Oncologic Emergency Research Articles

Oncologic emergency in patients with skeletal metastasis of unknown primary.

Patients with skeletal metastasis from prediagnosed primary malignancy sometimes have concurrent oncologic emergency (OE) during the first visit. This study aims to investigate the types of OEs and treatment outcome in such patients. We have experienced 359 patients with skeletal metastasis from unknown primary malignancy. Among them, 130 patients required immediate admission for OE treatment (OE group), 229 patients had no OE and did not required immediate admission (non-OE group). The recognized types of OE were spinal cord compression in 60 patients, cancer pain in 30, hypercalcemia in 19, delirium in 16, deep vein thrombosis in 13, acute renal failure in 6, respiratory failure in 3, gastrointestinal hemorrhage in 3, and disseminated intravascular coagulation in 1. The overall 5-year survival rates were 28% and 37% in the OE and non-OE groups, respectively (P<0.001). The multivariate analysis revealed that delirium (hazard ratio 4.2; 95% confidence interval, 1.6-12.5; P<0.005) and respiratory failure (hazard ratio 22.6; 95% confidence interval, 4.5-92.8; P<0.001) were significant prognostic factors in patients with OEs, whereas other OEs did not confer a significant risk for patient outcomes. In this study, OE was observed in as many as 36% of patients with skeletal metastasis from unknown primary malignancy. Delirium and respiratory failure were only two significant prognostic risk factors, which suggest that many of the OEs in untreated advanced cancer patients have probable chance to resolve. Early detection followed by appropriate treatment of such OEs is recommended.

Dados da vida real de uma enfermaria de oncologia em um hospital universitário brasileiro

OBJECTIVE: Analyze data regarding patients in need of hospital care admitted in our oncology in?rmary aiming for better clinical practices, clinical support and scope for ?nancial and structural needs for institutions. METHODS: A prospective study of 191 patients admitted for in-hospital care during a year, who were strati?ed by diagnosis, age, sex, admission reason, duration of stay, re-admission rate and outcomes. RESULTS: 97 male and 94 female patients were admitted, with a 61-year-old mean age; the mean stay was 13,4 days; and a re-admission rate of 9,4%. Main admission causes: terminality [de?ned by PSECOG=4, with a 30 day or less estimated life expectancy]: 30 patients (15,7%); total pain: 23 (12,0%); oncological emergencies [febrile neutropenia, malignant hypercalcemia, medullar compression, superior vena cava syndrome]: 20 (10,4%); clinical deterioration [de?ned as worsening of patients performance or malnutrition]: 15 (7,8%); abdominal pain [without acute abdomen]: 14 (7,3%). Most common primary tumor sites were: colorectal=30 (15,7%), breast=28 (14,6%), stomach=20 (10,4%), lung=14 (7,3%), ovary=12 (6,2%) and prostate=10 (5,2%). RESULTS: 99 deaths (mortality rate 52,1%). Patients in terminality presented a 90% ratio of mortality within an average of 6,6 days of hospital care. Febrile neutropenia (42,8%) and abdominal pain (35,7%) both achieved above expected mortality rates. 91 patients were discharged from the hospital and went back to ambulatory care. CONCLUSION: Our analysis pointed at an admission rate of 1,2%, pointing at good clinical ambulatory practices. The mean in-hospital stay comparison between patients who were discharged and those who died, not considered terminal ill, was unexpectedly similar, 11,7 versus 13,4 days, respectively, suggesting that in-hospital care should be focused on symptoms - not outcomes. Patients with febrile neutropenia and gastrointestinal cancer should be evaluated with caution due to higher than expected mortality rates

The review of admissions of oncologic patients to emergency service: A cross-sectional study

