chemotherapy-related neutropenic septic shock in gynecological … · 2019-08-23 ·...
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Chemotherapy-related neutropenic septic shockin gynecological cancer
Ji Geun Yoo
Department of Obstetrics and Gynecology
Seoul St. Mary’s Hospital
The Catholic University of Korea
Introduction
• For patients with gynecologic cancer, adjuvant chemotherapy has played an important role.
• Chemotherapy induces myelosupression, resulting in neutropenia and sepsis which is a major toxicity.
• Febrile neutropenia– Morbidity : 20-30%– Overall in-hospital mortality : ~10%
• Septic shock : 40% mortality
Annals of Oncology 27 (Supplement 5): v111–v118, 2016
Introduction
Shock. 2018 Apr;49(4):371-384.
Crit Care. 2004 Oct;8(5):R291-8.
Introduction
• Taxane-platinum combination chemotherapy– Incidence of G3-4 neutropenia : 64% - 84%– Incidence of febrile neutropenia : 7% during primary treatment– Incidence of neutropenic septic shock : around 1%
• Incidence of septic shock during chemotherapy is not well known.
• We conducted a retrospective review, focusing on the incidence of septic shock according to cancer type, age, lines, and chemotherapeutic regimens
Methods
• Seoul St. Mary’s Hospital, 2009 – 2017• Patients diagnosed with gynecological cancers and received
chemotherapy • Concurrent chemoradiotherapy was not included• Definition of neutropenic septic shock group
– Patients with sepsis– Neutropenia <500/mcL or <1000/mcL with predicted decline to
500/ul within next 2 days– Vasopressor requirement to maintain a MAP of 65mmHg
despite adequate fluid resuscitation– Septic shock events during the course of chemotherapy
or within 4 weeks of the last cycle
Methods
• Patients who corresponding to sepsis, but hypotension is caused by other fatal co-morbidities were excluded(aspiration pneumonia, GI bleeding, biliary obstruction, …)
• Statistical analysis: IBM SPSS 20
– Fisher’s exact test– Mann-Whitney U test– Univariate and multivariate logistic regression
Results
• Total 1,009 patients received 10,246 chemotherapy cycles• 30 (3.0%) patients experienced 33 septic shock events• 12 events of death occured (mortality : 36.4%)
0.00%
1.00%
2.00%
3.00%
4.00%
5.00%
6.00%
0
50
100
150
200
250
~44 45~49 50-54 55-59 60-64 65-69 70-74 75~
Age at chemotherapy administration
Patients, n. Septic shock, %
0.00%
1.00%
2.00%
3.00%
4.00%
5.00%
6.00%
7.00%
0
50
100
150
200
250
~44 45~49 50-54 55-59 60-64 65-69 70-74 75~
Age at the first treatment
Patients, n. Septic shock, %
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
3.00%
3.50%
4.00%
0
100
200
300
400
500
600
700
800
900
1000
1st line 2nd line 3rd line 4th and over
Patients %
Discussion
• Definition of septic shock in neutropenic patients– The Third International Consensus Definitions for Sepsis
(SEPSIS-3, 2016)– Elevated lactate level is reflective of cellular dysfunction
with higher levels predictive of higher mortality• >2 mmol/L : 42.3% mortality• <2 mmol/L : 30.1% mortality
– Lactate level does not affect initial resuscitation of septic shock
• Incidence of septic shock was higher than previous studies– Ethnic differences in the toxicity of chemotherapy
• Japanese ovarian cancer patients : 70-80% grade 4 neutropenia• Breast, lung, renal cell carcinoma
Discussion
• Limitations– Retrospective settings– Small cases due to low incidence– Risk factors of septic shock did not identified
• BMI, performance status, stage, comorbidities, …– Septic shock events reported officially was counted
• Events treated in other hospitals were not identified• 20 patients had not visited since the last chemotherapy,
and 5 patients died within a month since the last chemotherapy• The true incidence is likely to be higher
Thank you for your attention!