Oncologic Emergencies:

Diagnosis and treatment

Mayo Clin Proc Jun 2006; 81(6): 835-848

R 劉志強
 Introduction
• Tumor lysis syndrome
• Superior vena cava syndrome
• Neutropenic fever
• Malignant pericardial effusion
• Hyperviscosity
• Hyperleukocytosis and leukostasis
• Brain metases and IICP
• Malignant spinal cord compression
 Tumor lysis syndrome
• Release of intracellular contents after
tumor cell death
• Nucleic acid products released result in
hyperuricemia, resulting in tubular flow
obstruction and ARF
• Release of intracellular potassium
resulting in hyperkalemia
• Increasing levels of phosphorus result in
hypocalemia
 Clinical presentation
• Symptoms and signs are usu. nonspecific
• Decreased urine ouput
• Symptoms of uremia or volume overload
• Seizures or arrhythmias
• Lab: elevated uric acid, phosphorus,
potassium, and lactate dehydrogenase
levels and a low calcium level
 Treatment
• Anticipate and prevent TLS
• Risk can be reduced by administering
allopurinol for 2~3 days before C/T
• P’ts at high risk: tumor with high
proliferative rate, high baseline uric acid,
large tumor burden, chemosensitive
disease may benefit with IV recombinant
urate oxidase (rasburicase)
 Superior vena cava syndrome
• Occlusion or compression of SVC,
restricting blood flow to the heart
• Malignancies are the most common
cause; lung cancer and lymphoma
• Intraluminal thrombus and indwelling
central venous catheters
 Clinical presentation
• Most common Sx: dyspnea, facial
swelling, and cough that may be
aggravated by bending forward
• Most common signs: distended neck and
chest wall veins, facial edema, and
plethora, and edema of upper extremities
 Treatment
• Stenting of SVC
• Radiotherapy is a standard tx modality for
sensitive tumors
• Chemotherapy and corticosteroids can
also be used
 Neutropenic fever
• Single oral temp. >38.3OC
• Sustained temp. >38OC for more than 1 hr
• ANC < 1000/uL as neutropenia
• ANC < 500/uL as severe neutropenia
• Neutrophil nadir typically occurs 5~10
days after the last C/T dose
• WBC recovery occurs within 5 days of the
nadir
 Clinical presentation
• Fever is commonly the only symptom
• Lung infections without pulmonary
infiltrates
• UTI without pyuria
• Meningitis without nuchal rigidity
• Skin infections may manifest as subtle
rash or erythema
Treatment
 Malignant pericardial effusion
• Commonly seen in advanced cancer and
frequently asymptomatic
• Poor prognosis, most p’ts die within 1 yr
• Result from metastases to the
pericardium, direct invasion of the cancer
 Clinical presentation
• Sx: dyspnea, cough, chest pain,
dysphagia, hiccups, and hoarseness
• Signs: tachycardia, distant heart sounds,
fixed jugular venous distension, upper and
lower extremity edema, and pulsus
paradoxus, cardiac tamponade
• EKG: low voltage, non-specific ST-T
changes
 Treatment
• Echocardiographically guided
pericardiocentesis
• Surgically: placing a percutaneous
pericardial drain or pericardium resection
• Systemic and intrapericardial C/T
• Radiation therapy
 Hyperviscosity
• Defined as an increased intrinsic
resistance of fluid to flow
• Seen in Waldenstrom macroglobulinemia
and acute leukemias
• Related to the high levels of large IgM
molecule (WM)
• IgA more prone than IgG due to the
tendency to polymerize
 Treatment
• Caution with RBC transfusion because
increased hematocrit greatly increase
plasma viscosity
• Plasmapheresis
• Control of the underlying disease with
glucocorticoids and C/T
 Hyperleukocytosis and leukostasis
• Well recognized complication associated
with acute leukemias
• Seen in up to 13% with AML
• Increased number of circulating
leukocytes was the major factor that
resulted in sluggish capillary blood flow
(leukostasis)
• Abnormal expression of adhesion
molecules
 Clinical presentation
• Pulmonary symptoms: dyspnea
• Fever is common but not related to
infection
• Thrombocytopenia and coagulopathy
 Treatment
• Leukapheresis
• Commonly begun when leukocyte count >
100000/uL
• Goal is to reduce to at least 50000/uL
• Leukapheresis may reduce early mortality
but improvement in overall survival is less
certain
• C/T: hydroxyurea 50~100mg/kg daily can
be used first
 Brain metases and IICP
• Intracranial metastases occur in up to ¼ of
patients dying of cancer
• Most common: lung ca, breast ca,
melanoma
• Metastases arise from hematogenous
spreading and 90% found in supratentorial
• Commonly located at the junction of gray
and white matter
• Brain edema and tumor expansion result
in IICP
 Clinical presentation
• Headaches (50%)
• Acute seizures
• Sx of IICP: nausea, vomiting, ocular
palsies, altered level of consciousness,
papilledema
• Cushing's triad involves an increased
systolic BP, a widened pulse pressure,
bradycardia, and an abnormal respiratory
pattern; Cheyne-Stokes respiration,
hyperventilation
Malignant spinal cord compression
• 2.5%~6% of p’ts have MSCC as a
complication
• Breast, lung, and prostate cancers
account for 2/3 of all cases
• The neurologic status at diagnosis and the
time to development of symptoms are
important prognostic factors
 Pathophysiology
• Develop from tumors metastatic to the
vertebral bodies
• Thoracic spine is the most common
location
• Cancers that occupy the paraspinous
space may enter the spinal canal through
the intervertebral foramen and cause cord
compression
 Clinical presentation
• 90% of p’ts have back pain
• Back pain in a p’t with a known cancer
should be considered secondary to MSCC
until proved otherwise
• Radicular pain, motor weakness, gait
disturbance and dysfunction of bladder
and bowel function
• MRI is the imaging study of choice
 Treatment
• Dexamethasone is most commonly used,
initial IV dose 10~16mg followed by 4mg
Q4H
• Radiation therapy has been the mainstay
tx (?)
• A recent study by Patchell et al showed
that is better in p’ts who undergo radical
tumor resection
• Indications for surgery continue to be
debated