SAPA WEBINAR SERIES Oncological Emergencies - PowerPoint Presentation

1. SAPA WEBINAR SERIESOncological EmergenciesEarly Recognition and TreatmentDr Helder De QuintalPaediatric Haematology/Oncology​Red Cross War Memorial Children’s Hospital &​The University of Cape Town

2. IntroductionAcute condition brought on by cancer or its treatment requires rapid intervention to avoid death or severe, permanent damage and to improve clinical outcomes

3. ClassificationMetabolicTumour Lysis syndromeHaematologicalFebrile NeutropaeniaHyperleukocytosis and Hyperviscosity syndromeStructural/Mass-effectSuperior vena cava syndrome and Superior mediastinal syndromeSpinal cord compressionRaised intracranial pressure

4. MetabolicTumour Lysis Syndrome:Life-threatening oncological emergencyRapid lysis of tumour cells and abrupt release of intracellular content into the circulationResults in life-threatening metabolic derangementsCan occur spontaneously or at the time of chemotherapy commencementCommonly occurs in Non-Hodgkin lymphoma, acute leukaemias and other bulky, solid tumours that are very chemo sensitiveHighest risk within 12-72 hours after initiation of chemotherapyMost common clinical manifestations: tetany, paraesthesia, seizures, cardiac dysrhythmias and sudden death

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6. Pathophysiology of Tumour Lysis

7. Management of Tumour Lysis SyndromeAnticipate TLSIdentify patients at high-risk of TLS:High white cell countRaised LDHBulky diseaseChemo sensitive tumours

8. Prevention and Treatment of Tumour LysisHydration at 3L/m2 per day (potassium-free)Allopurinol for medium risk patientsRasburicase for high risk patientsUrine output 2-3ml/kg/hourSix-hourly monitoring of serum electrolytesCorrecting electrolyte derangementsDialysis for life-threatening and refractory electrolyte derangements, AKI and/or fluid overload

9. HaematologicalFebrile Neutropaenia:Common in oncological patients – 80% of haematological malignancies develop FN at least onceMedical emergency‘Golden Hour’Temperature ≥38°c and ANC <500 cells/µL or <1000 cells/µL and expected to fall within 48 hoursFN septic shock death

10. Management of FNFollow standard A, B, CPrompt IV accessOxygen deliveryFluid resuscitationObtain blood cultureDeliver first dose of broad-spectrum antibioticsConsider other cultures where appropriate (e.g., urine, sputum, CSF)Chest x-ray, if indicatedTransfusion of blood products, if required

11. Hyperleukocytosis/Hyperviscosity SyndromeWBC of >100x109 cells/LCommon in haematological malignancies (ALL, AML, CML)Medical emergency, if left untreated may result in leukostasis leading to multi-organ failure, haemorrhagic complications and possible deathPathogenesis:Leukaemic blasts are less deformableCausing sludging and thrombi formation in the microcirculationOrgan hypo-perfusionMay present concomitantly with TLS

12. Symptoms of Hyperleukocytosis and LeukostasisOrgan SystemSigns and SymptomsNeurologicAltered level of consciousness, headache, seizures, confusion, stroke and/or intracranial haemorrhageRespiratoryARDS, dyspnoea, tachypnoea, hypoxia and/or respiratory failureCardiacPulmonary oedema and/or myocardial infarctionGenitourinaryPriapism and/or acute renal failureOcularBlurred vision, diplopia, central retinal vein occlusion and/or retinal detachment

13. Management of hyperleukocytosis and leukostasisHyper-hydration 3L/m2 per dayMonitoring of urine output and maintaining euvolemic stateAvoiding unnecessary blood transfusionsPlatelet transfusions to maintain platelet count above 50 to prevent bleeding and CNS complicationsCommence chemotherapyPrevent tumour lysis syndrome and correcting electrolyte derangementsLeukapheresis and exchange transfusions may be considered

14. Structural / Mass-effectsSuperior vena cava syndrome and Superior mediastinal syndromeSVC syndrome:External compression by mass or lymph nodes or internal occlusion of SVC by tumour or thrombusImplantable intravenous devices increase risk of thrombosis of SVCSuperior mediastinal syndrome:Mediastinal mass compresses trachea or mainstem bronchi leading to airway compromise

