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ONCOLOGIC EMERGENCIES

ONCOLOGIC EMERGENCIES. Pediatric Resident Education Series. MASS EFFECTS HYPERVISCOSITY METABOLIC INFECTIONS. CNS CV GI GU OCULAR OTHER. ONCOLOGIC EMERGENCIES. MASS EMERGENCIES. SPINAL CORD SUPERIOR VENA CAVA/TRACHEA GENITOURINARY GASTROINTESTINAL CNS. SPINAL CORD COMPRESSION.

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ONCOLOGIC EMERGENCIES

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  1. ONCOLOGIC EMERGENCIES Pediatric Resident Education Series

  2. MASS EFFECTS HYPERVISCOSITY METABOLIC INFECTIONS CNS CV GI GU OCULAR OTHER ONCOLOGIC EMERGENCIES

  3. MASS EMERGENCIES • SPINAL CORD • SUPERIOR VENA CAVA/TRACHEA • GENITOURINARY • GASTROINTESTINAL • CNS

  4. 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 74:70, 1991

  5. 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

  6. 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 18:476, 1990

  7. SUPERIOR VENA CAVA SYNDROME In a patient on treatment consider: • relapse • effusion • infection • thrombosis (especially if a CVL is present)

  8. 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 18:476, 1990

  9. 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.

  10. 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

  11. 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 <.001 BUNIN JCO 3:1590, 1985

  12. 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?

  13. 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

  14. METABOLIC EMERGENCIES:hyperuricemia hypoxanthine xanthine oxidaseallopurinol xanthine xanthine oxidaseallopurinol uric acid uric acid oxidase allantoin

  15. 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 TUMOR LYSIS SYNDROME: Rx

  16. 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

  17. Tumor Primary Metastatic Hyperleukocytosis Stroke Seizure Leukoencephalopathy Post-XRT somnolence Chemotherapy Drugs Metabolic Infection Hypo/hypertension Dehydration Hypoxia Liver failure Depression CNS EMERGENCIES: acute alterations in consciousness

  18. 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

  19. Tumor Primary Metastatic Hyperleukocytosis Stroke Leukoencephalopathy Chemotherapy Intrathecal Systemic Drugs Metabolic Infection Hypertension Hypoxia CNS EMERGENCIES: seizures

  20. GI EMERGENCIES • OBSTRUCTION • tumor • vincristine, narcotics • HEMORRHAGE • INFECTION • typhlitis • perirectal abscess “treat the rectum with respect” • PANCREATITIS • corticosteroids, asparaginase • infection

  21. GI EMERGENCIES: VOD VENOCCLUSIVE DISEASE ETIOLOGY: POST-TRANSPLANTATION : DACTINOMYCIN : THIOGUANINE CLINICAL : WEIGHT GAIN :HEPATOMEGALY : HYPERBILIRUBINEMIA

  22. 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

  23. 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

  24. 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 GU EMERGENCIES: SIADH

  25. 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

  26. 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

  27. INFECTIOUS EMERGENCIES • If a central access line is present, cultures through eachline 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

  28. 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

  29. HYPOVOLEMIC SEPSIS HEMORRHAGE MESIS PANCREATITIS ADDISONIAN DIABETES HYPERCALCEMIA DISTRIBUTIVE ANAPHYLAXIS SEPSIS VOD SIADH CARDIOGENIC INFECTION METABOLIC TAMPONADE ANTHRACYCLINE CYCLOPHOSPHAMIDE IRRADIATION SHOCK IN CHILDREN WITH CANCER

  30. 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?

  31. 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

  32. Credits • Bruce Camitta MD

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