Transcript ONCOLOGIC EMERGENCIES - Medical College of Wisconsin

ONCOLOGIC
EMERGENCIES
Pediatric Resident
Education Series
ONCOLOGIC EMERGENCIES
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MASS EFFECTS
HYPERVISCOSITY
METABOLIC
INFECTIONS
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CNS
CV
GI
GU
OCULAR
OTHER
MASS EMERGENCIES
SPINAL CORD
 SUPERIOR VENA CAVA/TRACHEA
 GENITOURINARY
 GASTROINTESTINAL
 CNS
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SPINAL CORD COMPRESSION
EWING SARCOMA
NEUROBLASTOMA
OSTEOSARCOMA
RHABDOMYOSARCOMA
SOFT TISSUE SARCOMA
GERM CELL TUMOR
HODGKIN DISEASE
HEPATOMA
WILMS TUMOR
OTHER
TOTAL
30/168
32/402
16/243
14/287
4/102
5/130
8/404
1/69
2/290
0/164
113/2259
KLEIN
(17.9%)
( 7.9%)
( 6.5%)
( 4.9%)
( 3.9%)
( 3.8%)
( 2.0%)
( 1.4%)
( 0.7%)
( 5.0%)
JNs 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
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SUPERIOR VENA CAVA SYNDROME
DISEASE
ALL
AML
HODGKIN
NHL
NBLASTOMA
GERM CELL
SARCOMAS
No.
1,464
392
333
330
332
114
696
MED. MASS
130
9
102
230
69
10
26
SVCS
6
0
2
8
3
2
3
INGRAM
MPO 18:476, 1990
SUPERIOR VENA CAVA SYNDROME
In a patient on treatment consider:
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relapse
effusion
infection
thrombosis (especially if a CVL is present)
SVC SYNDROME: SX, FINDINGS at DX
Cough/dyspnea
Dysphagia/orthopnea
Wheezing
Hoarseness
Facial edema
Chest pain
Pleural effusion
Pericardial effusion
11 (68)
10 (63)
5 (31)
3 (19)
2 (12)
1 ( 6)
8 (50)
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
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CONSULTS
 ENT/ANESTHESIA
 SURGERY
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TREATMENT
 O2,
IV ACCESS, IVF
 SURGERY
 IRRADIATION
 CHEMOTHERAPY
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CORTICOSTEROIDS
OTHER
DIAGNOSIS
•LOCAL ANESTHESIA
•ALTERNATE SITE
•DELAY OF 48 HOURS
DOES NOT USUALLY
PREVENT ACCURATE
DIAGNOSIS
HYPERVISCOSITY
COMPLICATION
METABOLIC
HYPERKALEMIA
LO CA, HIGH PO4
RENAL FAILURE
RESPIRATORY
HEMORRHAGE
CNS
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ALL (161)
22
16
15
5
0
4
2
AML (73)
4
2
3
4
6*
14*
9
p <.001
BUNIN
JCO 3:1590, 1985
HYPERVISCOSITY: treatment
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OXYGEN
HYDRATION
TRANSFUSIONS
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KEEP PLATELETS > 20,000/ul
AVOID PRBC UNLESS SYMPTOMATIC SINCE THEY
MAY INCREASE VISCOSITY
LOWER WBC
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EXCHANGE TFX = LEUKAPHERESIS
CHEMOTHERAPY
?IRRADIATION?
