2011
Welcome to
The 4th Annual Chemotherapy Conference
Friday 18th March , Foresight Centre, Liverpool
A Conference Hosted by Merseyside and Cheshire Cancer Network
Sponsored by: Amgen, Astra Zeneca, Bristol-Myers Squib, Celgene,
GlaxoSmithKline, Janssen-Cilag, Lilly, Napp, Novartis, Shire
Merseyside & Merseyside
Cancer Network
Acute Oncology Update 2011
Ernie Marshall
Macmillan Consultant in Medical
Oncology
The Cancer Journey
Significant progress in elective cancer care
Diagnosis
New
Cancers
(UKP)
23%
Treatment
Complications of
treatment
Follow up
Complications of
Cancer
Lack of focus on emergency Inpatient Care: Prolonged stay, poorly
coordinated, poor pt experience
•Inpt cancer care ~12% acute inpt beds,
•Admissions up 25% in 8yrs,
•40% inpatient cancer is emergency,
•60% managed by GIM
•60% chemotherapy 2002-06
Aspects of AO
• Management of inpatients
• Aim is to incorporate oncology input early in the
inpatient journey rather than near the end
• New cancers (UKP) – not on established
pathway
• Complications of chemo (radiotherapy)
• Complications of cancer (recurrence)
Transforming Inpatient Care
www.improvement.nhs/cancer
Chemotherapy Services in England:
Ensuring quality and safety: NCAG Aug
2009
– Key Recommendations:
• Chemotherapy pathway measures
• Acute Oncology: All hospitals with emergency
depts should establish AO Teams
– MCCN Recommendation (Oct 2009)
• 12month funding pump primed via CQUIN with
cash releasing efficiency in 2011/12
• Aim to recruit AO team 01/04/10
• (NCAG- Aim for AOTs by 2011)
Estimated savings from AOT
Trust
Emergency
admissions
Beds savings
Potential
savings
assuming 3days
reduction in LOS
COCH
231
693
£173,250
RLBUHT
390
1,170
£292,500
S&O
218
654
£163,500
SHK
359
1,077
£269,250
UHA
414
1,242
£310,500
W&H
304
912
£228,000
WHT
336
1,008
£252,000
Total
2,252
6,756
£1,689,000
Cost per AO team 131K =915K across network
AO Peer Review 2011
• SA to be completed August 2011
Key Measures for Network, CCO and Units
– Establishment of
•
•
•
•
•
•
•
AO Teams
Patient Flagging system (Alerts)
24/7 Advice Line and Consultant Oncology On-Call
Pathways, protocols, training
MSCC pathway
Acute Oncology Fast Track Clinics
FN: 1hr target (‘door to needle time’)
MCCN AO Teams
6 Medical Oncologists appointed at CCO 2010/11
Major job plan review completed (>15 consultants)
5 sessions Oncology
1 wte CNS
Admin Support (office)
Pathways
Protocols
Awareness
MDTs
Audit
Minimum dataset
Established in:
RLUH(3)
Aintree (3)
STHK (2)
S&O (2)
APH (2)
5 sessions Oncology
released for:
NCH (3)
COCH (1)
Network AO Structure
Network AO Group
(NSO CNG)
CCO ‘TSG’
RLUH
Aintree
APH
AO
Team
CUP CNG
CCO CUP TSG
STHK
Steering
Grp
S&O
NCH
COCH
Flagging System: Alerts
New
Hospital
Chemo PAS
Episode
Admission
A&E
attendance
Email alert
to CNS
Early
review
Or FU
StHK: Well established (1/3 of referrals)
roll out to Haem, palliative care, trials
APH: rolling out via CCO Data Warehouse
Network solution: central alert system linked to CCO IM& T strategy
(TPoulter)
MCCN AO Activity
Unit
Oct 10
Nov 10
Dec 10
Total
LOS
(days)
LOS
>14d
Aintree
7
11
18
36
6
14%
RLUH
27
44
50
121
5
19%
S&O
14
46
26
86
6
15%
StHK
40
55
39
134
7
17%
Wirral
17
26
35
78
12*
38%
Total
105
182
168
455
6
21%
Median LOS by type
Type I (new cancer) =14days
