ONCOLOGIC EMERGENCIES

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ONCOLOGIC EMERGENCIES

• Pediatric Resident
• Education Series

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ONCOLOGIC EMERGENCIES

• MASS EFFECTS
• HYPERVISCOSITY
• METABOLIC
• INFECTIONS

• CNS
• CV
• GI
• GU
• OCULAR
• OTHER

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MASS EMERGENCIES

• SPINAL CORD
• SUPERIOR VENA CAVA/TRACHEA
• GENITOURINARY
• GASTROINTESTINAL
• CNS

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SPINAL CORD COMPRESSION

• EWING SARCOMA 30/168 (17.9)
• NEUROBLASTOMA 32/402 ( 7.9)
• OSTEOSARCOMA 16/243 ( 6.5)
• RHABDOMYOSARCOMA 14/287 ( 4.9)
• SOFT TISSUE SARCOMA 4/102 ( 3.9)
• GERM CELL TUMOR 5/130 ( 3.8)
• HODGKIN DISEASE 8/404 ( 2.0)
• HEPATOMA 1/69 ( 1.4)
• WILMS TUMOR 2/290 ( 0.7)
• OTHER 0/164 -
• TOTAL 113/2259 ( 5.0)

KLEIN JNs 7470, 1991
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SPINAL CORD COMPRESSION Rx

• ASYMPTOMATIC
• DEXAMETHASONE
• CHEMOTHERAPY (ESP. LEUKEMIA, LYMPHOMA AND
  NEUROBLASTOMA)
• IRRADIATION
• SURGERY
• SYMPTOMATIC 24 HOUR RULE
• DEXAMETHASONE
• SURGERY (ESP. IF NO DISSEMINATED TUMOR)
• IRRADIATION

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SUPERIOR VENA CAVA SYNDROME

• DISEASE No. MED. MASS SVCS
• ALL 1,464 130 6
• AML 392 9 0
• HODGKIN 333 102 2
• NHL 330 230 8
• NBLASTOMA 332 69 3
• GERM CELL 114 10 2
• SARCOMAS 696 26 3

INGRAM MPO 18476, 1990
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SUPERIOR VENA CAVA SYNDROME

• In a patient on treatment consider
• relapse
• effusion
• infection
• thrombosis (especially if a CVL is present)

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SVC SYNDROME SX, FINDINGS at DX

• Cough/dyspnea 11 (68)
• Dysphagia/orthopnea 10 (63)
• Wheezing 5 (31)
• Hoarseness 3 (19)
• Facial edema 2 (12)
• Chest pain 1 ( 6)
• Pleural effusion 8 (50)
• Pericardial effusion 3 (19)

INGRAM MPO 18476, 1990
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SVC SYNDROME evaluation

• Pulse oximetry
• Chest XR the trachea is a 3-dimensional
  structure. It must be evaluated with both PA and
  lateral views. The latter often requires a
  high-KV film.
• Echocardiogram if any question re size, motion
• Pulmonary function if considering anesthesia.
  Should be performed in both upright and recumbent
  positions.

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SVC SYNDROME TREATMENT

• CONSULTS
• ENT/ANESTHESIA
• SURGERY
• TREATMENT
• O2, IV ACCESS, IVF
• SURGERY
• IRRADIATION
• CHEMOTHERAPY
• CORTICOSTEROIDS
• OTHER

• DIAGNOSIS
• LOCAL ANESTHESIA
• ALTERNATE SITE
• DELAY OF 48 HOURS
• DOES NOT USUALLY
• PREVENT ACCURATE
• DIAGNOSIS

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HYPERVISCOSITY

• COMPLICATION ALL (161) AML (73)
• METABOLIC 22 4
• HYPERKALEMIA 16 2
• LO CA, HIGH PO4 15 3
• RENAL FAILURE 5 4
• RESPIRATORY 0 6
• HEMORRHAGE 4 14
• CNS 2 9
• p lt.001

BUNIN JCO 31590, 1985
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HYPERVISCOSITY treatment

• OXYGEN
• HYDRATION
• TRANSFUSIONS
• KEEP PLATELETS gt 20,000/ul
• AVOID PRBC UNLESS SYMPTOMATIC SINCE THEY MAY
  INCREASE VISCOSITY
• LOWER WBC
• EXCHANGE TFX LEUKAPHERESIS
• CHEMOTHERAPY
• ?IRRADIATION?