Aim: Oncological emergencies constitute a considerable part of emergency admissions. The early and correct diagnosis ofoncological emergencies increases both life quality and decreases mortality rate due to oncologic emergency. In this study, weevaluated the admissions of oncologic patients to emergency service.Materials and Methods: This study was conducted retrospectively and patients with cancer admitted to emergency service of thirddegree university hospital between October 2012-2013. Demographic characteristics of the patients, the frequency of admission,admission time, diagnosis, co morbid diseases, and treatment process were investigated.Results: In the study 1472 admission that belongs to 593 patients are assessed. 59,2 % of patients are male, 40.8 % of patientsare female. Mean of age is 62. Repeated admission rate is 55.81%. The two most frequent complaints are dyspnea 14.2% andstomachache 10.4%. The two most common types of cancer were lung (19.73%) and stomach (12.47%) cancer. While 64.90% ofpatients were discharged, 33.80% of patients are hospitalized. The mortality rate in emergency service was 0.1%.Conclusions: Distinguishing the oncological from other emergencies will contribute to patients in terms of reducing mortality andmorbidity.

1228. The Role of Procalcitonin (PCT) and Lactic Acid in Febrile Neutropenic Cancer Patients in an Oncological Emergency Center

BackgroundProcalcitonin (PCT) and lactic acid have emerged as biomarkers that increase in bacterial infections/sepsis and have been used in conjunction with clinical judgment to guide antibiotic administration. The Multinational Association for Supportive Care in Cancer (MASCC) risk index has been used to classify the risk for patients with neutropenic fever. However this index includes subjective elements and complex metrics that make it difficult to use in an oncological emergency center (EC). The purpose of this study is to evaluate the role of serum PCT alone and in combination with lactate to predict bloodstream infections (BSI), hospitalization and 14 days mortality in febrile neutropenic cancer patients presenting to the EC.MethodsWe conducted a retrospective study of all febrile neutropenic cancer patients who presented to our EC between April 1, 2018 and April 30, 2019 and had a serum PCT and lactic acid levels done. Fever was defined either as a documented temperature of ≥100.4 °F or a chief complaint of fever reported at home. Neutropenia was defined as an absolute neutrophil count ≤500 cells/mL.ResultsWe included 550 cancer patients of which 385 (70%) had hematologic malignancies and 165 (30%) had solid tumors. A BSI was documented in 116 (21%) patients due to gram negative organisms in 66%, gram positive organisms in 30%, and both in 4%. A higher rate of mortality within 14 days of EC presentation was seen in patients whose PCT ≥ 0.25 compared to those with PCT < 0.25 (5.2% vs 0.7%; p=0.002). Similarly a higher rate of BSI and a longer hospital stay was seen in patients whose PCT ≥ 0.25 compared to those with PCT < 0.25. A PCT ≥ 0.25 or a lactate level >2.2 had a sensitivity of 93% and a negative predictive value of 100% for a 14 day mortality. A logistic regression analysis showed an association between BSI and hematological malignancy, PCT ≥ 0.25, and lacate level >2.2 mmole/L.ConclusionA PCT ≥ 0.25 was associated with BSI, LOS and 14 day mortality. The combination of PCT / serum lactate have a good sensitivity and high negative predictive value for BSI and mortality. Because this combination could be useful in identifying the high risk febrile patients requiring hospital admission, it will be compared to the standard but more labor intensive MASCC score index.Disclosures Issam I. Raad, MD, Citius (Other Financial or Material Support, Ownership interest)Cook Medical (Grant/Research Support)Inventive Protocol (Other Financial or Material Support, Ownership interest)Novel Anti-Infective Technologies (Shareholder, Other Financial or Material Support, Ownership interest)

Critically Ill Pediatric Oncology Patients: What the Intensivist Needs to Know? Pediatric Critical Care Medicine

Cancer is an evolving cause of morbidity and mortality in children worldwide. In recent decades, there has been a significant increase in the survival of children with cancer, after applying new methods and treatment protocols in practice. However, the complexity of the disease itself, as well as the intensity and toxicity of treatment is such that many children require admission to the pediatric intensive care unit (PICU) which should be well equipped and led by personnel who have adequate training and expertise to provide optimum care to these complex patients. Most oncology patients who require PICU admission categorized into oncological emergencies, and/or decompensation from treatment and its side effects. In this study, we provide a summary of the essential and most recent evidence-based recommendations from published reviews and articles to aid PICU physicians and to ensure the best treatment and outcome possible for the children with such disease.How to cite this article: Al Haj Moussa A, Maaz AUR, Faqih N, Sundaram M. Critically Ill Pediatric Oncology Patients: What the Intensivist Needs to Know? Pediatric Critical Care Medicine. Indian J Crit Care Med 2020;24(12):1256–1263.