Type II (treatment complication) = 4days
Type III (cancer complication) = 6days
Estimated numbers per
year: StHK 536 ( vs
359NatCatSat)
Referral and Review
NCAG: Hospitals should aim to provide expert
Oncological assessment within 24hours at least 5 days
per week
Unit
TT referral
TT review
TT discharge
Aintree
2
1
3
RLUH
1
1
3
S&O
1
1
5
StHK
1
1
4
Wirral
2
1
7
Total
1
1
4
2011 Challenges
• Peer Review
– Alerts: optimise efficiency and develop local IT
solution for all AO patients
– 24/7 Triage: definition, funding, links to CCO
Oncology on call
– Protocols (overlap with Triage/Pall Care)
– Clinic capacity (‘fast track’)
• Registration: ownership and funding
• Outcome measures: ?LOS, resource use, quality
measures
• Funding: 1year funding to be replaced by
efficiency savings
Febrile Neutropenia
• Key aspect of NCAG and NCEPOD
Reports
• Evidence for Fragmented care and
delayed antibiotics despite FN protocols
– 24 hour triage
– FN pathway,
– 1 hour door to needle time
– No defined code for FN -
CCO Triage for Suspected FN
Audit findings ( Ford, 2009)
•
•
•
•
•
3 month Triage calls (164 calls)
73 attended CCO: majority low risk
66 ‘other’: hospital, GP, community nurse
50% of cases not neutropenic
Average Time from triage call to arrival 4
hours (range - 13hours)
• Low risk LOS = 2.7days, High risk LOS =
7days
• Examples of dislocated care at DGH
DGH: Case I
•
•
•
•
•
•
Cancer Centre Triage call 16.30
Advised to attend local A&E 18.30
‘Low risk’ :
CCO informed and advice sought
Patient commenced oral antibiotics at 22.00
On call pharmacy input with switch to Imipenem
and G-CSF
• Patient continued capecitabine further 24hrs
• Hospital LOS : 9days
MCCN FN Audit
• Methods
–
–
–
–
3 month retrospective audit (feb-Apr10)
Weaknesses: Data incomplete, retrospective
97 Patient episodes (91pts )
67 Oncology; 32 Haematology
• 5 Trusts
–
–
–
–
–
Aintree (20)
CCO (39)
COCH (17)
Southport (7)
St H&K (14)
Summary I
• Multiple routes of admission
– 48% admitted via A&E. (55-85% for units)
•
•
•
•
60% via Triage (except CCO)
Median Neutrophil count = 0.3
MEWS = 87.6% (44/85= 0-2)
MASCC= 12.4%
Summary II
• Time to Abs:
– 0-1hr -23%,
– 0-2hr 45%
– 0-4hr 60%
• Median inpatient stay = 6days (1-43)
– Haem :Acute Leuk=12d, others=8d
– Solid : 5days
– Intravenous Ab = 6d, oral Ab (24) = 4d
• Deaths =9 (10%)
Next Steps
• Small numbers and patchy data
– Requires more analysis
•
•
•
•
•
•
Multiple pathways but A&E critical
1hr target not achieved (not realistic?)
Scope for risk stratification ?
10% Mortality – relate to risk
Need for prospective audit
(capecitabine toxicity)
Conclusions
•
•
•
•
•
AO evolving rapidly across MCCN
Evidence for Increasing activity and awareness
Evidence for speedy review
Improved communication
Reduce admission rate ?
– Yes but difficult to quantify
• Reduce LOS ?
– Probably, but little impact on hospital bed base
• Improve quality and safety ?
– Yes, intuitively but needs Qualitative R&D,
– AO ‘major benefit’ 50% cases (St H&K)
• Save Money ?
– Not easily realised but good value ?
National Cancer
Peer Review
Programme
Millie Forde – Assistant Quality
Manager - North Zone
Aims of Today
To promote an
understanding of the
revised National Cancer
Peer Review process
The New Healthcare Environment
What is Cancer Peer Review?
