Oncologic emergencies pediatric Resident



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ONCOLOGIC EMERGENCIES

  • Pediatric Resident

  • Education Series


ONCOLOGIC EMERGENCIES

  • MASS EFFECTS

  • HYPERVISCOSITY

  • METABOLIC

  • INFECTIONS



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%)



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



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)



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


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



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



TUMOR LYSIS SYNDROME: Rx

  • HYPERURICEMIA

    • Hydration
    • Allopurinol
    • Uric acid oxidase
    • Bicarbonate
  • High PO4, low Ca

    • Phosphate binder
    • Calcium gluconate


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



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


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



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


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



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