To see or not to see - or to wait and see: clinical decisions in an oncological emergency telephone consultation.

Cancer treatment is often given on an outpatient basis. An oncological emergency telephone line has been established to improve access to cancer care and prevent life-threatening side effects. However, healthcare professionals need to make clinical decisions without being able to assess patients face-to-face, which may be problematic. This study explores how healthcare professionals experience clinical decision-making in oncological emergency telephone consultations. An exploratory qualitative approach applying three focus groups with healthcare professionals from a Danish university hospital were undertaken. Data were analysed using inductive content analysis. An overall theme elucidated how healthcare professionals ended up deciding during each call whether the problem could be solved on the phone or the patient had to come for a face-to-face consultation or to wait and see whether the condition changed. Some decisions were easy to make, while others were moderate or difficult. The decision was influenced by several factors that could be structured into three themes: reliance on one's own knowledge and experience, consideration of different perspectives and the influence of context. This study demonstrated that clinical decision-making in oncological emergency telephone consultations includes three types of decisions that are intertwined with intra-personal, inter-professional and contextual factors such as personal knowledge, collaboration and workload. These factors are essential for the timely referral of patients to the right level of service.

Arrhythmia in tumor lysis syndrome and associated in-hospital mortality: A nationwide inpatient analysis.

BackgroundTumor lysis syndrome (TLS) is a life‐threatening oncologic emergency associated with fatal complications including arrhythmia. The epidemiology and mortality outcomes of arrhythmia in TLS are scarcely studied in the literature.MethodsWe used the National Inpatient Sample (NIS) to study the prevalence and outcome of arrhythmia in patients hospitalized with TLS (ICD‐9 code 277.88) from 2009 to 2014. Baseline characteristics, burden of arrhythmia, and pertinent outcomes were analyzed. Multivariable regression analysis was performed to identify the impact of underlying malignancy in predicting TLS‐related mortality.ResultsA total of 9034 cases of arrhythmia among 37 861 TLS patients were identified. More than half of the arrhythmia cases (67%) were found among white old (>65) males admitted to large bed size and urban teaching hospitals. Arrhythmic cohort showed higher frequency of comorbidities such as fluid‐electrolyte disturbances, hypertension, congestive heart failure, renal failure, dyslipidemia, diabetes, pulmonary circulatory disorders, chronic pulmonary disease, coagulopathy, and deficiency anemia. The most common malignancies were leukemia, lymphoma, metastatic tumor, and solid tumor without metastasis. We found significantly higher odds of in‐hospital mortality among patients with TLS compared to general inpatient population on unadjusted (OR 9.69, 95% CI: 9.27‐10.13, P < .001) and adjusted (OR 4.62, 95% CI: 4.39‐4.85) multivariable analyses. Overall in‐hospital mortality (32% vs 21.3%), median length of stay (11 days vs 9 days), and hospital charges were higher among arrhythmic than nonarrhythmic patients.ConclusionWith the availability of more advanced cancer therapy in the US, nearly one in four inpatient encounters of TLS had arrhythmia. Arrhythmia in TLS patients was associated with higher odds of mortality and increased resource utilization. Therefore, strategies to improve the supportive care of TLS patients plus timely diagnosis and treatment of arrhythmia are of utmost importance in reducing mortality and health‐care cost.

Managing tumor lysis syndrome.

Tumor lysis syndrome (TLS) is one of the most common oncologic emergencies, occurring when tumor cell contents are rapidly released into the bloodstream. This release of cellular contents, including uric acid, phosphate, and potassium, can rapidly overwhelm the body's homeostasis mechanisms, leading to renal failure, seizures, cardiac dysrhythmias, or death. With an estimated 1.8 million new diagnoses of cancer projected in 2020 and an increase in the use of targeted agents for treatment, healthcare providers must be able to recognize, diagnose, and manage patients presenting with TLS.

