7. 57 year old F with long smoking history states
that she has been feeling tired lately. Noticed
she appears flushed sometimes.
Has been having worsening DOE and states
people have told her that she looks
differently, something about her facial
features.
8. Not Really, this is her…
https://casereports.bmj.com/content/2018/bcr-2018-225220
12. Most Commonly
Lung CA (especially apical)
Other:
Goiter, pericardial constriction, primary thrombosis,
aneurysm, indwelling catheter,
other mechanical obstructions
Mimics
CHF
Tamponade
13. Management
Emergent Rad-Onc consult
Chemo
Stenting
Anticoagulation if indicated
AW management if needed
Prognosis
25% survival at 1 year
14.
15. 61 year old M with h/o CML, HTN, DM,
CAD/stent who p/w LUQ abd pain and chills x
2 days. She is ill appearing but in NAD. Has
LUQ tenderness, no guarding. Generalized
body tenderness.
TriageVitals: HR 92, BP 160/89, RR 14,T 101.0
What is your work up?
What is the likely management and dispo?
16. WBC 42
Blasts 30%
H/H: 8/24
Platelets: 105
Urines: +Nitrite,WBC 10-25k, +LE
What is the likely management and dispo?
Broad spectrum antibiotics, IV Fluids
Heme/Onc consult
Admit for Blast Crisis
17. Making the diagnosis
ElevatedWBC, Blasts > 20%
Pancytopenia, functionally neutropenic
May present septic or with non specific sx
Bone pains often present
May present with stroke, MI,VTE symptoms
Sometimes: Priapism, bowel infarctions, limb
ischemia, renal insufficiency
18. Broad spectrum antibiotics
IV fluids
Use caution with PRBC
May hemorrhage, may need platelets
Leukostasis (often withWBC > 50) may
require Leukophoresis
Emergent Heme/Onc Consult
MICU?
19.
20. 68 year old F undergoing treatment for
melanoma (Yervoy) p/w 3 days of abdominal
pain, chills, diarrhea (5-6 daily). Has noted
some blood streaking. Otherwise eating and
drinking, and in USOH. Mild diffuse abd
tenderness on exam, well appearing.
TriageVitals: HR 88, BP 143/89, RR 10,T 99.0
What is your work up?
What is the likely management and dispo?
26. Majzoub et al. Adverse Effects of Immune Checkpoint Therapy in Cancer Patients Visiting the Emergency Department of a Comprehensive Cancer Center. Ann
Emerg Med. 2019;73:79-87
Native
Med
Med
Native
27. Immune Related Adverse Events
Most common systems involved:
GI (diarrhea, colitis, Hepatitis)
Pulmonary (Pneumonitis)
Skin (Various rashes, Sweet’s Syndrome,TEN, SJS)
Endocrine (Hypohysitis, Hypothyroidism, Grave’s,
Thyroid Storm, IDDM, Adrenal Insufficiency)
28. Recent study in theAnnals of EM (MD Anderson)
1026 visits by 628 pts on CI’s
66.5% overall admission rate
25% of visits due to irAE
81.7% admission rate for irAE visits
Prevalence of irAE changes by agent
Majzoub et al. Adverse Effects of ImmuneCheckpointTherapy in Cancer PatientsVisiting the Emergency
Department of a Comprehensive Cancer Center. Ann Emerg Med. 2019;73:79-87.
29. Based on: NationalCancer Institute's CommonTerminologyCriteria for Adverse Events (CTCAE), version 5
30. Grade
1/2
Symptomatic
Mgm’t
r/o infection
+/- Prednisone
0.5-1 mg/kg
Outpt Onc f/u
Likely DC
Grade
3/4
ABC’s/Resusc
Emergent Onc
Steroid* 1-2
mg/kg
PossibleABx
Admit,
Possible
ICU
*Steroid: Prednisone or Methylprednisolone
Based on: Brahmer et al. Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy:
American. Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2018 June 10; 36(17): 1714–1768.
31. 68 year old F undergoing treatment for melanoma
(Yervoy), found to have colitis.
What is your work up?
Sepsis panel, C. diff, GI PCR, O&P; Get PR temp
Obtain CTAP?
What is the likely management and dispo?
Grade 2 colitis
IV Fluids, pain control if needed
Discuss with Heme/Onc, possible Prednisone 1 mg/kg,
possible Loperamide
Possible discharge
32.
33. Tisagenlecleucel (Kymriah)
Axicabtageneciloleucel (Yescarta)
Llanfairpwllgwyngyllgogerychwyrndrobwllllan
tysiliogogogoch (Welsalta)
St Mary's Church in the Hollow of theWhite Hazel near a RapidWhirlpool and the
Church of St.Tysilio near the Red Cave
36. Cytokine Release Syndrome (majority of pts
get this; within 3 days; usually admitted for
infusion anyway, less likely in ED)
Neurotoxicity+CRES (CART Related
Encephalopathy Syndrome), may be 8 wks or
more after infusion
ON target/OFF tumor
Immunosuppression/Neutropenia
Fulminant HLH/MAS
38. Checkpoint Inhibitors
Take the brakes off ofT cells
irAE are generally inflammatory
Not necessarily immunosuppressed
Staging, Management
CAR-T
ChimericT cells target tumor antigen
Variable irAE
Complex management
Often immunosuppressed
40. Hematologic emergencies may be very subtle
Maintain a high index of suspicion
Send broad labs:
CBC + diff
CompVBG
CMP+Mg+Phos(+Uric Acid if indicated)
Get some advice…
41. Based on: NationalCancer Institute's CommonTerminologyCriteria for Adverse Events (CTCAE), version 5
42. Grade
1/2
Symptomatic
Mgm’t
r/o infection
+/- Prednisone
0.5-1 mg/kg
Outpt Onc f/u
Likely DC
Grade
3/4
ABC’s/Resusc
Emergent Onc
Steroid* 1-2
mg/kg
PossibleABx
Admit,
Possible
ICU
*Steroid: Prednisone or Methylprednisolone
Based on: Brahmer et al. Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy:
American. Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2018 June 10; 36(17): 1714–1768.