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METABOLIC EMERGENCIES

• HYPERURICEMIA
• HYPERKALEMIA
• HYPERPHOSPHATEMIA
• HYPOCALCEMIA
• Due to rapid turnover of tumor cells (with or
  without anti-tumor therapy)
• HYPERCALCEMIA
• Due to bone metastases, PTH-like peptide
  production, PGE2 or calcitriol

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METABOLIC EMERGENCIEShyperuricemia

• hypoxanthine
• xanthine oxidase allopurinol
• xanthine
• xanthine oxidase allopurinol
• uric acid
• uric acid oxidase
• allantoin

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TUMOR LYSIS SYNDROME Rx

• HYPERURICEMIA
• Hydration
• Allopurinol
• Uric acid oxidase
• Bicarbonate
• High PO4, low Ca
• Phosphate binder
• Calcium gluconate

• HYPERKALEMIA
• Cardiac monitor
• Kayexalate
• Insulin/glucose
• Bicarbonate
• Calcium gluconate
• Aminophylline
• dialysis

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HYPERCALCEMIA Dx, Rx

• SIGNS, SYMPTOMS nausea, constipation, polyuria
  weakness, bradyarrhythmias, renal
  insufficiency, coma
• TREATMENT
• excretion NSS, furosemide (not thiazide)
• mobilization prednisone (acts slowly)
• calcitonin
• biphosphonates
• Treatment of the malignancy

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CNS EMERGENCIES acute alterations in
consciousness

• Tumor
• Primary
• Metastatic
• Hyperleukocytosis
• Stroke
• Seizure
• Leukoencephalopathy
• Post-XRT somnolence
• Chemotherapy

• Drugs
• Metabolic
• Infection
• Hypo/hypertension
• Dehydration
• Hypoxia
• Liver failure
• Depression

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Chemotherapy causing acute alterations in
consciousness

• Corticosteroids mood swings, hallucinations,
  psychosis
• Cytosine arabinoside cerebellar dysfunction,
  seizures, coma
• Methotrexate encephalopathy, seizures
• Ifosfamide somnolence
• Retinoic acid pseudotumor

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CNS EMERGENCIES seizures

• Tumor
• Primary
• Metastatic
• Hyperleukocytosis
• Stroke
• Leukoencephalopathy
• Chemotherapy
• Intrathecal
• Systemic

• Drugs
• Metabolic
• Infection
• Hypertension
• Hypoxia

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GI EMERGENCIES

• OBSTRUCTION
• tumor
• vincristine, narcotics
• HEMORRHAGE
• INFECTION
• typhlitis
• perirectal abscess
• treat the rectum with respect
• PANCREATITIS
• corticosteroids, asparaginase
• infection

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GI EMERGENCIES VOD

• VENOCCLUSIVE DISEASE
• ETIOLOGY POST-TRANSPLANTATION
• DACTINOMYCIN
• THIOGUANINE
• CLINICAL WEIGHT GAIN
• HEPATOMEGALY
• HYPERBILIRUBINEMIA

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GU EMERGENCIES OLIGURIA

• PRERENAL dehydration, sepsis, low albumen
• RENAL tumor, tumor lysis products, antibiotics,
  SIADH, chemotherapy
• POST RENAL tumor, narcotics, v-zoster
• Avoid IV contrast agents if renal failure
• Treatment depends upon etiology

