ONCOLOGIC

EMERGENCIES

Pediatric Resident
Education Series
ONCOLOGIC EMERGENCIES

 MASS EFFECTS  CNS

 HYPERVISCOSITY  CV
 METABOLIC  GI
 INFECTIONS  GU
 OCULAR
 OTHER
MASS EMERGENCIES

 SPINAL CORD
 SUPERIOR VENA CAVA/TRACHEA
 GENITOURINARY
 GASTROINTESTINAL
 CNS
SPINAL CORD COMPRESSION
EWING SARCOMA 30/168 (17.9%)
NEUROBLASTOMA 32/402 ( 7.9%)
OSTEOSARCOMA 16/243 ( 6.5%)
RHABDOMYOSARCOMA 14/287 ( 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%)

KLEIN 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
SUPERIOR VENA CAVA SYNDROME
DISEASE No. MED. MASS SVCS
ALL 1,464 130 6
AML 392 9 0
HODGKIN 333 102 2
NHL 330 230 8
NBLASTOMA 332 69 3
GERM CELL 114 10 2
SARCOMAS 696 26 3

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
DIAGNOSIS
 SURGERY

 TREATMENT •LOCAL ANESTHESIA

 O2, IV ACCESS, IVF •ALTERNATE SITE
•DELAY OF 48 HOURS
 SURGERY
DOES NOT USUALLY
 IRRADIATION PREVENT ACCURATE
 CHEMOTHERAPY DIAGNOSIS
 CORTICOSTEROIDS
 OTHER
HYPERVISCOSITY

COMPLICATION ALL (161) AML (73)

METABOLIC 22 4
HYPERKALEMIA 16 2
LO CA, HIGH PO4 15 3
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, PGE2 or calcitriol
METABOLIC EMERGENCIES:
hyperuricemia

hypoxanthine
xanthine oxidase allopurinol
xanthine
xanthine oxidase allopurinol
uric acid
uric acid oxidase
allantoin
TUMOR LYSIS SYNDROME: Rx

 HYPERURICEMIA  HYPERKALEMIA
 Hydration  Cardiac monitor
 Allopurinol  Kayexalate
 Uric acid oxidase  Insulin/glucose
 Bicarbonate  Bicarbonate

 High PO4, low Ca  Calcium gluconate

 Phosphate binder  Aminophylline

 Calcium gluconate  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  Drugs
 Primary  Metabolic
 Metastatic  Infection
 Hyperleukocytosis
 Hypo/hypertension
 Stroke
 Dehydration
 Seizure
 Hypoxia
 Leukoencephalopathy
 Liver failure
 Post-XRT somnolence
 Depression
 Chemotherapy
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  Drugs
 Primary  Metabolic
 Metastatic  Infection
 Hyperleukocytosis
 Hypertension
 Stroke
 Hypoxia
 Leukoencephalopathy
 Chemotherapy
 Intrathecal
 Systemic
GI EMERGENCIES
 OBSTRUCTION
 tumor
 vincristine, narcotics
 HEMORRHAGE
 INFECTION
 typhlitis
 perirectalabscess
“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 DIAGNOSIS
 CNS INFECTION URINE/SERUM
 TUMORS OSMOLALITY, Cr, LYTES
 CNS TREATMENT
 LYMPHOMA  FLUID RESTRICTION
 CHEMOTHERAPY  NSS
 VINCRISTINE  SLOW CORRECTION OF
 CYCLOPHOSPHAMIDE LOSSES (3% SALINE)
 IFOSFAMIDE  FUROSEMIDE
 IATROGENIC
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
 Pneumocystiscarinii pneumonia
 Pulmonary embolism
SHOCK IN CHILDREN WITH CANCER
 HYPOVOLEMIC  DISTRIBUTIVE
 SEPSIS  ANAPHYLAXIS
 HEMORRHAGE  SEPSIS
 MESIS  VOD
 PANCREATITIS  SIADH
 ADDISONIAN  CARDIOGENIC
 DIABETES  INFECTION
 HYPERCALCEMIA  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