• A quality assurance process for cancer services
• An integral part of Improving Outcomes – A Strategy
for Cancer
• Assesses compliance against IOG for NHS patients in
England
• A driver for service development and quality
improvement
• Supported by a set of measures
Measures Development
• Developed by an expert group
• Aimed to measure areas detailed in the
national documentation e.g. NICE Improving
Outcomes Guidance and national reports such
as NCAG and NRAG reports.
• Three month consultation on new measures
New Measures
Topic
Consultation
Closes
Publication Commence Peer
Date
review
Brain&CNS
31st March
Apr-11
2011
Out to Consultation
Sarcoma
16th May
May-11
2011
Out to Consultation
Acute Oncology
NA
Mar-11
2011
Waiting Gateway Approval
Chemotherapy
Closed
Mar-11
2011
Editing Meeting 7th March
Patient Partnership Measures
NA
Mar-11
2011
Awaiting Gateway Approval
TYA
5th April
Apr-11
2011
Out to Consultation
Comments
Aims of Cancer Peer Review
To ensure services are as safe as possible
To improve the quality and effectiveness of care
To improve the patient and carer experience
To undertake independent, fair reviews of services
To provide development and learning for all involved
To encourage the dissemination of good practice
The Peer Review Programme
Peer Review
Visits
Targeted
External Verification
of Self AssessmentsA sample each year
Internal Validation of Self
Assessments
Every other year
(Half of the topics covered each year)
Annual Self Assessment
All teams/services
The National Schedule
Dec
Jan
Feb
Mar
April
A team either has a peer
review visit or completes a
self assessment.
May
June
July
Aug
Sept
Oct
Nov
Jan
Complete Self Assessment
Complete Internally Validated Self
Assessment
Targeted
External
Verification
Feedback
to teams
Notification
of visit
Programme
Notification
of visit
Programme
Prepare for visit complete Self
Assessment
Dec
Peer Review Visits
From May to March
Feb
Mar
April
May
Outcomes of Peer Review
Speedy identification of major
Confirmation of the quality of
cancer services
shortcomings in the quality of
cancer services where they
occur so that rectification can
Published reports that
provide accessible public
information about the quality
take place
of cancer services
Timely information for local
commissioning as well as for
Validated information which
specialised commissioners in
is available to other
the designation of cancer
stakeholders
services
The Process
Self Assessment Report
Forms part of the self assessment
Short summary report completed by the lead clinician
Commentary that reflects the level of compliance with
the measures, patient experience and clinical
outcomes. Includes development and achievements
over the past year.
Self Assessment Report – Key Themes
Structure and Function
Co-ordination of Care/Pathways
Patient experience
Clinical Outcomes/Indicators
Self Assessment Report
• Will be a public document
• Will form basis of Annual Peer Review Report for those
teams not subject to internal validation
• Handbook contains guidance on identifying Immediate
Risks, Serious Concerns and Concerns
Chemotherapy ServiceEvidence Documents (only required
every other year)
Operational
Policy
Describing how the service
functions and how care is
delivered across the patient
pathway
Outlining policies/processes
that govern safe / high quality
care
Agreement to and
demonstration of the clinical
guidelines and treatment
protocols for team.
Annual Report
Summary assessment of
achievements & challenges
Demonstration that the service is
using available information (including
data) to assess its own service
- Workload & Activity Data
-National Audits
-Local Audits
-Patient Feedback
-Trial Recruitment
-Work Programme Update
Work
Programme
How the team is planning
to address weaknesses
and further develop its
service.
Outline of the teams
plans for service
improvement &
development over the
coming year
-Audit Programme
-Patient feedback
-Trial Recruitment
-Actions from Previous
reviews
Demonstrating
Agreement
• Where agreement to guidelines and policies is required
there should be a statement on the front cover of the
document indicating the groups and individuals that have
agreed the document and the date of agreement.
• Evidence Guides will indicate the groups and individuals
that need to be documented as agreeing the key
evidence documents.
Evidence Guides
Guidance to help you structure your
evidence documents
Guidance for compliance
Always refer to the full measure in
making assessments against measures
Internal Validation
– the purpose
to ensure accountability for the self assessment within organisations
and to provide a level of internal assurance
to develop a process whereby internal governance rather than external
peer review is the catalyst for change
to confirm that, to the best of the organisation’s knowledge, the
assessments are accurate and therefore fit for publication and sharing
with stakeholders
to identify and share areas of good practice
Who is responsible for internal
validation?
