Oncologic Emergencies¶

Bradley Christensen, Madeleine Turcotte

Leukostasis¶

Presentation¶

Primarily occurs with acute myeloid leukemia and acute lymphoblastic leukemia. This is not common with CLL or CML with high leukocyte counts in the absence of a significant increased portion of peripheral blasts
Respiratory: dyspnea, hypoxia (note CXR may be normal)
PaO2 by ABG often falsely low from WBC consuming O2 in vitro. Trust SpO2.
CNS: headache, AMS, vision changes, dizziness, tinnitus, gait instability, neuro deficit

Evaluation¶

CBC with diff and peripheral blood smear
Imaging: CT head to evaluate neuro deficit and to check for ICH
Chest X-Ray vs CT chest to evaluate dyspnea and air space abnormalities

Management¶

Call hematology
Emergent cytoreduction
Leukapheresis: page nephrology and place dialysis catheter
Hydroxyurea and chemotherapy per hematology fellow
Transfer/admit to ICU

Tumor Lysis Syndrome¶

Background¶

Lysis of malignant cells either spontaneously or in response to chemotherapy causing release of K, Phos, nucleic acids, and cytokines
Consequences:
- Hyperkalemia: most urgent and immediately life threatening
- Hyperphosphatemia: binds Ca and leads to CaPhos crystal deposition AKI, HypoCa
- Hyperuricemia (from breakdown of DNA) precipitation in renal tubules AKI
- Hypotension, AKI from cytokine release
Laboratory TLS
Uric acid ≥ 8, Ca2+ ≤ 7, K+, or PO43- ≥ 4.5
or > 25% change from baseline in these values

Evaluation¶

Risk Stratification:
- Highest risk after starting chemotherapy, but can occur spontaneously
- Tumor characteristics which confer a higher risk of developing TLS:
  - High (>5% risk): ALL (WBC> 100K or LDH 2x ULN), AML (WBC> 100K), Burkitt’s (III/IV or LDH≥2xULN, DLBCL with bulky disease, intermediate risk + AKI/CKD
  - Intermediate: ALL (WBC<100K, LDH <2x ULN), AML (WBC 25-100K), Burkitt’s LDH<2x ULN), DLBCL (non-bulky, LDH>ULN), CLL (if tx with fludarabine, rituximab, lenalidomide, or venetoclax +LN 5-10 cm or ALC≥25K), plasma cell leukemia, rare chemo-sensitive solid tumors (small cell)
  - Low: all others

Management¶

Prevention:
- High risk: q6-8h TLS labs, IVF (±loop diuretic if volume overload), allopurinol, ± rasburicase
- Intermediate – q8h TLS labs, IVF, allopurinol
- Low – daily TLS labs, IVF
  - Significant hydration: goal to maintain UOP 80-100 mL/hr
  - Allopurinol: 300 mg PO BID for CrCl > 20 mL/min, UpToDate renal dosing if lower
  - Rasburicase ($$$): contraindicated in G6PD (send G6PD if not urgent and AA, Asian or Jewish descent)
    - Given if uric acid > 8 mg/dL: get fellow approval before ordering
Treatment: (Can use as night/cross cover handoff)
- K+ > 5.5: STAT EKG. Kayexalate 30g orally or 60g per rectum (unless contraindicated) x1
  - Give 10 U insulin/1 amp D50
  - If EKG changes, then calcium gluconate and D5W at 100 mL/hr with repeat BG in 1 hr
- Uric acid > 8 with 25% change from baseline: page hematology fellow to discuss rasburicase
- PO4 > 4.5 with 25% change from baseline: start/↑ phos binder (sevelamer)
- Dialysis may be necessary in patients with poor renal function.
- IV calcium: do not administer unless symptomatic AND hyperphosphatemia is corrected
  - With high phos, IV calcium can lead to calcium deposition and renal failure
- Hemodialysis: pt with anuria, refractory hyperkalemia, and symptomatic hypocalcemia

Superior Vena Cava (SVC) Syndrome¶

Background¶

Commonly Associated Malignancies: Lung Cancer, Non-Hodgkin or Hodgkin Lymphoma, Mediastinal Germ Cell Tumors, Thymic Malignancies
Partial or complete obstruction of the SVC impedes blood return from the upper extremities, head, neck, and brain resulting in upstream congestion
Can be 2/2 a mass in the mediastinum or thrombosis (foreign body i.e. catheter)