METABOLIC EMERGENCIES
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HYPERURICEMIA
HYPERKALEMIA
HYPERPHOSPHATEMIA
HYPOCALCEMIA
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HYPERCALCEMIA
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Due to rapid turnover of tumor cells (with or
without anti-tumor therapy)
Due to bone metastases, PTH-like peptide
production, PGE2 or calcitriol
METABOLIC EMERGENCIES:
hyperuricemia
hypoxanthine
xanthine oxidase
allopurinol
xanthine
xanthine oxidase
uric acid
uric acid oxidase
allantoin
allopurinol
TUMOR LYSIS SYNDROME: Rx
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HYPERURICEMIA
 Hydration
 Allopurinol
 Uric
acid oxidase
 Bicarbonate
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High PO4, low Ca
 Phosphate
binder
 Calcium gluconate
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HYPERKALEMIA
 Cardiac
monitor
 Kayexalate
 Insulin/glucose
 Bicarbonate
 Calcium gluconate
 Aminophylline
 dialysis
HYPERCALCEMIA: Dx, Rx
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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
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CNS EMERGENCIES: acute
alterations in consciousness
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Tumor
 Primary
 Metastatic
 Hyperleukocytosis
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Stroke
Seizure
Leukoencephalopathy
Post-XRT somnolence
Chemotherapy
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Drugs
Metabolic
Infection
Hypo/hypertension
Dehydration
Hypoxia
Liver failure
Depression
Chemotherapy causing acute
alterations in consciousness
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Corticosteroids:
mood swings, hallucinations, psychosis
Cytosine arabinoside:
cerebellar dysfunction, seizures, coma
Methotrexate: encephalopathy, seizures
Ifosfamide: somnolence
Retinoic acid: pseudotumor
CNS EMERGENCIES: seizures
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Tumor
 Primary
 Metastatic
 Hyperleukocytosis
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Stroke
Leukoencephalopathy
Chemotherapy
 Intrathecal
 Systemic
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Drugs
Metabolic
Infection
Hypertension
Hypoxia
GI EMERGENCIES
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OBSTRUCTION
 tumor
 vincristine,
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narcotics
HEMORRHAGE
INFECTION
 typhlitis
 perirectal
abscess
“treat the rectum with respect”
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PANCREATITIS
 corticosteroids,
 infection
asparaginase
GI EMERGENCIES: VOD
VENOCCLUSIVE DISEASE
ETIOLOGY: POST-TRANSPLANTATION
: DACTINOMYCIN
: THIOGUANINE
CLINICAL : WEIGHT GAIN
: HEPATOMEGALY
: HYPERBILIRUBINEMIA
GU EMERGENCIES: OLIGURIA
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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
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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
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CNS INFECTION
TUMORS
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CHEMOTHERAPY
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CNS
LYMPHOMA
DIAGNOSIS
URINE/SERUM
OSMOLALITY, Cr, LYTES
TREATMENT
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VINCRISTINE
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CYCLOPHOSPHAMIDE
IFOSFAMIDE
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IATROGENIC
FLUID RESTRICTION
NSS
SLOW CORRECTION OF
LOSSES (3% SALINE)
FUROSEMIDE
HYPERTENSION
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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
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RISK FACTORS
NEUTROPENIA (ANC or APC < 500/ul)
 IMMUNE SUPPRESSION
 FOREIGN BODIES
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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
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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
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INFECTIOUS EMERGENCIES
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Perirectal pain (treat the anus with respect)
 Look
 Palpate
 Test
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tube proctoscopy better than rectal exam
Fever, tachypnea, hypoxemia, clear lungs
 Sepsis
 Pneumocystis
carinii pneumonia
 Pulmonary embolism
SHOCK IN CHILDREN WITH CANCER
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HYPOVOLEMIC
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SEPSIS
HEMORRHAGE
MESIS
PANCREATITIS
ADDISONIAN
DIABETES
HYPERCALCEMIA
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DISTRIBUTIVE
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ANAPHYLAXIS
SEPSIS
VOD
SIADH
CARDIOGENIC
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INFECTION
METABOLIC
TAMPONADE
ANTHRACYCLINE
CYCLOPHOSPHAMIDE
IRRADIATION
OTHER EMERGENCIES:
RETINOIC ACID SYNDROME
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FEVER
RESPIRATORY DISTRESS
WEIGHT GAIN
PLEURAL/PERICARDIAL EFFUSIONS
HYPOTENSION
(USUALLY) RISING WBC DURING INDUCTION
TREATMENT: HOLD ATRA
: DEXAMETHASONE
: ?LOWER WBC?
OTHER EMERGENCIES
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INFILTRATION OF THE OPTIC NERVE
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can lead to rapid, permanent loss of vision
emergency irradiation +/- chemotherapy
SKIN EXTRAVASATION OF VESSICANTS
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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
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Bruce Camitta MD