaphylaxis.

Observation and biphasic reactions

A period of observation is recommended after an anaphylactic reaction. This may be from four to six hours, to an admission, depending on the severity of the reaction.

There is the possibility of the recurrence of symptoms after the effects of the adrenaline have worn off, although these are usually milder than the initial attack. A biphasic reaction is the recurrence of symptoms after the complete resolution of symptoms. This can occur in 3–20% of patients after an anaphylactic reaction.

At discharge, consider prescribing anti-histamines and oral steroids for up to three days to help treat urticaria (may also decrease the risk of a further reaction).

Ongoing management and retreatment

After the acute episode has abated further treatment with the offending drug may be considered. This is dependent on the grade of the reaction and the ‘value’ of pursuing further treatment with the same drug, or the benefits of any possible alternatives. There may be the possibility of increasing premedication regimens for the reaction or reducing the infusion rate. All such decisions should be undertaken by a senior member of the treating team. Refer to local guidelines regarding drug re-challenges and for desensitisation protocols.

References

Gleich GJ, Leiferman KM. Anaphylaxis: implications of monoclonal antibody use in oncology.

Oncology

(Williston Park). 2009. 23(2 Suppl. 1): 7–13.

Resuscitation Council (UK) Emergency treatment of anaphylactic reactions guidelines for healthcare providers (annotated July 2012). Available from:

http://www.resus.org.uk/pages/reaction.htm

(accessed 1 January 2014).

Viale PH. Management of hypersensitivity reactions: a nursing perspective.

Oncology

(Williston Park). 2009. 23(2 Suppl. 1): 26–30.

Bleeding

Overview

Bleeding can occur in up to 10% of patients with advanced cancer. This may increase to up to 30% in those with a haematological malignancy.

There are multiple causes for bleeding in cancer patients:

Related to the cancer:

Varies dependent on the size, type and location of the primary tumour and the presence of lymphadenopathy or metastases.

Higher risk tumours include head and neck cancers, pelvic malignancies and fungating tumours, particularly if there is direct vascular invasion or damage from the cancer.

Related to cancer treatment:

Chemotherapy – thrombocytopenia.

Radiotherapy – bleeding secondary to inflammation or tumour shrinkage.

Surgery.

Related to comorbidities or other treatments:

Anticoagulants.

Liver impairment with subsequent coagulation deficiency.

Concurrent infection can raise the risk of bleeding due to inflammation.

Antibiotic treatment may lower the risk.

Clinical presentation

The presentation can vary markedly:

Sub-acute or occult bleed:

Presenting as iron-deficiency anaemia

Anaemia beyond that expected from systemic therapies

Relating to the site of bleed, for example subarachnoid haemorrhage, intra-femoral bleed post fracture

Bleeding metastases (most commonly from malignant melanoma or RCC)

Visible bleed:

Bruising

Minor bleeding

Major/catastrophic bleeding

Clinical assessment

Appropriate management will depend on assessing:

Cancer history and treatment intent:

Prior surgery

Systemic treatment – discuss with senior if unsure of related bleeding risk

Time and severity of bleed:

Patient consciousness

Observations: pulse, BP, oxygen saturations, visible evidence of bleed

Identify the site of bleeding from history and examination.

Note: a minor bleed may herald further more severe bleeding.

Bloods including: FBC, U&E, LFT, coagulation, group and save.

Management

General measures

Patients receiving adjuvant or curative treatment should be treated as per any other patient, with prompt assessment and intervention as needed. Major catastrophic haemorrhage is rare in cancer patients, but should be assessed in an acute environment and with the use of appropriate local protocols. Most emergency departments will have a specific catastrophic haemorrhage algorithm. Blood tests and IV access should be sought early and IV fluids administered as appropriate. IV fluids may further dilute the blood, so consider the use of blood products (see section on systemic interventions).

Particular consideration should be given to the patients’ prior treatment and the bleeding risk associated with this, for example after surgery. There are situations where patients at the end of life may have an unexpected or predicted catastrophic bleeding event. These should be managed with a very different approach, as detailed in the next section.

Local interventions

Packing:

Consider in nasal, vaginal or rectal bleed.

Haemostatic agents (e.g. topical sulcralfate, topical tranexamic acid) may be useful.

Dressings provide direct compression and can be soaked in tranexamic acid to try and stem the bleeding further.

Endoscopy:

Particularly useful as it is able to visualise and treat multiple sources of bleeding.

Consider in upper GI, lung and bladder bleeds.

Interventional radiology:

Transcutaneous arterial embolisation with beads/particles, glue or coils:

Restricted by patient factors and site of bleed.

Requires good patient selection to improve outcomes.

Benefit reported in patients with head and neck, pelvis, lung, liver and GI tract cancers.

Radiotherapy:

Most commonly used for bleeding in cancers of the lung, vagina, skin, rectum and bladder.

May be considered in head and neck cancers and in upper GI cancers.

There is a delay between treatment and effect, so not considered in the acute setting.

Surgery:

May be appropriate with good performance status and prognosis.

Particularly important in adjuvant patients with possible bleed secondary to resection.

Reserved for those who have failed conservative measures in advanced cancer.

Systemic interventions

Vitamin K:

IV is quicker but associated with more ‘over-correction’, usually at doses between 2.5 and 10 mg.

SC and oral administration are also effective if time is not of the essence.

Vasopressin/desmopressin:

Continuous infusions are reported to control half of patients with upper-GI malignancy-related bleeding.