Service
Responsibility for Validation
MDT
Host Trust
Cross Cutting Service
Host Trust
Locality Group
Host Trust
NSSG
Host Network Management Team
Network Cross Cutting Group
Host Network Management Team
Internal Validation –
what we expect
the process is agreed within the organisation
the process adopted has agreement with the commissioners
within the locality and the cancer network
accountability for the self assessments is confirmed by
agreement of the chief executive of the organisation
there is commissioner and patient / carer involvement within
the process
the process and outcome of the validation is reported on the
nationally agreed proforma
Internal Validation –
suggested approaches
Desk-Top
Review
Small panel review
and validate
assessment
Panel
Review
Small panel review
assessment
Meet with
representatives of the
MDT/NSSG to
discuss key issues
and finalise validation
Internal Validation –
the process
Agreed validation process takes place
Further clarification may be sought on some issues / opportunity
of re-submission of specific evidence
Validation report agreed
Validated compliance recorded on CQuINS
Validation report uploaded
The Internal Validation Report
• Will be a public document
• Will form basis of Annual Peer Review Report for those
teams not subject to external review
• Handbook contains guidance on identifying Immediate
Risks, Serious Concerns and Concerns
Using CQuINS V4
Available via the web site at: www.cquins.nhs.uk
• Secure web based database supporting each stage of
the cancer peer review process
• Records assessments, compliance with the measures
and reports
• Provides information for national analysis and reporting
Completing the Self Assessment
1. Upload Key Documents - (Alternate
years only)
2. Enter Compliance on CQuINS
3. Complete Team Report
Completing the Self Assessment
1
2
1 Upload Key Documents
1
2
3
Enter Compliance
Enter Compliance
1
4
3
2
Complete Overview Report
Self Assessment - Evidence
Key Documents - teams/services should ensure the evidence
requirement stated for each measure is included either in one of the
key documents i.e. operational policy, annual report, work programme
or if not in one of these key documents it should be included as an
appendix.
Additional Evidence - If the actual evidence is not included in the
upload documents on CQuINS then the team should include a
statement which makes clear this evidence requirement has been
checked by the team/service and would be available if a peer review
team were to visit.
Use of Internet Hyperlinks - it is acceptable for teams/services to
include internet hyperlinks but these links must have open access and
not be on the closed section of the trust or organisation intranet
system.
Internal Validation - Evidence
• Key Documents - Ensure all the evidence required against
the measures for a team/service has been checked and is
available on the CQuINS database via the key documents.
• Additional Evidence - If any evidence is not available on the
CQuINS system, the internal validation panel should confirm
they have seen the evidence or give details of the spot checks
they have undertaken.
• Confirmation - This should be made clear on the internal
validation report form. It is not sufficient to give an overall
statement that all evidence has been seen. Details of the
specific evidence seen against measures should be identified
and noted on the compliance spreadsheet.
Peer Review Visit - Evidence
• Key Documents - A full copy of all evidence uploaded onto CQuINS
must be available to reviewers on the peer review visit. This can be
either hard copy or electronic.
• Patient Records - Peer Review zonal teams will normally request 5
sets of patient notes in order to check compliance against the
measures. Teams may sometimes require more than 5 set of patient
notes but this should never exceed 10. Only clinical NHS staff will
review patient notes.
General Principles
Personal details / patient information
•It is essential that no identifiable patient data including
hospital number should be uploaded on the CQuINS
database.
•The personal details of individual staff in a team/service
should not be uploaded e.g. certificates or job plans.
•Identification of individuals should not be made on reports
uploaded onto CQuINS. Reports should refer to the roles
they carry out.
General Principles
Agreements
•The role of the person indicated on the agreement should
include any delegated role they are undertaking for others.
•The front cover of any document uploaded should show
the date, version and planned review date.
General Principles
Configuration of the Network
•The configuration of the network
is essential to the review of a
particular tumour site and
ensuring compliance against the
Improving Outcomes Guidance.