Gynecological cancers and the global COVID-19 pandemic

Coronavirus disease-2019 (COVID-19) has reduced the availability of health resources which will affect treatment of gynecological cancers. The present study aimed to provide a treatment protocol for patients with gynecological cancers during the global COVID-19 pandemic. International databases with keywords of COVID-19; Severe Acute Respiratory Syndrome; Middle East Respiratory Syndrome; gynecologic cancer; cervical cancer; and vaginal cancer, vulvar cancer, ovarian cancer, endometrial cancer, tumor, elective surgery, chemotherapy, radiotherapy, cancer, guideline, guidance, women, management, outpatient clinic visits, and triage were comprehensively searched. All the obtained guidelines were studied and the contents were summarized. During the COVID-19 pandemic, early stage endometrial cancer was preferably treated with hormone therapy while radiotherapy was given in preference in later stages. Cervical intraepithelial neoplasia 3 and high-grade squamous intraepithelial lesions should be treated immediately after diagnosis using at least a loop electrosurgical excision procedure while any major surgery should be postponed by 10-12 weeks. In the early stage of cervical cancer, surgery may be delayed by 2-4 weeks, and radiotherapy prescribed for the intervening period. In cases of an ovarian mass with negative tumor markers, no sign of cancer on imaging investigations, no ascites, a low serum CA-125 level, and no papillary projection or vegetation in the base of the cyst, the patient may be given hormone therapy for 2-3 months. In cases of newly diagnosed confirmed ovarian cancers, surgery should be performed as early as possible (maximum: 2-3 weeks). Vulvar and vaginal cancers can be treated within 10-12 weeks of diagnosis, but radiotherapy should be given in preference in this situation. A molar pregnancy is an oncological emergency for which a suction curettage is mandatory; the patient must be monitored for metastases. Information concerning the choice between open or laparoscopic surgery is limited. Given that any patient may be an asymptomatic carrier of the coronavirus, major surgery should be preceded by chest computerized tomography, with and without contrast medium, in order to detect lung lesions. Evidence concerning these recommendations is limited because of the novel and unknown nature of the COVID-19 pandemic. Furthermore, data pertaining to ethical debates about delayed treatment and treatment approaches deviating from current guidelines are also limited.

A narrative review of evolving roles of radiotherapy in advanced non-small cell lung cancer: from palliative care to active player.

Radiotherapy, along with other loco-regional interventions, is conventionally utilized as a palliative approach to alleviate symptoms and mitigate oncological emergencies in advanced non-small cell lung cancer (NSCLC). Thanks to the ongoing improvement of medical treatments in the last decade, such as targeted therapy and immunotherapy, the survival of patients with advanced NSCLC has been considerably prolonged, making it feasible and clinically beneficial for radiotherapy to play a more active role in highly selected subpopulations. In this review, we will focus on the evolving roles of radiotherapy in advanced NSCLC. First of all, among patients who are initially unable to tolerate aggressive treatment due to severe symptoms caused by metastases and/or tumor emergencies, timely radiotherapy could significantly improve their performance status (PS) and general condition, thus giving them a chance for intensive treatment and prolonged survival. The efficacy, potential candidates, and optimal dose-fractionation regimens of radiotherapy in this clinical scenario will be discussed. Additionally, radiotherapy can play a curative role as a concurrent therapy, consolidation therapy, and salvage therapy for patients with oligo-metastatic, oligo-residual, and oligo-progressive disease, respectively. Accumulating evidence from recent clinical trials, basic research, and translational investigations regarding the potentially curative roles of radiotherapy in NSCLC patients with oligo-metastatic disease will be summarized. Moreover, with the advent of various small molecular tyrosine kinase inhibitors (TKIs), the treatment efficacy and overall survival of oncogene-addicted NSCLC with brain metastases have been significantly improved, and the clinical value and optimal timing of cranial radiotherapy have become topics of much debate. Finally, synergistic antitumor interactions between radiotherapy and immunotherapy have been repeatedly demonstrated. Thus, the immune sensitizing role of radiotherapy in advanced NSCLC is also highlighted in this review.