43. Online Checkpoint Inhibitor Toolkit (Cancer Care Ontario):
https://www.cancercareontario.ca/en/guidelines-advice/modality/immunotherapy/immune-
therapy-toolkit
Cited Works:
• Azim, A. New OncologicTherapies Mean NewOncologic Emergencies: An Approach to Immunotherapy-RelatedAdverse Events.
MedicalConcepts Case Series, CanadiEM.Accessed online May 10, 2019. https://canadiem.org/an-approach-to-immunotherapy-
related-adverse-events/
• Ballard D,Vinson D. MedicallyClear: New Immunotherapy Revolutionizes Cancer Care but GuessWhere Adverse Events End Up?
Emergency Medicine News: Sept 2018 – 40(9): 29.Accessed online May 10, 2019. https://journals.lww.com/em-
news/pages/articleviewer.aspx?year=2018&issue=09000&article=00015&type=Fulltext#pdf-link
• Brahmer et al. Management of Immune-Related Adverse Events in PatientsTreatedWith Immune Checkpoint InhibitorTherapy:
American. Society of ClinicalOncology Clinical PracticeGuideline. J Clin Oncol. 2018 June 10; 36(17): 1714–1768.
• Doyle C. Immunotherapy-RelatedToxicities May Be More CommonThan Originally Reported.TheASCO Post. December 25, 2018.
Accessed online May 10, 2019. https://www.ascopost.com/issues/december-25-2018/immunotherapy-related-toxicities-may-be-more-
common-than-originally-reported/
• Majzoub et al. Adverse Effects of Immune CheckpointTherapy in Cancer PatientsVisiting the Emergency Department of a
Comprehensive Cancer Center.Ann Emerg Med. 2019;73:79-87.
• Nixon et al. Current landscape of immunotherapy in the treatment of solid tumours, with future opportunities and challenges. Curr
Oncol. 2018Oct; 25(5): e373–e384.
• Palin et al. Immune-relatedAdverse Events in Cancer Patients.Academic Emergency Medicine. 2018;25:819–827
• Simmons D, Lang E (October 13, 2017)The Most Recent Oncologic Emergency:What Emergency Physicians Need to KnowAbout the
PotentialComplications of Immune Checkpoint Inhibitors.Cureus 9(10): e1774. DOI 10.7759/cureus.1774
• Srivastava,A. Immunotherapy Complications in the Emergency Department: Be on the Lookout for theCheckpoints! AAEMCritical
Care Medicine Section Report. Common Sense November/December 2018.
Notas del editor
Too much or too little of each, abnormalities of each.
This talk will not discuss bleeding disorders, also, this year is building on Dr. Rahman’s talk – she had covered several topics.
Patients with known or suspected malignancy
Take these patients seriously, high index of suspicion needed. You will miss important Dx otherwise. Can be subtle.
Stokes’ sign – neck swelling/edema leading to increase in collar size
Pemberton – Facial swelling, dyspnea, cyanosis with arm elevation – sx start within 1 minute
Stokes’ sign – neck swelling/edema leading to increase in collar size
Pemberton – Facial swelling, dyspnea, cyanosis with arm elevation – sx start within 1 minute
Stokes’ sign – neck swelling/edema leading to increase in collar size
Pemberton – Facial swelling, dyspnea, cyanosis with arm elevation – sx start within 1 minute
Successful so far (though some mixed outcomes) and AE thought to be less common/less severe than traditional chemo
Checkpoint:
Metastatic Melanoma: > 50% increases in mean survival and 2 year survival
NSCLC: Similar benefits
Head and neck Squamous Cell CA
Renal Cell Carcinoma
Urothelial Carcinoma (bladder)
Hodgkin’s Lymphoma
CAR-T
ALL
Large B Cell Lymphoma
Reference Landscape of Immunotherapy/Nixon article for numbers (Current Oncology 2018)
Nondescriminate poison vs tailor made solutions
Sweet's syndrome (SS), or acute febrile neutrophilic dermatosis is a skin disease characterized by the sudden onset of fever, an elevated white blood cell count, and tender, red, well-demarcated papules and plaques that show dense infiltrates by neutrophil granulocytes on histologic examination.
Discuss relative frequencies – 3% - 30% - Several, including Hypophysitis, have been shown to be more common in practice than on validations.
AND MOST IMPORTANTLY THE MGMT IS DIFFERENT.
Based on: National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE), version 5
Grade 5 AE for all = DEATH!
THESE MAY BE SUBACUTE OR EVEN DELAYED IN ONSET (WEEKS-MONTHS OUT)
Why? Seems to have very good cure/remission rates – though high risk.
Hemophagocytic lymphohistiocytosis (HLH)
Based on: National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE), version 5
Grade 5 AE for all = DEATH!
THESE MAY BE SUBACUTE OR EVEN DELAYED IN ONSET (WEEKS-MONTHS OUT)