Emergencies in high-risk patients with cancer can lead to complications, and nurses are often the first line of defense to recognize signs and symptoms and initiate a therapeutic response. During a session at the ONS 40th Annual Congress in Orlando, FL, Martha Lassiter, MSN, AOCNS®, BMTCN, adult bone marrow transplant (ABMT) clinical nurse specialist, Duke University ABMT Program in North Carolina, and Juanita Madison, RN, oncology nurse educator, Catholic Health Initiatives Franciscan Health in Washington, discussed case-based complications associated with various cancers.
Metastatic spinal cord compression (MSCC) is caused by pathologic vertebral collapse and/or direct tumor expansion and may result in partial or complete loss of neurologic function. Most cases of MSCC (77%) are diagnosed in patients with a history of cancer, with 23% presenting with MSCC at first presentation of malignancy. The most common locations in the spine include thoracic (69%), lumbosacral (29%), and cervical (10%).
The cancers most commonly associated with MSCC are breast (15%–20%), lung (15%–20%), prostate (15%–20%), multiple myeloma (10%–15%), renal cell carcinoma (5%–10%), non-Hodgkin lymphoma (5%–10%), and Hodgkin disease (5%).
Back pain occurs in 90% of patients with MSCC, and the median time of onset of pain to diagnosis of spinal cord compression is two months.
The following are good prognostic indictors for MSCC.
- Breast cancer as the primary site
- Solitary or few spinal metastases
- Ability to walk aided or unaided
- Minimal neurologic impairment
- No previous radiotherapy
The following are poor prognostic indicators for MSCC.
- Lung or melanoma primary
- Multiple spinal metastases
- Visceral metastases
- Inability to walk
- Severe weakness
- Recurrence after radiotherapy
Early symptoms of MSCC include
- Pain in the thoracic or cervical spine
- Progressive lumbar spinal pain
- Severe unremitting lower spinal pain
- Significant change in nature of long-standing pain
- Spinal pain aggravated by straining (e.g., at stool, coughing, sneezing)
- Localized spinal tenderness
- Nocturnal spinal pain preventing sleep.
Advanced symptoms of MSCC include
- Neurologic symptoms (i.e., radicular pain, any limb weakness, difficulty in walking, sensory loss)
- Loss of coordination
- Bladder or bowel dysfunction
- Neurologic signs of spinal cord or cauda equine compression.
The overall treatment goals for MSCC management include controlling pain, prevention of spinal collapse and/or paralysis, prolongation of survival, and palliation of residual symptoms. The disease should be managed via a combination of corticosteroids, surgery, radiation therapy, chemotherapy, and rehabilitative therapy for pain management, constipation, spinal instability, and psychologic and social distress.
The primary purpose of surgery is to preserve or recover neurologic function. Traditional indications for surgery include rapidly progressing paraplegia, spinal instability, pathologic fracture with dislocation of bone fragments, circumferential epidural tumor, biopsy for histologic diagnosis, intractable pain, recurrence after prior radiotherapy, radio resistant tumors, and life expectancy of less than three months.
The nurse’s role in the management of MSCC includes early recognition and detection, pain management, mobility and safety, bowel and bladder function, skin care, rehabilitation, and palliative care. Nurses should inform patients and caregivers at high risk of developing bone metastases to detect symptoms early. For pain management, nurses should have a baseline assessment of pain and implement an analgesic regimen immediately following presentation of MSCC. For opioid-naïve patients, mild to moderate pain should be remedied with nonsteroidal anti-inflammatory drugs or acetaminophen, and more severe pain should be treated with short-acting opioids. Patients who are tolerant of opioids and experiencing breakthrough pain should have medications titrated until an acceptable pain level is reached.
Although the evidence-based guidelines for patient mobilization and safety contains gaps, the National Health and Nutrition Examination Survey guidelines recommend flat bed rest until a magnetic resonance imaging is conducted and reviewed. If no signs of neurologic or bone instability are present on assessment, patients should gradually sit from supine to 60 degrees in stages over a period of four hours. Patients should then be closely monitored for signs of instability or increased pain.
The speakers concluded, “Early diagnosis and treatment [of MSCC] may prevent irreversible neurologic damage.”
The presentation then examined tumor lysis syndrome (TLS), which is commonly associated with clinically aggressive non-Hodgkin lymphoma, acute lymphoblastic leukemia, and Burkitt lymphoma/leukemia. Symptoms of TLS include edema, fluid overload, cardiac dysrhythmias, seizures, muscle cramps, and elevated potassium and uric acid, among others.
The management of TLS for low-risk patients includes hydration and laboratory monitoring, and moderately at-risk patients should be managed with hydration and loop diuretic. High-risk patients should be managed with hydration and rasburicase.
Patient hydration should be started 24–48 hours prior to treatment for as long as 72 hours post-treatment. Diuretics, allopurinol (600–900 mg daily for one to two days prior to therapy), and rasburicase should be used to treat TLS. Toxicities associated with rasburicase include peripheral edema, vomiting, hyperbilirubinemia, sepsis, and fluid overload. Toxicities for allopurinol include joint pain and stiffness and rash.
The nurse’s role in the management of TLS includes cardiac monitoring, identifying and initiating preventive measures, understanding signs and symptoms of electrolyte imbalances, checking patient renal function, providing supportive care, educating and supporting the patient and caregiver, administering TLS preventive medications as ordered, understanding the hospital standard operating procedure, and staying up-to-date on society guidelines and treatment updates.
Lassiter, M., & Madison, J. (2015). Oncologic emergencies: A case-based approach. Session presented at the ONS 40th Annual Congress, Orlando, FL, April 25, 2015.