1. Oncologic Emergencies
Alex Raufi PGY2
Updated: 5/2015

2. Objectives Identify key oncologic emergencies
Review initial management
Know when to consult

3. Identifying Oncologic Emergencies
Tumor Lysis Syndrome
Hyperleukocytosis and Leukostasis
Disseminated Intravascular Coagulation (DIC)
Spinal Cord Compression
Brain Metastases causing increased ICP
*Superior Vena Cava (SVC) Syndrome
NOT a true emergency!
NOTE: SVC syndrome NOT true emergency and is the only one of these scenarios that does NOT require an urgent heme-onc consult

4. Case 1
A 30 y/o male p/w 4 wk hx of rapidly enlarging cervical LAD & fevers x1 wk
Vitals: 39C, BP 95/60, HR 110, RR 24
PE sig. for cervical and axillary LAD as well as splenomegaly
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55,
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LDH 12,000 mg/dL
Phosphorus 9.9 mg/dL
Urate 18.6 mg/dL

5. Case 1 Next step in management? Combination chemotherapy
Corticosteroid therapy
Hemodialysis, IV NS, rasburicase
Radiation therapy
To answer this question one must first recognize that the patient is presenting with Tumor Lysis Syndrome.

6. Tumor Lysis Syndrome Etiology: rapid cell turnover Pathophysiology:
Most commonly ALL & Burkitt Lymphoma
Spontaneous or treatment induced
Pathophysiology:
Tumor cell death
↑ PO42-
↓ Ca2+
↑ K+
↑ Urate
↑ Lactate
↑ LDH

7. Tumor Lysis Syndrome Initial management:
Frequent electrolyte monitoring
Initial IVF rate: ~3L/m2/day
Rasburicase (superior to Allopurinol)
Sodium bicarbonate
Urine target pH of 7.0
prevents urate deposition in renal tubules
Dialysis for:
Severe oliguria
Persistent hyperkalemia
Hyperphosphatemia-induced symptomatic hypocalcemia
Rasburicase will require heme-onc fellow approval by pharmacy

8. Case 1 Next step in management? Combination chemotherapy
Corticosteroid therapy
Hemodialysis, IV NS, rasburicase
Radiation therapy
To answer this question one must first recognize that the patient is presenting with Tumor Lysis Syndrome.

9. Case 1 Next step in management? Combination chemotherapy
Corticosteroid therapy
Hemodialysis, IV NS, rasburicase
Radiation therapy
Treatment for TLS, as we will discuss shortly, includes Hemodialysis, IV NS, rasburicase, hence answer C is correct.

10. Hyperleukocytosis & Leukostasis
Etiology:
Commonly AML (large blasts)
Presentation:
Neuro: confusion, somnolence, CVA
Pulm: dyspnea, respiratory alkalosis
Cards: angina, rarely MI
Dx:
WBC >100,000 + signs/sx from tissue hypoxia
Lower level of suspicion for hyperleukocytosis/stasis if WBC<100,000 as it is very rare

11. Hyperleukocytosis & Leukostasis
Initial management: Cytoreduction via
Chemotherapy = 1st line
If symptomatic but must delay chemo:
Leukapheresis + Hydroxyurea
If NO symptoms but must delay chemo:
Hydroxyurea
20-40% of these patients die within 1st week of presentation!
Of note Chemotherapy is only treatment proven to improve survival

12. Disseminated Intravascular Coagulation (DIC)
Etiology:
Leukemia (acute promyelocytic leukemia [APL])
Gram negative sepsis
Chemo: L- Asparaginase
Pathophysiology:
Excess thrombin generation
Consumption of clotting factors & platelets
Accelerated fribinolysis
Presentation:
Thrombosis and bleeding

13. Disseminated Intravascular Coagulation (DIC)
Diagnosis
+ schistocytes (30% of cases)
↓ platelets
↓ or decreasing fibrinogen
↑ D-dimer (fibrin split products)
↑PT/PTT
Initial management:
Treat underlying cause
APL: All-trans retinoic acid (ATRA)
If serious bleeding:
FFP
Cryoprecipitate – less volume than FFP
Platelets
Consulting heme-onc depends on severity and cause

14. Case 2
64 y/o male p/w 3 mo hx of progressive back pain and 2 wk hx of lower extremity weakness.
Vitals: 37C, BP 110/71, HR 111, RR 18
PE sig. for tenderness at T10-T11 vertebral bodies, lower extremity muscle strength 3+ bilaterally, & increased reflexes in both lower extremities

15. Case 2
Labs:
Hg 6.5 g/dL, WBC 8500/uL, Ca 12 mg/dL, Total protein 13 g/dL
MRI shows vertebral body mass with extension into epidural space (T12) with compression of spinal cord

16. Case 2 Next step in management? Biopsy of epidural mass
Corticosteroids followed by radiation therapy
Lenalidomide
Radiation therapy

17. Spinal Cord Compression
Etiology:
Breast
Lung
Prostate MM
Lymphoma
Presentation:
Sudden weakness, heaviness
Incontinence of bowel
Urinary retention
Dx:
MRI

18. Spinal Cord Compression
Initial management:
Dexamethasone 20mg IV then maintenance
Radiation therapy
Surgical decompression
Rad/Onc or Neurosurgery should be consulted before heme-onc

19. Case 2 Next step in management? Biopsy of epidural mass
Corticosteroids followed by radiation therapy
Lenalidomide
Radiation therapy
Clearly this is cord compression but what one must keep in mind is that radiation therapy alone would not address the swelling associated with spinal cord compression. Steroids also have the added benefit of directly treating the hypercalcaemia in this case of MM (bx results not shown) with invasion into the cord

20. Brain Metastases causing increased Intracranial Pressure (ICP)
Etiology:
Melanoma, Breast, Lung
Presentation:
Persistent HA, nausea/vomiting, AMS
Dx:
CT/MRI
Initial Treatment
Dexamethasone 8-10mg IV q6 hrs
Mannitol
Whole brain radiation
Rad/Onc or Neurosurgery should be consulted before heme-onc

21. Superior Vena Cava Syndrome
Etiology:
Lung (65% of cases)
Diffuse Large B Cell Lymphoma
Hodgkin Disease
Presentation
Dyspnea
Facial edema, cyanosis, plethora
Cough
Upper extremity edema

22. Superior Vena Cava Syndrome
Initial management:
CXR
Treatment directed towards underlying d/o
Bx is required
NOT an oncologic emergency

23. Summary Tumor Lysis Syndrome Hyperleukocytosis and Leukostasis
Fluids, electrolyte monitoring, rasburicase, dialysis
Hyperleukocytosis and Leukostasis
1st Chemo, 2nd hydroxyurea + Leukapheresis if sx
Disseminated Intravascular Coagulation (DIC)
Treat underlying cause, FFP/cryo/plts for severe bleeding
Spinal Cord Compression
Brain Metastases causing increased ICP
Both require steroids and radiation
Superior Vena Cava (SVC) Syndrome
NOT a true emergency! Biopsy to determine therapy

24. Bibliography
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