Details of PCT referral pathway
and populations are essential.
Membership
•When a measure asks for the
membership of a group then the
name, role and organisation the
individual represents should be
indicated on the evidence.
General Principles
Patient Information
•Does not require uploading on
CQuINS
•Copies available for IV panel and
Peer Review Team
•The IV report should confirm that the
patient information has been seen
and that it covers all the essential
elements of the measure.
•At self assessment the team/service
should list the patient information they
have in the key documents uploaded
on CQuINS.
Patient Experience Exercise
•A summary of the exercise including
the key points and action
implemented is sufficient in the key
documents.
•A copy of the patient exercise should
be seen available for both peer
review and IV
•IV assessment should confirm this
has been seen.
•The national cancer patient survey
would be acceptable for this measure.
Specific Evidence Requirements
Working practice of a team/Spot checks
•Where measures ask for reviewers to ask about working practice of
teams/services or to undertake spot checks, they will do this when on a review.
•IV should mirror this and include comments in the IV report.
•For self assessment teams/services should state that they have completed a
spot check and the results of the spot check or give details of the working
practice.
Annual Meetings
•It is only necessary to make a statement in the key documents to confirm the
time/date of the meeting and that a record has been made.
•IV should confirm this meeting has taken place.
•If it is unclear that a meeting has taken place reviewers on a peer review visit
may ask for minutes of the meeting.
Specific Evidence Requirements
Attendance records /Meeting dates
This can often be satisfied by one clear piece of evidence showing:
•Dates of the meetings
•Name, role and organisation represented of those who have attended each meeting
•The SA report form should comment about any roles not covered or attending
appropriately
•Any summaries of attendance should demonstrate individual attendance at each
meeting for all members as well as the summary
Policies /Guidelines/Plans
•The date and version should be shown on all policies/guidelines and plans
•These should be uploaded on CQuINS either as an internet hyperlink (see above) within
the key documents or in the appendix
•National guidelines should have been adopted the local context should be explained.
•Flow charts are an acceptable means to explain details within guidelines
•If it is unclear that a meeting has taken place to sign off the guidelines/policies and plans
reviewers on a peer review visit may ask for minutes of the meeting
External Verification
– The Purpose
Verify that self-assessments are accurate
Check consistency across organisations
Ensure that a robust process of self-assessment and internal
validation has taken place
Provide a report on performance against the measures and
associates issues relating to IOG implementation
Identify teams or services who will receive an external peer
review visit in accordance with the selection criteria.
Zonal team members annual meeting
with network representatives
• December each year
• The purpose of the meeting will be to;
– inform the Zonal team of key issues within the
Network such as implementation of Improving
Outcomes Guidance, Service Configuration changes
– discuss the teams to be visited and schedule for the
following year.
Peer Review Visit Criteria
Milestones not met for implementation of an IOG as agreed with CAT
Immediate Risks identified at previous peer review visits that have not yet
been resolved
Requests from organisations i.e. SHAs, local and specialist commissioners,
PCTs, Networks, Acute Trusts
% compliance with measures within lowest performance grouping
Concerns regarding rigor of Internal Validation
Stratified random sample based on % compliance (if available capacity)
The Peer Review
Visit Plan
January
Notification in
January to
teams to be
peer reviewed
during May March
Preparation for
review
- 4 WEEKS
Deadline for
submission of
evidence for
all teams to be
visited
- 2 Weeks
Self
Assessment
evidence and
compliance
matrix sent to
reviewers and
copied to
teams
+ 8 WEEKS
Visits
MAY-MARCH
Each Network is
allocated one
month. Can
take from 1 to 4
weeks to
complete a
Network –
normally 1 day
per Locality
Report
published 8
weeks after
last review
day
Peer Review Teams
• Between two and five reviewers per session
• Plus a member of the Zonal Quality Team
• Reviewers should normally include “Peers”
– people who are trained and working in the same
discipline as those they are reviewing
Outcomes of the Process – Network
Reports
• Published January and June each year
• Including IV, EV and PR Visit Assessments
• Executive Summary from Quality Director
• Quality Director will discuss key issues with Network
Schedule of Teams for
Internal Validation
2011/12 (INTRODUCTION YEAR)
Acute Oncology
2012/13 (EVEN YEARS)
Breast
2013/14 (ODD YEARS)
Acute Oncology
Chemotherapy
Lung
Chemotherapy
Teenage and Young Adults
Colorectal
Teenagers and Young Adults
Sarcoma
Upper GI
Sarcoma
Brain and CNS
Head and Neck
Brain and CNS
Gynaecology
Skin
Gynaecology
Urology
Cancer Research Network
Urology
Network Service User
Partnership Group
Radiotherapy
Network Service User Partnership
Group
Rehabilitation
Children’s
Complementary Therapy
Cancer of Unknown Primary
Psychology
Specialist Palliative Care
Haematology
Recruitment Drive
• Wednesday 11 May 2011 – Lancashire
Teaching Hospitals (POSCU)
• Wednesday 15 and Thursday 16 June
2011 – Sheffield Children’s Hospital (PTC)
Paediatric Oncologists / Haematologists
required for above dates
Thank You
Any Questions ?
