Early recognition, prevention, and treatment of oncological emergencies improves clinical outcomes. Both at initial presentation and during treatment, pediatric cancer patients can develop acute, severe, and life-threatening conditions (Table 133-1). This chapter reviews the presentation and management of the most commonly encountered emergent conditions seen in pediatric cancer patients. The pediatric hospitalist should be able to identify at-risk patients, adopt preventive strategies, recognize clinical deterioration, and initiate prompt treatment of these emergencies.
TABLE 133-1Pediatric Oncologic Emergencies ||Download (.pdf) TABLE 133-1 Pediatric Oncologic Emergencies
| Tumor lysis syndrome
| Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
| Hyperleukocytosis, leukostasis
| Hemorrhage and DIC
|Infectious and inflammatory emergencies
| Febrile neutropenia
| Septicemia, shock
| Neutropenic enterocolitis
| Superior vena cava syndrome, superior mediastinal syndrome
| Pleural and pericardial effusions
| Cardiac tamponade
| Spinal cord compression
| Increased intracranial pressure
| Altered mental status
| Malignant hypertension
When a new diagnosis of cancer or an oncologic emergency is suspected, a pediatric oncologist should be consulted to aid in the initial diagnostic evaluation and therapeutic management. Pediatric cancer patients benefit from rapid referral to a tertiary care center with a subspecialty pediatric oncology program. Ideal treatment of some oncologic emergencies will involve the initiation of chemotherapy or radiation therapy, which must be done at a facility experienced in the administration of these modalities in children and adolescents.
The rapid release of the intracellular contents of tumor cells into the plasma can cause significant metabolic derangements that can progress to multiorgan failure and death. The laboratory abnormalities most often associated with this tumor lysis syndrome (TLS) include hyperuricema, hyperphosphatemia, hyperkalemia, and hypocalcemia. There are no strict criteria defining TLS, but recently it has been proposed that TLS can be categorized into “laboratory” and “clinical” entities, the former being defined by simultaneous presence of two or more electrolyte abnormalities and the latter by the presence of renal dysfunction, seizures, cardiac dysrhythmia, or multiorgan system failure.1
TLS is most commonly encountered shortly after initiation of therapy for malignancies with high tumor burden. TLS can also be identified prior to the initiation of therapy, especially in tumors with high cellular proliferation such as acute lymphoblastic leukemia (ALL) or Burkitt lymphoma. Recently, TLS management guidelines based on risk stratification have been proposed.2,3 High-risk clinical features include diagnoses of acute myelogenous leukemia (AML), ALL and advanced stage non-Hodgkin lymphoma (NHL), WBC count greater than 100,000 cells/mm3, elevated lactate dehydrogenase (LDH), presence of renal dysfunction, or multiple electrolyte abnormalities (Table 133-2). Incorporation of these guidelines into prospective pediatric studies may lead to further improvement in TLS prevention and treatment. Rapid identification of at-risk patients should expedite the initiation of prophylactic strategies to avoid complications ...