Presentation¶

Facial or neck swelling without generalized edema
Sense of head fullness, exacerbated by leaning forward or lying down
Pulmonary symptoms including dyspnea, stridor, hoarseness, cough - due to edema narrowing the nasal passages and larynx or mechanical airway obstruction
Physical Exam: facial and neck edema particularly of the eye lids in the morning, distended neck and chest veins; can also sometimes see upper extremity swelling, papilledema, plethora. Look for associated lymph node enlargement anywhere particularly including supraclavicular, cervical, and axillary region

Evaluation¶

CXR: may show mass, perihilar or mediastinal disease
Contrasted CT scan ± CT Venography: Phased to get a view of clot contribution to obstruction guides decision regarding anticoagulation or stenting
Radiology attending can coordinate with techs (requires verbal direct request)
MRI/MRV may provide additional information (often not possible due to pt too sick)

Management¶

Assess airway and prepare for intubation if needed
Keep head of bed elevated
Thrombosis:
- Removal of lines/catheters associated with thrombus
- Consideration of anticoagulation
Tumor compression: the type of tumor guides treatment (tissue biopsy is key)
Stat/urgent consultations:
- Interventional radiology for possible stenting/dilatation
- Radiation oncology- for radiation therapy
- Interventional pulmonology – for help with tissue dx
- Medical oncology – for help with diagnosis and chemotherapy

Spinal Cord Compression¶

Background¶

Malignancies where cord compression is most common:
- Multiple Myeloma, Lymphoma (both Hodgkin and NHL), Lung, Breast, Prostate Cancer
Tumor mass & compressed and often displaced bone impinges thecal sac or nerve roots spinal cord or any spinal nerves including the cauda equina

Presentation¶

Back pain, motor, or sensory deficits
Cauda Equina syndrome bowel or bladder incontinence, ataxia

Evaluation¶

Neurologic exam with sensation testing seeking level below an identified dermatome
Lab testing: If no known malignancy check CBC, CMP, SPEP, and (in males) PSA
Bladder US if suspicion or retention with or without overflow incontinence

Management¶

If suspected, order MRI without and with contrast; if patient unable to have MRI, CT myelography may be considered
Immediate high dose steroids (dosing is controversial with recommendations ranging from 4 to 100 mg of dexamethasone q6h - choice of dexamethasone is to minimize mineralocorticoid effects. Most common dosing is 10mg IV x1 followed by 4mg IV q6h)
Consider stat/urgent consultation with:
- Neurosurgery for diagnostic/therapeutic intervention
- Radiation oncology- for radiation therapy
- Medical oncology – for help with diagnosis and chemotherapy
Ensure regular neuro-vascular checks and close monitoring.

Brain Metastases¶

Background¶

Common malignancies: Lung (NSCLC), breast, kidney, colorectal carcinomas & melanomas
Significantly more common than primary brain tumors
80% of brain metastasis occur in the cerebrum at grey/white matter junction

Presentation¶

Highly variable: consider brain mets in any cancer pt w/ neurologic or behavioral changes
Headache: worse in the mornings, with bending over or with valsalva
Nausea/vomiting
Cognitive dysfunction: changes in memory, mood or personality
Focal neurologic deficits
Signs of elevated ICP: papilledema, vision changes, drowsiness, presyncope
Seizures
Stroke (particularly in melanoma, choriocarcinoma, thyroid & renal carcinomas)

Evaluation¶

STAT CT if concerned for stroke or elevated ICP
MRI with contrast: most sensitive, can differentiate between metastases vs. other lesions
- Suggestive features: multiple lesions, location, circumscribed margins, vasogenic edema
If pt has no known primary tumor: consider CT C/A/P ± PET to identify primary
Biopsy with histopathology & IHC: if diagnosis in doubt or if only a single lesion is present

Management¶

If severe HA, N/V, focal deficits: systemic glucocorticoids
Dexamethasone 10mg IV x1 followed by 4mg IV q6h (can be PO if tolerated)
Stat/urgent consults:
- Neurosurgery – for diagnostic/therapeutic intervention
- Radiation oncology – for radiation therapy
- Medical oncology – for help with diagnosis and chemotherapy
Ensure regular neuro-vascular checks and close monitoring
Do not perform LP without input from neurology

Last update: 2022-06-25 02:05:01