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
- K+ > 5.5: STAT EKG. Kayexalate 30g orally or 60g per rectum (unless
contraindicated) x1
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