Oncologic Emergencies
Alex Raufi PGY2
Updated: 5/2015
Objectives

Identify key oncologic emergencies

Review initial management

Know when to consult
Identifying Oncologic Emergencies
Tumor Lysis Syndrome
2. Hyperleukocytosis and Leukostasis
3. Disseminated Intravascular Coagulation (DIC)
4. Spinal Cord Compression
5. Brain Metastases causing increased ICP
1.
*Superior Vena Cava (SVC) Syndrome
◦
NOT a true emergency!
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

137
| 103
| 6
/
LDH 12,000 mg/dL
------------------------------ 112
Phosphorus 9.9 mg/dL
6.6
Urate 18.6 mg/dL
| 27
| 3.8
\ 6.6 /
55,000 --------- 90
/ 20.1 \
\
Case 1

Next step in management?
a)
b)
c)
d)
Combination chemotherapy
Corticosteroid therapy
Hemodialysis, IV NS, rasburicase
Radiation therapy
Tumor Lysis Syndrome

Etiology: rapid cell turnover
◦ Most commonly ALL & Burkitt Lymphoma
◦ Spontaneous or treatment induced

Pathophysiology:
Tumor cell
death
↑ PO42-
↑ K+
↑ Lactate
↑
LDH
↑ Urate
↓ Ca2+
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
Case 1

Next step in management?
a)
b)
c)
d)
Combination chemotherapy
Corticosteroid therapy
Hemodialysis, IV NS, rasburicase
Radiation therapy
Case 1

Next step in management?
a)
b)
c)
d)
Combination chemotherapy
Corticosteroid therapy
Hemodialysis, IV NS, rasburicase
Radiation therapy
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
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!
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
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
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

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
Case 2

Next step in management?
a)
b)
c)
d)
Biopsy of epidural mass
Corticosteroids followed by radiation therapy
Lenalidomide
Radiation therapy
Spinal Cord Compression

Etiology:
◦
◦
◦
◦
◦

Breast
Lung
Prostate
MM
Lymphoma
Presentation:
◦ Sudden weakness, heaviness
◦ Incontinence of bowel
◦ Urinary retention

Dx:
◦ MRI
Spinal Cord Compression

Initial management:
◦ Dexamethasone 20mg IV then maintenance
◦ Radiation therapy
◦ Surgical decompression

Rad/Onc or Neurosurgery should be
consulted before heme-onc
Case 2

Next step in management?
a) Biopsy of epidural mass
b) Corticosteroids followed by radiation
therapy
c) Lenalidomide
d) Radiation therapy
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
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
Superior Vena Cava Syndrome

Initial management:
◦ CXR
◦ Treatment directed towards underlying d/o
 Bx is required

NOT an oncologic emergency
Summary
Tumor Lysis Syndrome
1.
◦
Fluids, electrolyte monitoring, rasburicase, dialysis
Hyperleukocytosis and Leukostasis
2.
◦
1st Chemo, 2nd hydroxyurea + Leukapheresis if sx
Disseminated Intravascular Coagulation (DIC)
3.
◦
Treat underlying cause, FFP/cryo/plts for severe bleeding
Spinal Cord Compression
Brain Metastases causing increased ICP
4.
5.
◦
Both require steroids and radiation
Superior Vena Cava (SVC) Syndrome
6.
◦
NOT a true emergency! Biopsy to determine therapy
Bibliography
http://www.clevelandclinicmeded.com/me
dicalpubs/diseasemanagement/hematology
-oncology/oncologicemergencies/Default.htm
 MKSAP16
 http://www.uptodate.com/
