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Oncologic Emergencies

Oncologic Emergencies. Shahina Qureshi State University of New York Downstate Medical Center. Oncologic Emergencies. Metabolic and Endocrine Tumor Lysis Syndrome, Hypercalcemia, SIADH Cardiothoracic Superior Vena Cava ,SMS, Pleural ,Pericardial Effusions, Pneumothorax, ATRA Abdominal

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Oncologic Emergencies

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  1. Oncologic Emergencies Shahina Qureshi State University of New York Downstate Medical Center

  2. Oncologic Emergencies • Metabolic and Endocrine • Tumor Lysis Syndrome, Hypercalcemia, SIADH • Cardiothoracic • Superior Vena Cava ,SMS, Pleural ,Pericardial Effusions, Pneumothorax, ATRA • Abdominal • GI, GU • Neurologic • Spinal Cord Compression, Seizures, CVA • Shock • DIC, Pancytopenia

  3. Tumor Lysis Syndrome • Potentially fatal metabolic complication due to rapid destruction of of tumor cells during or12-72 hrs after treatment. Leading to • Hyperuricemia [ uric acid > 15mg/dl ] • Hyperkalemia • Hyperphosphatemia [phos >8 mg/dl] • Hypocalemia • Renal Failure

  4. Tumor Lysis SyndromeRisk Factors • Elevated Leukocyte Count • High proliferation rate • Chemosensitivity • Large tumor burden • Elevated pretreatment uric acid and LDH levels [ Cohen et al Am j Med 1980] • Preexisting renal impairment, Dehydration

  5. Highest risk Moderate risk Low risk Lymphoblastic Lymphoma Burkitts Lymphoma ALL Low grade lymphom Breast cancer Small cell lung cancer Seminoma Medulloblastoma Adenocarcinoma of GI tract Lymphoma treated with interferon Tumor Lysis Syndrome

  6. Pathway of Uric acid production Purine catabolism Hypoxanthine Xanthine Uric acid Allantoin Xanthine oxidase Urate oxidase

  7. Tumor lysis syndromeManagement • Hydration • Alkalinization • Diuresis • Uric acid reduction • Metabolic abnormalities

  8. TLS Management • Hydration • 2-4 times maintainance fluid D5 I/4 NS+ 40 mEq/L NaHCO3 • Maintain urine output>100 ml/m2/hr • Urine Sp Gr<1.010

  9. TLS Management • Maintain Urine pH at 7.0- 7.5 • Diuresis with Furosemide [0.5 –1.0 mg/kg] ,Mannitol[ 0.5g/kg ] • Hyperkalemia • Na Polystyrene sulphonate1g/kg • Calcium gluconate 100-200mg/kg • Insulin0.1. Units/kg=25% Glucose 2ml/kg • Hyperphosphatemia • Aluminum hydroxide 15 ml q 4-8h • Hypocalcemia • Calcium Gluconate I.v only if symptomatic

  10. TLS Indications for Dialysis • Volume overload [Effusions] • Renal failure

  11. TLS Uric acid reduction • Allopurinol • Inhibits xanthine oxidase so decreases production of uric acid • Also inhibits p450 • Interferes with metabolism of 6-MP • Takes 24 hrs to reduce uric acid level • P.O.dose 10mg/kg/day two days before chemotherapy • I.V. form approved in 2001 for pts unable to tolerate p.o 40-150mg/m2 q 8 h

  12. TLS Uric acid reduction • Urate Oxidase • Non Recomboinant[uricozyme] developed in France in 1992 • Recombinant[rasburicase] developed in 1996 • Oxidizes Uric acid to allantoin which is 5-10 times more soluble, does not need urine alkalinization. • Generates H2O2,not used in G6PD- def pts • Well tolerated 1% hypersensitivity, 5% antibody formation • 90% reduction of plasma uric acid in 4 hrs • 0.45 risk of new renal complications

  13. I.V rasburicase Year of study 1999-2002 No of pts 778 Duration of Tr 3 d Tr success 98% Prophlaxis success 100% Comparison of IV Allopurinol and Rasburicase

  14. TLS Comparision of allopurinol and rasburicase

  15. Oncologic EmergenciesSuperior Vena Cava Syndrome • Due to invasion or compression of SVC by: • Malignancy in 78-85%,e.g lung cancer, lymphoma • Infection • Thrombosis

  16. Superior vena cavasyndromeSigns and Symptoms • Dyspnoea, cough 68% • Facial pain or swelling 12% • Wheezing 31% • Facial plethora • Venous distension in the neck and chest wall • Pleural effusion 50% • Pericardial effusion 19% Ingram, Med Ped Onc 1990;18:476

  17. Incidence of SVCSt.Judes Study 1973-1998

  18. Superior Vena cava SyndromeDiagnosis • Chest X-ray • Chest CT • Helical CT • MRI • Histologic Diagnosis , Sputum, Bone marrow, Bronchoscopy

  19. Superior vena cava syndromeTreatment • Radiotherapy • Emergency Chemotherapy • IV methyl prednisolone • Surgery

  20. Oncological Emergencies Spinal Cord compressionIncidence Kleinsl etal J. Neurosurg 1991;74:70

  21. Spinal Cord CompressionSigns and Symptoms • Back pain in 80% • Progressive Weakness • Sensory Abnormalities • Paresis • Paraplegia and Quadriplegia • Sphincter dysfunction

  22. Spinal Cord Compression Evaluation • MRI scans T1, T2 weighted • CT Myelography • CSF examination

  23. Spinal Cord CompressionTreatment • Dexamethasone IV 1.0-2.0mg/kg bolus • Local Radiotherapy • Surgical decompression • Chemotherapy if diagnosis is known

  24. Oncological EmergenciesHyperleukocytosis • WBC count >100,000 • ALL 9-13% • AML 5-22%

  25. HyperleukocytosisComplications Bunin NJ, Piu CH, J. Clin Oncol 1985;3:1590

  26. HyperleukocytosisSigns and Symptoms • Mental Status Changes, Headache, Blurred Visions, Seizures, Coma • Pulmonary Leukostasis, dyspnea, hypoxia, cyanosis, acidosis • Priapisim, dactylitis • Renal failure

  27. HyperleukocytosisTreatment • IV hydration • Maintain hemoglobin below 10g/dL • Exchange transfusion 52-66% reduction • Leukapharesis 48-62% reduction • Systemic chemotherapy • Cranial irradiation upto 400 cGy prevents CNS hemorrhage

  28. Oncological Emergencies • Anticipate • Prevent

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