Oncologic Emergencies

Oncologic Emergencies – Madeleine Turcotte

Leukostasis

Presentation

  • Respiratory: dyspnea, hypoxia (note CXR may be normal)
    • PaO2 by ABG often falsely low dt 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

 

Management

  • Page hematology fellow for guidance if you feel this dx is likely
  • Hydrea (discuss with fellow) Hydrea 50 – 100 mg/kg/day divided between bid dosing
  • Emergent cytoreduction
    • Leukapheresis: page nephrology and place dialysis catheter
  • Chemotherapy per hematology fellow
  • Transfer/admit to ICU

 

 

Tumor Lysis Syndrome - Bradley Christensen

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 Ca2+ and leads to CaP crystal deposition-> AKI, HypoCa
    • Hyperuricemia (from breakdown of DNA)->precipitation in renal tubules->AKI
    • Hypotension, AKI from cytokine release
  • Laboratory TLS (at least two within 2d before or 7d after start of chemotherapy):
    • Uric acid ≥ 8 mg/dL, Ca2+ ≤ 7 mg, K+ ≥ 6 mEq/L, or PO43- ≥ 4.5 mg/dL /dL 
    • OR > 25% change from baseline in these values
  • Clinical TLS: laboratory TLS + AKI, arrhythmia, seizure, tetany, death

 

Evaluation

  • Risk Stratification:
    • Highest risk after tarting 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:  q8h 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
  • Consequence of WBC’s plugging up microvasculature
  • Most common in AML with hyperleukocytosis (defined as WBC > 100K/ µL)
  • If cell not sticky (CLL) generally not going to cause despite high WBC count.

 

 

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, which may indicate cerebral edema
  • 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

  • AFP, β-hCG if no tissue Dx
  • 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 (risks vs benefits patient dependent)
  • 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
  • Impingement causes pain and can lead to neurologic dysfunction

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, MRI without and with contrast best for diagnosis; 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.
  • Early PT if LE weakness

 

 

Brain Metastases

Background

  • Common Malignancies: Lung (NSCLC), breast, kidney, colorectal carcinomas & melanomas
  • Significantly more common than primary brain tumors
  • Occur in 10 - 30% of adults w/systemic malignancies
  • 80% of brain mets occur in the cerebrum at grey/white matter junction

 

Presentation

  • Highly variable: so consider brain mets 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 contras: most sensitive, can differentiate b/w 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