15. Mediastinal massesAnterior Mediastinum:Hodgkin lymphomaT-cell lymphoma/leukaemiaB-cell lymphomaGerm-cell tumourThymomaPosterior Mediastinum:Neuroblastoma

16. Clinical presentationSVC Syndrome:Facial swellingProminent superficial chest veinsPlethoraHeadachesAltered mental stateVisual disturbancesSuperior Mediastinal Syndrome:DyspnoeaRespiratory distressStridorCoughCyanosisOrthopnoea (ominous)

17. DiagnosisChest x-rayCT scan (avoid sedation and supine position)FBC + blood film, tumour markers (LDH, AFP, BHCG)Peripheral blood and/or pleural fluid immunophenotypingBone marrow aspiration or lymph node biopsy under local anaestheticMediastinal biopsy

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19. ManagementAvoid painful proceduresPosition of comfortA, B, CDelivery of oxygenIV access and IV fluidsAvoid sedationCommencement of steroids and appropriate chemotherapyRadiotherapyThrombus related SVC obstruction:Removal of intravascular device, commencement of anti-coagulationVascular stenting or surgical intervention

20. Spinal cord compressionSCC is a medical emergencyPermanent neurological impairment if treatment delayedReported in 5% of solid tumours in childhoodCan be presenting symptom of malignancy, as a result of late metastasis, or can be an isolated recurrenceMost are extraduralTumours:NeuroblastomaEwing sarcoma / OsteosarcomaLymphomasRhabdomyosarcomaLGG/ependymoma

21. Symptoms of SCCMost common presenting symptom is back pain (ominous sign)Gait abnormalityMotor and sensory deficitsFaecal and urinary incontinence

22. Diagnosis of SCCFormal neurological examMRI is preferred modalitySpinal x-rays are abnormal only in 30-35% of cases

23. Management of SCCTreatment of evolving neurological symptoms must be immediateAdministration of IV dexamethasoneAppropriate chemotherapyMulti-disciplinary approach (oncologist, neurosurgeon, radiotherapist)Laminectomy and spinal cord decompression and debulking of tumour (tissue biopsy for expedited diagnosis)Radiotherapy for radiosensitive tumours

24. Raised intracranial pressureUntreated can cause cerebral herniation rapidly leading to severe neurological disability and deathCauses are intracranial mass or an obstruction to CSF outflowSymptoms:HeadacheVomitingAltered level of consciousnessAtaxiaDiplopia (CN 6 palsy)SeizuresCushing reflex (bradycardia, hypertension and Cheyn-Stokes) – this is a late and ominous signDiagnosisCT headMRI brain

25. Diagnosis

26. Management of Raised ICPA, B, CIV dexamethasoneIV Mannitol / 3% Hypertonic salineNeuroprotective measures (head and midline, treatment of pyrexia, pain and seizures)Urgent neurosurgical intervention:EVD, ETV or VP shuntTumour resection or biopsyChemotherapyRadiotherapy

27. ConclusionOncological emergencies are associated with significant morbidity and mortalityEarly recognition and prompt treatment can reduce potential complications and improve clinical outcomeA multi-disciplinary approach is essentialInvolve your friendly paediatric oncologist early

28. References:Prusakowski, M., Cannone, D., Paediatric oncologic emergencies. Emergency Medicine Clinics of North America, Vol 32, Iss 3, Aug 2014.Leung, KKY., et al. Review: Therapeutics for paediatric oncological emergencies. Drugs in Context. 2021; 10-11-5.Spring, J., Munshi, L., Oncologic emergencies: traditional and contemporary. Crit Care Clin 37 (2021) 85-103.Oben, P. Fein, V., Comprehensive review of oncological emergencies seen in clinical practice. Medical Studies/Studia Medyczne 2019, 35/1.Higdon, ML. et al Oncologic emergencies: recognition and initial management. American Family Physician. Vol 97, Num 11, June 1, 2018.