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Case 1 Objectives Oncologic Emergencies
Auburn University, US has reference to this Academic Journal, Oncologic EmergenciesAlex Raufi PGY2Updated: 5/2015ObjectivesIdentify key oncologic emergenciesReview initial management Know when so that consultIdentifying Oncologic EmergenciesTumor Lysis SyndromeHyperleukocytosis in addition to LeukostasisDisseminated Intravascular Coagulation (DIC)Spinal Cord CompressionBrain Metastases causing increased ICP*Superior Vena Cava (SVC) Syndrome NOT a true emergency!
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Case 1A 30 y/o male p/w 4 wk hx of rapidly enlarging cervical LAD & fevers x1 wkVitals: 39C, BP 95/60, HR 110, RR 24PE sig. in consideration of cervical in addition to axillary LAD as well as splenomegaly 137 | 103 | 6 / 112 6.6 | 27 | 3.8 6.6 / 55,000 – 90 / 20.1 LDH 12,000 mg/dLPhosphorus 9.9 mg/dLUrate 18.6 mg/dLCase 1Next step in management?Combination chemotherapyCorticosteroid therapyHemodialysis, IV NS, rasburicaseRadiation therapyTumor Lysis SyndromeEtiology: rapid cell turnover Most commonly ALL & Burkitt LymphomaSpontaneous or treatment inducedPathophysiology:? LDH
Tumor Lysis SyndromeInitial management:Frequent electrolyte monitoringInitial IVF rate: ~3L/m2/dayRasburicase (superior so that Allopurinol)Sodium bicarbonate Urine target pH of 7.0prevents urate deposition in renal tubulesDialysis for:Severe oliguriaPersistent hyperkalemiaHyperphosphatemia-induced symptomatic hypocalcemiaCase 1Next step in management?Combination chemotherapyCorticosteroid therapyHemodialysis, IV NS, rasburicaseRadiation therapyCase 1Next step in management?Combination chemotherapyCorticosteroid therapyHemodialysis, IV NS, rasburicaseRadiation therapy
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Hyperleukocytosis & LeukostasisEtiology:Commonly AML (large blasts)Presentation: Neuro: confusion, somnolence, CVAPulm: dyspnea, respiratory alkalosisCards: angina, rarely MIDx:WBC >100,000 + signs/sx from tissue hypoxiaHyperleukocytosis & LeukostasisInitial management: Cytoreduction viaChemotherapy = 1st lineIf symptomatic but must delay chemo:Leukapheresis + HydroxyureaIf NO symptoms but must delay chemo: Hydroxyurea20-40% of these patients die within 1st week of presentation!Disseminated Intravascular Coagulation (DIC)Etiology: Leukemia (acute promyelocytic leukemia [APL])Gram negative sepsisChemo: L- Asparaginase Pathophysiology: Excess thrombin generationConsumption of clotting factors & plateletsAccelerated fribinolysisPresentation:Thrombosis in addition to bleeding
Diagnosis+ schistocytes (30% of cases)? platelets? or decreasing fibrinogen? D-dimer (fibrin split products)?PT/PTTInitial management:Treat underlying causeAPL: All-trans retinoic acid (ATRA)If serious bleeding:FFPCryoprecipitate ? less volume than FFPPlatelets Disseminated Intravascular Coagulation (DIC)Case 264 y/o male p/w 3 mo hx of progressive back pain in addition to 2 wk hx of lower extremity weakness.Vitals: 37C, BP 110/71, HR 111, RR 18PE sig. in consideration of tenderness at T10-T11 vertebral bodies, lower extremity muscle strength 3+ bilaterally, & increased reflexes in both lower extremitiesCase 2Labs:Hg 6.5 g/dL, WBC 8500/uL, Ca 12 mg/dL, Total protein 13 g/dLMRI shows vertebral body mass alongside extension into epidural space (T12) alongside compression of spinal cord
Case 2Next step in management?Biopsy of epidural massCorticosteroids followed by radiation therapyLenalidomideRadiation therapySpinal Cord CompressionEtiology:BreastLungProstateMMLymphomaPresentation: Sudden weakness, heavinessIncontinence of bowelUrinary retentionDx:MRISpinal Cord CompressionInitial management:Dexamethasone 20mg IV then maintenanceRadiation therapySurgical decompressionRad/Onc or Neurosurgery should be consulted before heme-onc
Case 2Next step in management?Biopsy of epidural massCorticosteroids followed by radiation therapyLenalidomideRadiation therapyBrain Metastases causing increased Intracranial Pressure (ICP)Etiology:Melanoma, Breast, LungPresentation: Persistent HA, nausea/vomiting, AMSDx:CT/MRIInitial TreatmentDexamethasone 8-10mg IV q6 hrsMannitolWhole brain radiationRad/Onc or Neurosurgery should be consulted before heme-oncSuperior Vena Cava SyndromeEtiology:Lung (65% of cases)Diffuse Large B Cell LymphomaHodgkin DiseasePresentation Dyspnea Facial edema, cyanosis, plethoraCoughUpper extremity edema
Superior Vena Cava Syndrome Initial management:CXRTreatment directed towards underlying d/oBx is requiredNOT an oncologic emergencySummaryTumor Lysis SyndromeFluids, electrolyte monitoring, rasburicase, dialysisHyperleukocytosis in addition to Leukostasis1st Chemo, 2nd hydroxyurea + Leukapheresis if sxDisseminated Intravascular Coagulation (DIC) Treat underlying cause, FFP/cryo/plts in consideration of severe bleedingSpinal Cord CompressionBrain Metastases causing increased ICPBoth require steroids in addition to radiationSuperior Vena Cava (SVC) Syndrome NOT a true emergency! Biopsy so that determine therapyBibliography clevelandclinicmeded /medicalpubs/diseasemanagement/hematology-oncology/oncologic-emergencies/Default.htmMKSAP16 uptodate /
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