Abstract 16331: Prevalence and Outcomes of Arrhythmia in Tumor Lysis Syndrome: A National Perspective

Introduction: Tumor lysis syndrome (TLS) is a life-threatening oncologic emergency. Epidemiology and mortality outcomes of arrhythmia in TLS are scarcely studied in the literature. Methods: We used the National Inpatient Sample (NIS) to study the prevalence and outcome of arrhythmia in patients hospitalized with TLS (ICD-9 code 277.88) from 2009-2014. Multivariable regression was performed to analyze TLS-related mortality. Results: A total of 9034 cases of arrhythmia among 37,861 TLS patients were identified. The trends in the prevalence of arrhythmia were stable with rates ranging from 19.8% to 25.8%, with the highest frequency recorded in 2014 (25.8%) (Fig. 1A). Atrial fibrillation (13.6%) was the most common arrhythmia followed by ventricular tachycardia in 2.6% of the patients (Fig. 1B). Sixty-seven percent of arrhythmias were among white old (&gt;65) males. Arrhythmic cohort showed a higher frequency of comorbidities like fluid-electrolyte disturbances, congestive heart failure, renal failure, pulmonary circulatory disorders, deficiency anemias, etc. The most common malignancies were leukemia and lymphoma. Overall in-hospital mortality (32% vs 21.3%), the median length of stay (11 vs. 9 days) and hospital charges were higher among arrhythmic TLS patients. Conclusions: In this population-based analysis, arrhythmia in TLS was associated with higher odds of mortality and increased resource utilization. Strategies to improve the management of TLS to prevent arrhythmia is of utmost importance.

How to manage patients with corticosteroids in oncology in the era of immunotherapy?

Corticosteroids are among the most prescribed drugs in oncology. The indications range from cancer-related indications for refractory symptoms, anti-cancer effects mainly in hematology, supportive measures for cancer-specific treatmentsand more recently immune-related adverse events induced by modern immunotherapies. In oncological emergencies, corticosteroids are common first-line treatments because of their rapid effect and wide variety of actions. In the last 5 years, with the advance of immune checkpoint inhibitors, corticosteroids are becoming routinely used to manage immune-related adverse effects. Preclinical studies suggested that corticosteroid-induced immunosuppression might dampen the activity of immunotherapies. Prospective clinical studies show that corticosteroid use is a prognostic marker for the cancer outcome in metastatic settingbut does not significantly alter the patient's response to immunotherapies per se. Here, we review the state of the art on corticosteroid use in oncology, with a focus on the drugs' potential impact on immunotherapy activity. The comprehensive pharmacological characteristics of corticosteroid drugs, clinical indications, modality of administration and associated precautions for use are discussed in this article.

Treatment of Pericardial Effusion in Cancer Patients

Pericardial effusion is the most common cardiac complication in cancer patients. Lung and breast cancers are the most common solid tumors associated with pericardial effusion. Multimodal tumor therapy improves the overall survival rate and reduces tumor complications. However, these patients need individualized treatment. This paper describes the treatment experience of pericardial effusion, from its pathophysiology, the correct classification of pericardial effusion related to malignant tumor, malignant pericardial effusion or pericardial cancer, to the methods of diagnosis and treatment. The incidence of pericardial effusion in our hospital was 12%. In 11 years of pericardial fenestration, pericardiectomy and subcutaneous catheter (tunneling) installation of pericardium or temporary pleurisy, the postoperative mortality was 1.2%, while the recurrence rate of pericardial effusion was 2.1%, and the recurrence rate of pericardial effusion was 33%. Malignant pericardial effusion is an oncologic emergency. It requires cost-effective management without increasing the incidence of patients who have deteriorated. Thoracoscopic pericardial fenestration (vats) and anterolateral small incision are ideal surgical approaches for malignant pericardial effusion.

