Oncologic emergencies
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Oncologic Emergencies. Shahina Qureshi State University of New York Downstate Medical Center. Oncologic Emergencies. Metabolic and Endocrine Tumor Lysis Syndrome, Hypercalcemia, SIADH Cardiothoracic Superior Vena Cava ,SMS, Pleural ,Pericardial Effusions, Pneumothorax, ATRA Abdominal

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Oncologic Emergencies

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Oncologic emergencies

Oncologic Emergencies

Shahina Qureshi

State University of New York

Downstate Medical Center


Oncologic emergencies1

Oncologic Emergencies

  • Metabolic and Endocrine

    • Tumor Lysis Syndrome, Hypercalcemia, SIADH

  • Cardiothoracic

    • Superior Vena Cava ,SMS, Pleural ,Pericardial Effusions, Pneumothorax, ATRA

  • Abdominal

    • GI, GU

  • Neurologic

    • Spinal Cord Compression, Seizures, CVA

  • Shock

    • DIC, Pancytopenia


Tumor lysis syndrome

Tumor Lysis Syndrome

  • Potentially fatal metabolic complication due to rapid destruction of of tumor cells during or12-72 hrs after treatment. Leading to

    • Hyperuricemia [ uric acid > 15mg/dl ]

    • Hyperkalemia

    • Hyperphosphatemia [phos >8 mg/dl]

    • Hypocalemia

    • Renal Failure


Tumor lysis syndrome risk factors

Tumor Lysis SyndromeRisk Factors

  • Elevated Leukocyte Count

  • High proliferation rate

  • Chemosensitivity

  • Large tumor burden

  • Elevated pretreatment uric acid and LDH levels [ Cohen et al Am j Med 1980]

  • Preexisting renal impairment, Dehydration


Tumor lysis syndrome1

Highest risk

Moderate risk

Low risk

Lymphoblastic Lymphoma

Burkitts Lymphoma

ALL

Low grade lymphom

Breast cancer

Small cell lung cancer

Seminoma

Medulloblastoma

Adenocarcinoma of GI tract

Lymphoma treated with interferon

Tumor Lysis Syndrome


Pathway of uric acid production

Pathway of Uric acid production

Purine catabolism

Hypoxanthine

Xanthine

Uric acid

Allantoin

Xanthine oxidase

Urate oxidase


Tumor lysis syndrome management

Tumor lysis syndromeManagement

  • Hydration

  • Alkalinization

  • Diuresis

  • Uric acid reduction

  • Metabolic abnormalities


Tls management

TLS Management

  • Hydration

    • 2-4 times maintainance fluid D5 I/4 NS+ 40 mEq/L NaHCO3

    • Maintain urine output>100 ml/m2/hr

    • Urine Sp Gr<1.010


Tls management1

TLS Management

  • Maintain Urine pH at 7.0- 7.5

  • Diuresis with Furosemide [0.5 –1.0 mg/kg] ,Mannitol[ 0.5g/kg ]

  • Hyperkalemia

    • Na Polystyrene sulphonate1g/kg

    • Calcium gluconate 100-200mg/kg

    • Insulin0.1. Units/kg=25% Glucose 2ml/kg

  • Hyperphosphatemia

    • Aluminum hydroxide 15 ml q 4-8h

  • Hypocalcemia

    • Calcium Gluconate I.v only if symptomatic


  • Tls indications for dialysis

    TLS Indications for Dialysis

    • Volume overload [Effusions]

    • Renal failure


    Tls uric acid reduction

    TLS Uric acid reduction

    • Allopurinol

      • Inhibits xanthine oxidase so decreases production of uric acid

      • Also inhibits p450

      • Interferes with metabolism of 6-MP

      • Takes 24 hrs to reduce uric acid level

      • P.O.dose 10mg/kg/day two days before chemotherapy

      • I.V. form approved in 2001 for pts unable to tolerate p.o 40-150mg/m2 q 8 h


    Tls uric acid reduction1

    TLS Uric acid reduction

    • Urate Oxidase

      • Non Recomboinant[uricozyme] developed in France in 1992

      • Recombinant[rasburicase] developed in 1996

      • Oxidizes Uric acid to allantoin which is 5-10 times more soluble, does not need urine alkalinization.