millie.forde@ncpr.org.uk
Metastatic Spinal Cord
Compression
Martin Wilby
Consultant Neurosurgeon
The Walton Centre
Overview
•
•
•
•
•
Significance
A little bit of anatomy
Diagnosis
Treatment
Case examples
Important
• Large number of patients
– 4000 new cases per year in UK
• Up to 25 % of patients with diagnosis of cancer
develop MSCC
• New and improved chemotherapy treatments are
improving patient life expectancy
• Adult spinal cord does not repair itself, likely that
deficits are permanent
Simple anatomy
Spinal cord ends L1/2, becomes “cauda equina”
Which tumours go to bone?
• 70% patients with
primary tumour
develop bony
metastases
• Spine most common
• Thoracic spine 60 %
• Tumours
–
–
–
–
Breast
Bronchus
Prostate
Kidney
Diagnosis
• If you don’t suspect the diagnosis, then
you will miss it!
• Symptoms
• Signs
Symptoms (UK Audit)
• Seems to be a step-wise progression of
symptoms
• PAIN
– Skeletal/bony pain
– More commonly thoracic
– Unremitting, present at night
– May develop into nerve root related pain,
trunk, arm/leg
• Leg weakness/difficulty walking (Ataxia)
• Sensory loss
Signs
• Bony tenderness on spine palpation
• Neurological deficits
• LMN (weakness, numbness, wasting) at
level
• UMN (tone, brisk reflexes) below level
Be suspicious
• Patients with known tumour…
• …and objective neurological signs
• Need urgent scan/MRI or seek advice
Recap
• Thoracic back pain in patients with known
primary malignancy = possible future
MSCC until proven otherwise
• Doesn’t matter if tumour not compressing
cord, patients have better outcome when
caught early
• MRI scan/refer on for advice
Goals of treatment
• Preserve neurological function
– Maintain independence
– Maintain walking ability
– Preserve patient dignity
• Reduce pain
• Allow patient to return home
Treatment 1
• Some years ago…
• Treat cord
compression with
posterior
decompression
• “Not good” G
Findlay
Treatment 2
• Radiotherapy and steroids
• Can shrink the tumour/reduce oedema
• But…
• Doesn’t really decompress the spinal cord
• Doesn’t address instability/pain
A little bit of evidence
• Lancet
• 2005
Patchell
• Randomised control trial
• 51 MSCC patients treated with RT and
steroids
• 50 MSCC patients treated with steroids,
surgery and then RT
Patchell
Patchell
Patchell evidence
• Surgery significantly improved outcome
• More patients walking (84 % vs 57%)
• More patients walking longer (122 days vs
14 days)
• 32 patients entered study “off legs”
– RT alone: 3 patients able to walk
– Sx + RT: 10 patients able to walk
Patchell evidence
• No difference in overall survival
• Continence more likely to be preserved
• Reduces analgesia requirements
Patchell recommendations
Scoring systems
Acute treatment: Stability
• When faced with a patient with MSCC,
assume instability and keep patient in bed
• Panjabi definition “physiological stability”
• Normal ROM without
– Deformity
– Excessive pain
– Neurological deficit
Case example: stability
55 yrs old
Multiple myeloma
Neck pain
No neurological deficit
Case: stability, CT
Stable?