Associated with myocardial, mesenteric and cerebral circulation ischaemia.

Somatostatin analogues (e.g. octreotide): used in upper GI bleeds, but no reports for efficacy in cancer patients.

Anti-fibrinolytic agents (e.g. tranexamic acid):

Act through reduced fibrin clot breakdown.

Cautious use in those with previous thrombotic event, renal failure (accumulation) and those with a cardiac stent.

Can be associated with GI side-effects (e.g. nausea, vomiting).

Blood products (e.g. platelets, fresh frozen plasma, coagulation factors, packed red blood cells):

Platelets – increased risk of bleeding if < 20, severe risk if < 10. May need four to six bags of platelets to reduce active bleeding – discuss with local bleed service or haematologist.

Fresh frozen plasma – selected for:

Coagulation deficiencies

Urgent reversal of INR in patients on warfarin

Urgent intervention needed (e.g. thoracic surgery)

Treatment of disseminated intravascular coagulation (DIC) when appropriate

Disseminated intravascular coagulopathy (DIC)

Associated with malignancy, sepsis and trauma. There is increased thrombin formation (with associated decreased fibrinogen, PT and APTT) and increased fibrinolysis (with associated increased d-dimer). There is an associated poor prognosis. The basis of treatment is:

Treatment of underlying condition (e.g. sepsis, malignancy)

Haemodynamic support

Platelet and FFP only if actively bleeding

Discussion with haematologist regarding further evaluation and management (e.g. use of heparin, blood films)

End of life considerations/catastrophic bleed

Advanced planning is crucial in palliation of expected catastrophic bleed. Patients undergoing palliation should have their chances of an acute catastrophic bleed identified early. An early, sensitive discussion with the family and patient about their wishes is paramount and can provide forewarning and reassurance. ‘Do not attempt resuscitation’ orders should be discussed and completed prior to any event.

Patients who are particularly at risk are those with:

Terminal head and neck cancer

Pelvic malignancy

Patients who presented with bleeding (e.g. haemoptysis)

The central focus of intervention is:

A calm approach to patient and family to reduce distress

Dark towels to soak up bleeding and provide direct pressure

Use of sedation (e.g. SC midazolam, lorazepam) for distress in the terminal event

Review of medications such as anticoagulation and NSAIDs

Care in a side room and timely ‘do not resuscitate’ decision

Other relevant sections of this book

Chapter 3, sections on anaemia, thrombocytopenia

References

Hulme B, Wilcox S. Yorkshire Palliative Medicine Clinical Guidelines Group: Guidelines on the management of bleeding for palliative care patients with cancer (2008). Available at:

http://www.palliativedrugs.com

(registration required) (accessed 1 January 2014).

Nauck F, Alt-Epping B. Crises in palliative care – a comprehensive approach.

Lancet Oncology

. 2008. 9(11): 1086–91.

Pereira J, Phan T. Management of bleeding in patients with advanced cancer.

The Oncologist

. 2004. 9(5): 561–70.

Central airway obstruction and stridor

Definition

Central airway obstruction (CAO)

: the central airways are defined as the trachea, main and lobular bronchi. These may become obstructed via an intraluminal, luminal or extraluminal pathology. The grading of tracheal obstruction is shown in

Table 2.1

.

Stridor

: this is a harsh noise associated with respiration due to reduction in lumen of upper airway tracts. The grading of stridor is shown in

Table 2.2

.

If there is stridor and dyspnoea at rest, the central airways are usually narrowed to < 25% of their cross-sectional area.

The causes and treatment for stridor in children are very different from that seen in adults. This chapter will focus on adult cases only.

Table 2.1 CTCAE (V4.03) grading of tracheal obstruction.

From the website of the National Cancer Institute (http://www.cancer.gov).

Grade

Criteria

1

Partial symptomatic obstruction on examination (e.g. visual, radiologic or endoscopic).

2

Symptomatic (e.g. noisy airway breathing), no respiratory distress, medical intervention indicated (e.g. steroids), limiting ADL.

3

Stridor, radiologic or endoscopic intervention indicated (e.g. stent, laser); limiting self-care ADL.

4

Life-threatening airway compromise; urgent intervention indicated (e.g. tracheotomy or intubation).

5

Death.

Table 2.2 CTCAE (V4.03) grading of stridor.

From the website of the National Cancer Institute (http://www.cancer.gov).

Grade

Criteria

1

—

2

—

3

Respiratory distress limiting self-care ADL; medical intervention indicated.

4

Life-threatening airway compromise; urgent intervention indicated (e.g. tracheotomy or intubation).

5

Death.

Causes

CAO can be the result of malignant or non-malignant causes. Malignancy is the most common pathology, and the most common malignant pathology leading to CAO is lung cancer. Lung cancer can obstruct the airway intraluminally or through extraluminal compression.

Malignant causes include:

Lung cancer

Metastatic cancer – colon, breast, oesophagus, kidney and melanoma

Metastatic lymphadenopathy

Non-malignant processes include:

Laryngeal pathology – anaphylaxis, acute epiglottitis

Inhaled foreign bodies, food or blood clots

Chronic medical conditions affecting the lung – TB stricture, Wegener’s granulomatosis, sarcoidosis

Secondary to previous trauma to the airways – post-endotracheal tube insertion, post tracheostomy, chemical burns, post-bronchial sleeve resection

Idiopathic

Symptoms

Symptoms are dependent upon the degree of airway stenosis. In some cases, symptoms can develop rapidly and become life threatening. Symptoms include:

Wheeze

Stridor