ONCOLOGIC EMERGENCIES Pediatric Resident Education Series

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

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

SPINAL CORD COMPRESSION EWING SARCOMA30/168(17.9%) NEUROBLASTOMA32/402( 7.9%) OSTEOSARCOMA16/243( 6.5%) RHABDOMYOSARCOMA14/287( 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%) KLEINJNs 74:70, 1991

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

SUPERIOR VENA CAVA SYNDROME DISEASENo. MED. MASS SVCS ALL 1, AML HODGKIN NHL NBLASTOMA GERM CELL SARCOMAS INGRAM MPO 18:476, 1990

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

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

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.

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

HYPERVISCOSITY COMPLICATION ALL (161)AML (73) METABOLIC 22 4 HYPERKALEMIA 16 2 LO CA, HIGH PO RENAL FAILURE 5 4 RESPIRATORY 0 6 * HEMORRHAGE 4 14 * CNS 2 9 * p <.001 BUNIN JCO 3:1590, 1985

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?

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, PGE 2 or calcitriol

METABOLIC EMERGENCIES: hyperuricemia hypoxanthine xanthine oxidase allopurinol xanthine xanthine oxidase allopurinol uric acid uric acid oxidase allantoin

TUMOR LYSIS SYNDROME: Rx HYPERURICEMIA  Hydration  Allopurinol  Uric acid oxidase  Bicarbonate High PO 4, low Ca  Phosphate binder  Calcium gluconate HYPERKALEMIA  Cardiac monitor  Kayexalate  Insulin/glucose  Bicarbonate  Calcium gluconate  Aminophylline  dialysis

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

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

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

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

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

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

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

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

GU EMERGENCIES: SIADH 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

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

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

INFECTIOUS EMERGENCIES If a central access line is present, cultures through each line 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

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

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

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?

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

Credits Bruce Camitta MD