ONCOLOGIC EMERGENCIES

Pediatric Resident

Education Series

ONCOLOGIC EMERGENCIES

MASS EFFECTS HYPERVISCOSITY METABOLIC INFECTIONS

CNS CV GI GU OCULAR OTHER

MASS EMERGENCIES

SPINAL CORD SUPERIOR VENA CAVA/TRACHEA GENITOURINARY GASTROINTESTINAL CNS

SPINAL CORD COMPRESSIONEWING 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 74:70, 1991

SPINAL CORD COMPRESSION: RxASYMPTOMATIC DEXAMETHASONE CHEMOTHERAPY (ESP. LEUKEMIA,

LYMPHOMA AND NEUROBLASTOMA)

IRRADIATION SURGERY

SYMPTOMATIC: 24 HOUR RULE DEXAMETHASONE SURGERY (ESP. IF NO DISSEMINATED

TUMOR) IRRADIATION

SUPERIOR VENA CAVA SYNDROMEDISEASE No. MED. MASS

SVCSALL 1,464 130 6AML 392 9 0HODGKIN 333 102 2NHL 330 230 8NBLASTOMA 332 69 3GERM CELL 114 10 2SARCOMAS 696 26 3

INGRAMMPO 18:476, 1990

SUPERIOR VENA CAVA SYNDROMEIn a patient on treatment consider:

relapse effusion infection thrombosis (especially if a CVL is

present)

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)

INGRAMMPO 18:476, 1990

SVC SYNDROME: evaluation

Pulse oximetryChest 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.

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 USUALLYPREVENT ACCURATE

DIAGNOSIS

HYPERVISCOSITY

COMPLICATION ALL (161) AML (73)METABOLIC 22 4

HYPERKALEMIA 16 2LO CA, HIGH PO4 15 3

RENAL FAILURE 5 4RESPIRATORY 0 6*

HEMORRHAGE 4 14*

CNS 2 9

* p <.001

BUNINJCO 3:1590, 1985

HYPERVISCOSITY: treatment

OXYGEN HYDRATION TRANSFUSIONS

KEEP PLATELETS > 20,000/ul AVOID PRBC UNLESS SYMPTOMATIC SINCE

THEY MAY INCREASE VISCOSITY LOWER WBC

EXCHANGE TFX = LEUKAPHERESIS CHEMOTHERAPY ?IRRADIATION?

METABOLIC EMERGENCIES

HYPERURICEMIA HYPERKALEMIA HYPERPHOSPHATEMIA HYPOCALCEMIA

Due to rapid turnover of tumor cells (with or without anti-tumor therapy)

HYPERCALCEMIADue to bone metastases, PTH-like peptide production, PGE2 or calcitriol

METABOLIC EMERGENCIES:hyperuricemia

hypoxanthine xanthine oxidase allopurinol

xanthine xanthine oxidase allopurinol

uric acid uric acid oxidase

allantoin

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

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

CNS EMERGENCIES: acute alterations in consciousness Tumor

Primary Metastatic Hyperleukocytosis

Stroke Seizure Leukoencephalopath

y Post-XRT

somnolence Chemotherapy

Drugs Metabolic Infection Hypo/

hypertension Dehydration Hypoxia Liver failure Depression

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

CNS EMERGENCIES: seizures

Tumor Primary Metastatic Hyperleukocytosis

Stroke Leukoencephalopa

thy Chemotherapy

Intrathecal Systemic

Drugs Metabolic Infection Hypertension Hypoxia

GI EMERGENCIES OBSTRUCTION

tumorvincristine, narcotics

HEMORRHAGE INFECTION

typhlitisperirectal abscess

“treat the rectum with respect” PANCREATITIS

corticosteroids, asparaginase infection

GI EMERGENCIES: VOD VENOCCLUSIVE DISEASE

ETIOLOGY: POST-TRANSPLANTATION

: DACTINOMYCIN : THIOGUANINE

CLINICAL : WEIGHT GAIN

: HEPATOMEGALY

: HYPERBILIRUBINEMIA

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 failureTreatment depends upon etiology

GU EMERGENCIES: HEMATURIA

THROMBOPENIA: MARROW DISEASE, DIC, CHEMOTHERAPY

INFECTION: BACTERIAL, VIRAL (CMV, BK, ADENO)

CHEMOTHERAPY: CYCLOPHOSPHAMIDE AND IFOSFAMIDE

RARELY LIFE-THREATENING PER SEDIAGNOSE, TREAT UNDERLYING

PROBLEM

GU EMERGENCIES: SIADH

ETIOLOGIES CNS INFECTION TUMORS

CNS LYMPHOMA

CHEMOTHERAPY VINCRISTINE CYCLOPHOSPHAMI

DE IFOSFAMIDE

IATROGENIC

DIAGNOSISURINE/SERUM

OSMOLALITY, Cr, LYTES

TREATMENT FLUID RESTRICTION NSS SLOW CORRECTION OF

LOSSES (3% SALINE) FUROSEMIDE

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

INFECTIOUS EMERGENCIES

RISK FACTORS NEUTROPENIA (ANC or APC < 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

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

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

SHOCK IN CHILDREN WITH CANCER HYPOVOLEMIC

SEPSIS HEMORRHAGE MESIS PANCREATITIS ADDISONIAN DIABETES HYPERCALCEMIA

DISTRIBUTIVE ANAPHYLAXIS SEPSIS VOD SIADH

CARDIOGENIC INFECTION METABOLIC TAMPONADE ANTHRACYCLINE CYCLOPHOSPHAMI

DE IRRADIATION

OTHER EMERGENCIES:RETINOIC ACID SYNDROME

FEVER RESPIRATORY DISTRESS WEIGHT GAIN PLEURAL/PERICARDIAL EFFUSIONS HYPOTENSION (USUALLY) RISING WBC DURING

INDUCTION

TREATMENT: HOLD ATRA : DEXAMETHASONE : ?LOWER WBC?

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

Credits

Bruce Camitta MD