How long?
Case: stability
Cementoplasty
• No role in MSCC
on its own
(decompression)
• Some role in
reduction of pain
in spine for nonsurgical patients
• Can be used
surgically as
“hybrid”
Case example
•
•
•
•
•
66 yr old male
Known non small cell lung ca
Short Hx of back pain and inability to walk
Preservation of leg power
CT staging: liver/parietal metastases
Case
Case
Hybrid procedure
Ambulant and continent for
remainder of life (over 1 year)
Off pain meds
53 y.o. female
• Presented acutely with sudden onset BP and weak legs
power 2/5
• Whole spine MRI; only abnormality seen L1/T12
• No significant PMH
• Urinary retention
Case
Case
•Urgent surgery,
staging done post
procedure
•Postero-lateral
instrumented
fusion and
laminectomy L1,
canal
decompressed.
Case
• Patient recovered
– Normal leg power
– Fully continent
– Ambulant
– Minimal back pain
– Quick return home
Overview
• Remember diagnosis
• Surgery + RT better than RT alone
• Best outcomes occur before loss of
ambulation and continence
The future
• Minimally
invasive
surgery?
The future
• Role for
Radiosurgery?
Questions?
Tumour Lysis Syndrome (TLS)
Daniel Collins
Haematology Pharmacist
What is it???
• Severe metabolic derangements
• Shortly after initiation of chemo
• Oncology & malignant Haematology
• Mainly seen alongside treatment of
• Leukaemia
• Lymphoma
• Can occur spontaneously
• “Pre-chemo”
Why does it happen???
• Certain tumours
• High proliferative rate
• Large tumour burden
• High sensitivity to Tx
• Initiation of Tx
• Intracellular anions & cations
• Metabolic products of proteins and DNA
• Hyperuricaemia
What happens to patients???
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Hyperuricaemia
Hyperphosphataemia
Hyperkalaemia
Hypocalcaemia
Renal impairment
• Life-threatening…
How often does it happen???
• High grade NHL = 42%
• Clinically significant 6%
• More common in Haem malignancies
• ALL
• High grade NHL e.g. Burkitts
• Some oncology patients
• Testicular, breast, small cell lung
• “High proliferative rates” &
“Chemosensitivity”
Can we classify TLS???
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Laboratory TLS
Clinical TLS
Grades 0 – V
High / Intermediate / Low
• Cairo-Bishop grading…???
How do we manage patients???
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High index of suspicion
Proactively identify patients quickly
Prevent/reduce any acute TLS
Delay subsequent chemo…???
Treat in appropriate units
Fluids, fluids, fluids…
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Vigorous hydration
Aggressive diuresis
Electrolyte management
Fluids
• Omit potassium/calcium/phosphate
• Adjust renally excreted drugs
• Urine alkalinisation controversial…
Medicines!!!
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Allopurinol…
Decreases formation of new urate
Reduces obstructive nephropathy
Limitations…???
Cheap as chips…
What do you see…???
Rasburicase
• Hyperuricaemia (urate >450)
• “Urate oxidase”
• 75kg pt = 15mg stat dose
• £580 per dose
• Give daily for 5-7 days
• ~£4000
• Caution = hypersensitivity…
• Bloods on ice!!!
Case Study
• JM 75yrs
• CMML → AML
• WBC = 103
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•
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High risk for TLS
Rx rasburicase 15mg stat
Rpt dose next day…???
Urate = 35
Rasburicase…
…does exactly what it says on the tin!!!
Practical Pointers
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Prevention is better than cure
Tumour burden & proliferation
TLS can precede chemo
Well hydrated & good UO
Baseline & regular blds
Practical Pointers
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Rasburicase…???
Monitor urate closely – ICE!!!
Not for od dosing x 7/7…
Delay chemo
Omit nephrotoxic meds
•
Reference – BJH 2004 127: 3-11