      • Generates H2O2,not used in G6PD- def pts

      • Well tolerated 1% hypersensitivity, 5% antibody formation

      • 90% reduction of plasma uric acid in 4 hrs

      • 0.45 risk of new renal complications


    Comparison of iv allopurinol and rasburicase

    I.V rasburicase

    Year of study 1999-2002

    No of pts 778

    Duration of Tr 3 d

    Tr success 98%

    Prophlaxis success 100%

    Comparison of IV Allopurinol and Rasburicase


    Oncologic emergencies

    TLS Comparision of allopurinol and rasburicase


    Oncologic emergencies superior vena cava syndrome

    Oncologic EmergenciesSuperior Vena Cava Syndrome

    • Due to invasion or compression of SVC by:

      • Malignancy in 78-85%,e.g lung cancer, lymphoma

      • Infection

      • Thrombosis


    Superior vena cava syndrome signs and symptoms

    Superior vena cavasyndromeSigns and Symptoms

    • Dyspnoea, cough68%

    • Facial pain or swelling12%

    • Wheezing31%

    • Facial plethora

    • Venous distension in the neck and chest wall

    • Pleural effusion50%

    • Pericardial effusion19%

      Ingram, Med Ped Onc 1990;18:476


    Incidence of svc st judes study 1973 1998

    Incidence of SVCSt.Judes Study 1973-1998


    Superior vena cava syndrome diagnosis

    Superior Vena cava SyndromeDiagnosis

    • Chest X-ray

    • Chest CT

    • Helical CT

    • MRI

    • Histologic Diagnosis , Sputum, Bone marrow, Bronchoscopy


    Superior vena cava syndrome treatment

    Superior vena cava syndromeTreatment

    • Radiotherapy

    • Emergency Chemotherapy

    • IV methyl prednisolone

    • Surgery


    Oncological emergencies spinal cord compression incidence

    Oncological EmergenciesSpinal Cord compressionIncidence

    Kleinsl etal J. Neurosurg 1991;74:70


    Spinal cord compression signs and symptoms

    Spinal Cord CompressionSigns and Symptoms

    • Back pain in 80%

    • Progressive Weakness

    • Sensory Abnormalities

    • Paresis

    • Paraplegia and Quadriplegia

    • Sphincter dysfunction


    Spinal cord compression evaluation

    Spinal Cord CompressionEvaluation

    • MRI scans T1, T2 weighted

    • CT Myelography

    • CSF examination


    Spinal cord compression treatment

    Spinal Cord CompressionTreatment

    • Dexamethasone IV 1.0-2.0mg/kg bolus

    • Local Radiotherapy

    • Surgical decompression

    • Chemotherapy if diagnosis is known


    Oncological emergencies hyperleukocytosis

    Oncological EmergenciesHyperleukocytosis

    • WBC count >100,000

      • ALL 9-13%

      • AML 5-22%


    Hyperleukocytosis complications

    HyperleukocytosisComplications

    Bunin NJ, Piu CH, J. Clin Oncol 1985;3:1590


    Hyperleukocytosis signs and symptoms

    HyperleukocytosisSigns and Symptoms

    • Mental Status Changes, Headache, Blurred Visions, Seizures, Coma

    • Pulmonary Leukostasis, dyspnea, hypoxia, cyanosis, acidosis

    • Priapisim, dactylitis

    • Renal failure


    Hyperleukocytosis treatment

    HyperleukocytosisTreatment

    • IV hydration

    • Maintain hemoglobin below 10g/dL

    • Exchange transfusion 52-66% reduction

    • Leukapharesis 48-62% reduction

    • Systemic chemotherapy

    • Cranial irradiation upto 400 cGy prevents CNS hemorrhage


    Oncological emergencies

    Oncological Emergencies

    • Anticipate

    • Prevent


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