腫瘤相關急性併發症 Emergency Complications of Malignancy

日期：



  1. Emergencies related to local tumor effects

  1. Malignant airway obstruction: 可能是很緩慢的過程，再因為一些原因（感染、出血、loss of muscle tone、放射治療等）導致acute compromise

  • 判定部位: upper airway(vocal cords以上) vs central airway (vocal cords to carina)

  • 判定來源: endoluminal, extraluminal, mixed

  • s/s: 喘, stridor, a mass in the pharynx, neck, or supraclavicular area

  • Direct laryngoscopy不建議!! 因為可能操作不慎造成水腫或出血，使partial變complete obstruction!!

  • 急性處置:

    • Heliox—typically a 50:50 mixture of helium and oxygen (for cancer-related upper airway obstruction); High-flow nasal oxygen; emergency transtracheal jet ventilation or cricothyroidotomy; awake fiberoptic intubation with a 5-0 or 6-0 endotracheal tube

  1. Bone metastases and pathologic fractures

  • 最常見: 中軸骨(包括頭蓋骨) ,四肢近端

  • 最多來自 solid tumors (e.g., breast, lung, prostate)

  • X ray只能看出一半 => 建議做CT (with contrast); MRI; bone scan

  • Management: parenteral analgesics; long-acting oral opioids; palliative radiotherapy (R/T可緩解約80%病理性骨折的疼痛); open surgical repair

  1. Malignant spinal cord compression

  • 20%癌症病人可能發生脊椎骨侵犯，3~6%病人發生spinal cord compression

  • T spine最常被侵犯

  • 90%病人有背痛症狀; 80%病人原先已知有癌症診斷
    => 所以癌症病人有背痛主訴時，應進行影像檢查

  • s/s: muscular weakness(近端肢體最常見), radicular pain, and bladder or bowel dysfunction, sensory change

  • 影像診斷: MRI with contrast

  • 治療: opioid analgesics, corticosteroids(10mg IV bolus, followed by 4mg PO or IV Q6H), radiation therapy(70%病患有改善), surgery



  1. Malignant pericardial effusion with tamponade

  • 大多沒症狀，有症狀的最多是肺癌或乳癌，也有來自melanoma, leukemia, or lymphoma或電療化療造成

  • S/S: Dyspnea, orthopnea, chest pain, dysphagia, hoarseness, hiccups, distant cardiac sounds, jugular venous distention, pulsus paradoxus

  • Tamponade: pericardial effusion + shock (常見的vital sign: tachycardia, hypotension, and a narrowed pulse pressure)

  • ECG: low voltage, electrical alternans

  • Echocardiography: diagnosis, evaluation cardiac function

  • Management: pericardiocentesis; treat cancer (C/T, radiotherapy or intrapericardial chemotherapy); pericardial window; indwelling intrapericardial catheter

  • 預後差，多數病患一年內expire

  1. Superior vena cava syndrome

  • 70% 來自肺癌; 20% 來自淋巴腫瘤; other from intravascular thrombosis or catheter (CVC, pacemaker leads…)

  • 症狀由常見至少見: facial swelling, dyspnea, cough, arm swelling, hoarse voice, syncope, headache, dizziness, visual changes, confusion, seizures, and obtundation
    有IICP sign時,病患很可能症狀於一至兩周內急遽惡化

  • CVP=20 to 40 mm Hg (正常2 to 8 mm Hg)

  • Management:

    • corticosteroids (evidence只有在lymphoma有效); loop diuretics; head elevation; O2; radiation therapy (75%有效,三天見效); intravascular stents (for thrombosis, fibrosing mediastinitis, mesothelioma); chemotherapy(80% lymphoma, SCLC有效); catheter-directed fibrinolytics and prophylactic LMWH for thrombosis

  1. Emergencies related to biochemical derangement

  1. Hypercalcemia ★★★常考

  • 最常見: Breast cancer, lung cancer, and multiple myeloma

  • 機轉:
    1. most commonly by production of a parathyroid hormone–related protein
    2. extensive local bone destruction
    3. production of vitamin D analogs (lymphoma 最常見)

  • S/S: lethargy, confusion, anorexia, nausea, constipation, general weakness, relative hypovolemia (due to osmotic diuresis)

  • 臨床症狀與血鈣上升之速率快慢有關，而非關血鈣的濃度高，因此血鈣濃度慢性上升的病人相對較無症狀。無症狀者超過14mg/dL才需要治療



  1. Hyponatremia due to inappropriate antidiuretic hormone secretion

  • 何時要懷疑SIADH?   Cancer+ euvolemic hyponatremia

  • 最常見:bronchogenic cancer

  • 其他原因: chemotherapy, opioid, carbamazepine, SSRI

  • Na > 125 大多無症狀，可以限水500ml/day即可

  • Na 110-125 可能有輕微症狀，可以N/S hydration + furosemide 0.5-1mg/kg PO

  • Na < 110 可能已經coma or status seizure，需補3% saline 100ml over 10-15min!! 然後再評估，可以視情況再補1-2次!!

  1. Adrenal insufficiency

  • 可能是meta或癌症的藥物治療(chronic glucocorticoid therapy)造成的

  • S/S: mild hypoglycemia, hyponatremia, hypotension refractory to volume loading and vasoconstriction therapy

  • Management: 抽cortisol level; IV hydration; hydrocortisone 100mg IV or dexamethasone 4mg IV

  1. Tumor lysis syndrome

  • 血液科的病人最常見!

  • Hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia, AKI, seizure, cardiac arrhythmia, arrest

  • Management:

    • 灌水到尿有出來; prophylactic allopurinol; EKG monitor; RI + glucose for hyperkalemia & hyperphosphatemia; 除非EKG有變化或seizure否則不要補Ca (會跟P結合成calcium phosphate crystals加重AKI); 洗腎

  1. Emergencies related to hematologic derangement

  1. Febrile neutropenia and infection

  • 定義: ANC < 1000 為neutropenia; ANC < 500為severe neutropenia; ANC <100為profound neutropenia

  • 通常化療後5-10天ANC會降到最低，之後5天就會恢復

  • 臨床評估: (1) 做全套sepsis survey，特別注意catheter entry site、oral cavity、perianal area (注意Digital examination在使用抗生素治療前是relative contraindication!)  (2) MASCC risk index或CISNE score算risk

  • Disposition:
    (1) 若檢查檢驗沒有infection evidence且病人評估為low risk則可以口服抗生素OPD follow up (2) profound neutropenia 可預期需要7天以上才會恢復者須住院 (3) 其他survey有異常也建議住院 (4) ANC < 500建議要用抗生素治療; ANC 500-1000看狀況


  1. Hyperviscosity syndrome

  • Plasma or cellular content 增加造成血液很濃
    (plasma: Waldenström’s macroglobulinemia and immunoglobulin A–producing myeloma; cellular: Polycythemia (hematocrit >60%) and leukemia (WBC >100,000)

  • S/S: fatigue, abdominal pain, headache, blurry vision, altered mental status(最常見), cutaneous or mucosal bleeding, Intravascular thrombosis, retinal venous engorgement, dyspnea, fever…

  • Normal plasma viscosity: 1.7-2.1; normal serum viscosity: 1.4-1.8; hyperviscosity: >4

  • Management: consult hematologist; emergency plasmapheresis or leukapheresis; 放血phlebotomy 1000ml + N/S 2-3L

  1. Venous thromboembolism (DVT or PE)

  • Cancer是DVT的risk factor

  • 第一線治療: Low-molecular-weight heparin (其他可選unfractionated heparin or fondadparinux)

  • 單純穩定追蹤癌症者可用DOAC (正在治療癌症者不建議)

  1. Emergencies related to therapy

  1. Chemotherapy-induced nausea and vomiting



  • For refractory N/V: BZD, dopamine receptor antagonist and antipsychotics 

  • For delayed vomiting (48 hrs-7 days): Neurokinin-1 receptor antagonists

  1. Chemotherapeutic drug extravasation

  • 抽出漏出的藥物、抬高患肢、可能要冰敷或熱敷、可考慮注射antidote (局部注射steroid or bicarbonate沒有evidence!)



  1. Complications due to biologic therapy

  • 注意常見的monoclonal antibodies (機轉:為一種人造的protein，會與T cell 結合，使T cell去殺死癌細胞)，Rituximab 可能會引發cytokine release syndrome (CRS)


                                

  • Cytokine release syndrome: T cell過度活化製造過多IL-6，引起身體的嚴重發炎反應，因此治療可以用anti-IL-6 agent (ex: Tocilizumab, siltuximab)。診斷常常難與Anaphylaxis區分。

                

  • Immune checkpoint inhibitor therapy: 有些癌細胞可以抑制T cell的作用導致T cell沒有辦法殺死癌細胞，這個療法就是藉由monoclonal antibodies打破這個問題，讓T cell得以恢復功能去殺死癌細胞

    • 常用藥物: ipilimumab, nivolumab, pembrolizumab

    • Adverse effect:
      ipilimumab最多副作用，最常見diarrhea, enterocolitis; nivolumab最常有pancreatitis; 其他可能會有的: Hypophysitis, inflammation of the pituitary gland, thyroiditis, pneumonitis, dermatitis, adrenalitis, nephritis, vasculitis, anemia, and uveitis

    • 治療: steroids!! 2nd可考慮anti-TNF-α therapy



  1. 考古題:


***************************範圍很大、平常常用、考試少考****************************

110.

答案: C

A: 是合成單株抗體沒錯，但沒有強化NK cell，也不知道是不是anti-PD-1

B: 沒有要routine給抗病毒和抗黴菌藥物

D: 常見副作用是AGE


109.

答案: D

A: GCS < 9為一級; GCS 10-13為二級

B: 肺炎有可能症狀只有輕微咳嗽而已，CXR有可能看不出來 (因為化療後免疫系統無法發炎反應所以CXR看不出有infiltration，但實際上有在感染!)

C: Digital要等到有給抗生素後才能做


106.

答案: B

這題應該是考euvolemic hyponatremia


答案: E

A: corrected Ca = 0.8* (normal albumin - pt’s albumin) + serum Ca level

 = 0.8* (4-3) + 15.5 = 16.3

E: Calcitonin為rapid onset


答案: E


105.

答案: B


103. 

答: D


101. 

答: D

A: SVC syndrome 症狀由常見至少見: facial swelling, dyspnea, cough, arm swelling, hoarse voice, syncope, headache, dizziness, visual changes, confusion, seizures, and obtundation

B: 最優先是IVF

C: 症狀表現取決於增加的速度

E: 70% from lung cancer


Edited by Chun, Chang / Ming-Ying, Chiang

Reference: Tintinalli's Emergency Medicine Chapter 240, Emergency Complications of Malignancy


留言

張貼留言