Just-in-Time Teaching (JiTT) Screencasts: A Randomized Controlled Trial of Asynchronous Learning on an Inpatient Hematology-Oncology Service

BACKGROUND: JiTT screencasts are effective teaching tools in some medical educational settings, but have not yet been evaluated for trainees on an inpatient adult hematology-oncology service (HOS). Our preceding pilot data identified six high-yield topics for this setting: venous thromboembolism, oncologic emergencies, sickle cell disease, hematologic emergencies, brain metastases, and spinal metastases. This study objective was to determine if the addition of educational screencasts on these six topics would be an effective educational intervention for trainees on a busy HOS. METHODS: All internal medicine residents scheduled to start a rotation on an HOS were eligible. Participants underwent block randomization to the usual educational curriculum either with screencast access (treatment) or without it (control). Allocation was concealed but participants were not blinded. Upon completion of the rotation, all participants received an anonymous online survey about their experiences. The primary outcome was the change in attitude among learners, measured as their self-reported confidence for managing the clinical topics that were covered. All randomized participants received a $20 gift certificate upon completion of the study. Exploratory data was also collected from medical students, fellows, and faculty who opted to participate; they were given access to the screencasts without randomization. RESULTS: Over the 29 week study period (12/9/2019 - 6/30/2020), 67 out of 78 eligible residents (86%) opted to participate; these 67 residents all underwent randomization and were analyzed by intention-to-treat. Enrollment continued to completion of the study. The final participant response rate was high at 91%. Demographic characteristics were well-matched between the arms with the exception of a higher prevalence of male gender (72% vs. 42%, p=0.022) in the screencast arm. The majority (64%) of residents in the screencast arm rated their clinical management comfort level as either "comfortable" or "very comfortable" as compared to just 21% of residents in the usual education arm (p = 0.0008), estimated difference = 43%, (95% CI 21%,66%) using a prespecified cumulative cutoff score. Nearly all participants on the screencast arm either agreed or strongly agreed that the screencasts improved their knowledge base in medical oncology (100%), will improve their care for cancer patients (92%), and enjoyed the format (96%). Most participants on the screencast arm felt that the intervention was optimal in terms of content (96%), length (82%), and accessibility (63%). Preferred viewing speed for the screencasts was 1.5x (52%). Nearly all participants felt that a similar database of screencasts would be helpful for all of their clinical rotations (96%). Medical knowledge as tested by a series of 6 clinical vignette multiple-choice questions was not different between the screencast and control arms (percentage correct: 77% vs. 80%, p=0.56). Burnout as tested by the Maslach Burnout Inventory was not different between the screencast and control arms in terms of total score (71 ± 12 vs. 69 ± 13, p=0.67) or personal accomplishment subscale (46 vs. 45, p=0.71). Exploratory data was also collected from 6 medical students, 8 fellows, and 6 attendings. Half of the students (50%) recommended the screencasts for the IM clerkship. Most fellows and faculty were neutral as to their interest in producing their own educational screencasts (77%) or contributing to a similar project (54%). CONCLUSIONS Resident trainees on a busy inpatient adult hematology-oncology service (HOS) found that a JiTT screencast series increased their clinical comfort level in the management of critical and commonly encountered patient problems unique to the HOS. The screencast content and delivery was overwhelmingly positive with nearly all (96%) wanting screencast series to be created for all their clinical rotations. Furthermore, as evidenced by the COVID-19 pandemic of 2020, novel distance and asynchronous learning platforms may be of increasing importance when traditional in-person methods are not feasible. Disclosures Williams: Certus Critical Care: Other: My spouse is co-owner of Certus Critical Care, Inc. This is a medical device company; they currently have no devices on the market.. Woods:Sanofi: Other: Advisory Board 2020.

Incorporating Hemoglobin Levels to Map Leukostasis Risk in Acute Leukemia Using Microvasculature-on-Chip Technologies

