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872 PART 7: Hematologic and Oncologic Disorders

Management of hyperleukocytosis is directed with the goal of prevent- • Vardiman JW, Harris NL, Brunning RD. The World Health
ing end-organ damage from leukostasis. Treatment includes vigorous Organization (WHO) classification of the myeloid neoplasms.
hydration and acute cytoreduction by leukapheresis, hydroxyurea (up Blood. 2002;100:2292.
to 2 g orally every 6 hours), and initiation of induction chemotherapy.
Leukapheresis can decrease WBC by 50% within 2 to 3 hours with a • Wandt H, Schaefer-Eckart K, Wendelin K, et al. Therapeutic plate-
single apheresis session. Elevated WBC and CNS or pulmonary mani- let transfusion versus routine prophylactic transfusion in patients
festations, or underlying renal dysfunction and high risk of TLS with with haematological malignancies: an open-label, multicentre,
induction chemotherapy should prompt consideration of leukapheresis. randomised study. Lancet. 2012;380(9850):1309-1316.
For CNS leukostasis, cranial irradiation may be indicated.
Leukapheresis is typically performed via a central venous catheter,
although it can be performed using a peripheral line. The procedure is REFERENCES
generally well tolerated, but carries risks common to any procedure per- Complete references available online at www.mhprofessional.com/hall
formed via central venous access, including bleeding and infection. Risk
of bleeding is significant, as patients requiring leukapheresis are usually
severely coagulopathic. Attempts to normalize coagulopathy should be
made prior to placement of the central venous catheter with infusion CHAPTER Oncologic Emergencies
of FFP and cryoprecipitate as indicated by coagulation parameters (see
previously discussed in “Disseminated Intravascular Coagulation”). It 93 Cristina Gutierrez
is worth noting that patients can become hypocalcemic as a result of Stephen M. Pastores
the use of citrated blood products. Leukapheresis can be performed
7
in patients with elevated WBC from AML or ALL. It is worth noting
that the National Comprehensive Cancer Network (NCCN) guidelines
do not recommend leukapheresis for hyperleukocytosis from APL KEY POINTS
(WBC >10,000/µL) unless other methods of cytoreduction have been
exhausted. This is in part a function of the fundamental difference in • Respiratory, neurologic, metabolic, thoracic, and cardiac emer-
1
leukemia pathophysiology, and also related to the high risk of central gencies constitute life-threatening complications in patients with
venous catheter placement resulting from the profound coagulopathy malignancies. These oncologic emergencies often result from the
that accompanies APL. 1,56 cancer itself and/or from treatment of the cancer.
Objective measurements of benefit to overall survival with leukapher- • Increased activation of the coagulation system, administration of
esis have been limited. Retrospective studies have shown a significantly thrombogenic chemotherapy regimens, and placement of intra-
lower risk for early death (first 2-3 weeks of treatment) but have failed to vascular venous catheters place cancer patients at higher risk for
show overall survival benefit, presumably because acute leukemias that pulmonary embolism and hemodynamic instability.
present with hyperleukocytosis carry a poor prognosis. 7,22,41,53 However, • Neurologic emergencies in cancer patients include status epilepticus,
due to the acuity of patients with hyperleukocytosis and the efficacy of malignant spinal cord compression, and intracranial hemorrhage.
leukapheresis in lowering the WBC count, it is still recommended in
conjunction with pharmacologic acute cytoreduction. • Radiation therapy and corticosteroids are the mainstays of treat-
ment of malignant spinal cord compression.
• Malignancy-associated hypercalcemia (MAH) can be divided
KEY REFERENCES into humoral, osteolytic, and calcitriol-associated hypercalcemia.
Bisphosphonates are the most efficient and recommended treat-
• Blum W, Porcu P. Therapeutic apheresis in hyperleukocytosis and ment for MAH.
hyperviscosity syndrome. Semin Thromb Hemost. 2007;33:350. • Tumor lysis syndrome is associated with hyperuricemia, hyper-
• Carlson KS, DeSancho MT. Hematological issues in critically ill phosphatemia, hypocalcemia, and hyperkalemia, which if left
patients with cancer. Crit Care Clin. 2010;26:107. untreated can lead to arrhythmias and death. Treatment includes
• Cornely OA, Maertens J, Winston DJ, et al. Posaconazole vs. aggressive hydration, specific treatment of individual metabolic
fluconazole or itraconazole prophylaxis in patients with neutrope- derangements, allopurinol or rasburicase, and hemodialysis for
nia. N Engl J Med. 2007;356:348. severe hyperphosphatemia and symptomatic hypocalcemia.
• Freifeld AG, Bow EJ, Sepkowitz KA, et al. Clinical practice guide- • Leukapheresis is usually initiated for the treatment of leukostasis
line for the use of antimicrobial agents in neutropenic patients associated with acute myelogenous leukemia if the WBC count
3
with cancer: 2010 update by the infectious diseases society of >50,000/mm and in acute lymphoblastic leukemia if the WBC
america. Clin Infect Dis. 2011;52:e56. count is >250,000/mm . 3
• Green D. Management of bleeding complications of hematologic • Ninety percent of malignant causes of superior vena cava syn-
malignancies. Semin Thromb Hemost. 2007;33:427. drome (SCVS) are due to lung cancer and lymphoma. Patients
• Levi M, Toh CH, Thachil J, et al. Guidelines for the diagnosis presenting with cerebral edema and airway compromise due to
SVCS should be treated urgently and considered for SVC stenting.
and management of disseminated intravascular coagulation.
British Committee for Standards in Haematology. Br J Haematol. • Treatment for cardiac tamponade requires emergent drainage by
2009;145:24. either pericardiocentesis or pericardial window.
• Mughal TI, Ejaz AA, Foringer JR, et al. An integrated clinical
approach for the identification, prevention, and treatment of
tumor lysis syndrome. Cancer Treat Rev. 2010;36:164. INTRODUCTION
• Roze des Ordons AL, Chan K, Mirza I, et al. Clinical characteris-
tics and outcomes of patients with acute myelogenous leukemia Significant advances in cancer care and preventive strategies have
admitted to intensive care: a case-control study. BMC Cancer. decreased the incidence of the classic oncologic emergencies (eg,
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