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GU EMERGENCIES HEMATURIA

• THROMBOPENIA MARROW DISEASE, DIC, CHEMOTHERAPY
• INFECTION BACTERIAL, VIRAL (CMV, BK, ADENO)
• CHEMOTHERAPY CYCLOPHOSPHAMIDE AND IFOSFAMIDE
• RARELY LIFE-THREATENING PER SE
• DIAGNOSE, TREAT UNDERLYING PROBLEM

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GU EMERGENCIES SIADH

• ETIOLOGIES
• CNS INFECTION
• TUMORS
• CNS
• LYMPHOMA
• CHEMOTHERAPY
• VINCRISTINE
• CYCLOPHOSPHAMIDE
• IFOSFAMIDE
• IATROGENIC

• DIAGNOSIS
• URINE/SERUM OSMOLALITY, Cr, LYTES
• TREATMENT
• FLUID RESTRICTION
• NSS
• SLOW CORRECTION OF LOSSES (3 SALINE)
• FUROSEMIDE

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HYPERTENSION

• RENAL VASCULAR COMPRESSION/OCCLUSION, TUMOR
  LYSIS, PARENCHYMAL DISEASE/TUMOR
• HUMORAL CATECHOLAMINES, RENIN, CORTICOSTEROIDS
  (TUMOR, TREATMENT)
• CNS TUMOR (CUSHING TRIAD), INFECTION
• OTHER MEDICATION, FLUID OVERLOAD, PAIN

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INFECTIOUS EMERGENCIES

• RISK FACTORS
• NEUTROPENIA (ANC or APC lt 500/ul)
• IMMUNE SUPPRESSION
• FOREIGN BODIES
• The usual signs of infection may be subtle or
  absent in patients unable to mount an effective
  inflammatory response due to neutropenia,
  lymphopenia or corticosteroid therapy

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INFECTIOUS EMERGENCIES

• If a central access line is present, cultures
  through each line are indicated. Peripheral blood
  cultures are less important.
• CXR rarely helpful in the absence of clinical
  signs or symptoms
• Urine culture may be useful in females
• Single, broad-spectrum antibiotic coverage is
  adequate for most patients (cefipime)
• Add vancomycin if sick, recent foreign body
  insertion, or site suggestive of staphylococcal
  infection
• Double gram negative/anaerobic coverage for
  suspected GI focus

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INFECTIOUS EMERGENCIES

• Perirectal pain (treat the anus with respect)
• Look
• Palpate
• Test tube proctoscopy better than rectal exam
• Fever, tachypnea, hypoxemia, clear lungs
• Sepsis
• Pneumocystis carinii pneumonia
• Pulmonary embolism

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SHOCK IN CHILDREN WITH CANCER

• HYPOVOLEMIC
• SEPSIS
• HEMORRHAGE
• MESIS
• PANCREATITIS
• ADDISONIAN
• DIABETES
• HYPERCALCEMIA

• DISTRIBUTIVE
• ANAPHYLAXIS
• SEPSIS
• VOD
• SIADH
• CARDIOGENIC
• INFECTION
• METABOLIC
• TAMPONADE
• ANTHRACYCLINE
• CYCLOPHOSPHAMIDE
• IRRADIATION

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OTHER EMERGENCIESRETINOIC ACID SYNDROME

• FEVER
• RESPIRATORY DISTRESS
• WEIGHT GAIN
• PLEURAL/PERICARDIAL EFFUSIONS
• HYPOTENSION
• (USUALLY) RISING WBC DURING INDUCTION
• TREATMENT HOLD ATRA
• DEXAMETHASONE
• ?LOWER WBC?

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OTHER EMERGENCIES

• INFILTRATION OF THE OPTIC NERVE
• can lead to rapid, permanent loss of vision
• emergency irradiation /- chemotherapy
• SKIN EXTRAVASATION OF VESSICANTS
• rare since central access device use
• can cause severe ulceration, scarring
• No good clinical trials of treatment.
• Alkylating agents Na thiosulfate, topical DMSO
• DNA intercalators cold, ?topical DMSO?
• Alkaloids, podophyllotoxins hyaluronidase

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Credits

• Bruce Camitta MD