Hyperleukocytosis, most commonly defined as a white blood cell (WBC) count &amp;gt; 100,000/μL, is an oncologic emergency in acute leukemia that can lead to leukostasis, which occurs when leukemia cells obstruct the microvasculature resulting in significant morbidity and mortality from neurologic (CNS hemorrhage, thrombosis) or pulmonary (respiratory distress, hypoxia) symptoms. The underlying mechanisms are poorly understood but are thought to be related to increased blood viscosity, secondary to high WBC count, leukemia cell aggregation, and the abnormal mechanical properties, size, and cell-cell interactions of leukemia cells. Leukapheresis is a commonly used therapy for rapid cytoreduction in symptomatic patients, but the procedure is not without risks. No existing methods reliably predict leukostasis or guide treatment including the commonly used WBC count, which only loosely correlates with leukostasis and does not accurately describe the blood viscosity at the microvascular level. Importantly, while hematocrit/hemoglobin levels (Hgb) are known to be major contributors to blood viscosity, they have not been systematically assessed in leukostasis risk, and Hgb often decreases as leukemic cell counts rise, complicating the issue. Incorporating Hgb levels may better predict leukostasis and assist physicians balancing the risk of hyperleukocytosis compared to the interventions themselves. To that end, we investigated how the differing presentations of acute leukemia lead to microvessel occlusion, thereby affecting effective blood viscosity at the microvascular level using "microvasculature-on-a-chip" devices that mimic the microvascular geometry (Figure 1) developed by our laboratory. This physiologically relevant microvascular model allows for in vitro investigation as in vivo studies are nearly impossible due to difficulty in visualizing and manipulating the animal microvasculature and cell counts. The devices were microfabricated using polydimethylsiloxane (PDMS). Acute T-cell lymphoblastic (Jurkat) and acute monocytic (THP-1) cell lines were maintained via standard cell culture conditions. Red cells from healthy donors were isolated and mixed with leukemia cells to achieve target Hgb and WBC levels. Various physiologic leukemia "mixtures" were then perfused under physiologic microcirculatory flow conditions through the microvascular device and microchannels occlusion was tracked via videomicroscopy (Figure 2). With T-cell leukemia, Hgb levels affected the risk of "in vitro leukostasis." Specifically, with severe anemia and WBC count less than the hyperleukocytosis range, time to microchannel occlusion was longer, and was more dependent on Hgb rather than WBC count. However, in cases with severe anemia and WBC counts &amp;gt; 100k/μL, WBC count exhibited a stronger effect on occlusion with little dependence on Hgb (Figure 3). At Hgb &amp;gt; 8g/dL, microchannel occlusion was dependent on WBC count regardless of hyperleukocytosis or not. In contrast, our data to date shows that with myeloid leukemia, in vitro leukostasis is not associated with Hgb levels, and is consistent with how myeloid leukemias in vivo cause leukostasis symptoms at lower WBC counts than lymphoid leukemias, not only due to size but also adhesive interactions. These data suggest when determining risk for leukostasis, WBC count should not be the sole determinant. Here we show Hgb levels affect microvascular blood viscosity and propensity for microvascular occlusion, but it appears to have a greater impact with T-cell leukemias versus myeloid leukemias (Figure 4). These studies indicate Hgb is an important clinical parameter for leukostasis risk in acute leukemia and will help inform guidelines for leukapheresis and even phlebotomy, a much simpler and safer procedure, to mitigate hyperviscosity in acute leukemia. These results can also impact decisions regarding the need for red blood cell transfusions, which iatrogenically increase blood viscosity. Studies incorporating patient myeloid and lymphoid leukemia cells and microvasculature-on-chip devices integrating live endothelium to assess leukemia cell adhesion are ongoing. Figure Disclosures Lam: Sanguina, Inc: Current equity holder in private company.

SP-0625: Merkel cell carcinoma: an oncologic emergency

SP-0625: Merkel cell carcinoma: an oncologic emergency

347P Histamine blockade with loratadine for prevention of granulocyte-colony stimulating factor (G-CSF)-associated bone pain: A meta-analysis

Chemotherapy remains to be one of the cornerstones of cancer management. Due to the inherent ability of chemotherapy to act on rapidly dividing cells, myelosuppression is one of the noted side effects. Febrile neutropenia (FN), an oncologic emergency, may be prevented with administration of granulocyte-colony stimulating factor (G-CSF) in patients who are at risk for neutropenia based on type and number of myelosuppressive chemotherapy agents used, the type of cancer and patient-related factors. Most common adverse events are injection site and bone pain. Recent studies showed promising results on prevention of G-CSF induced bone pain using histamine blockade. A systematic search of Pubmed, Cochrane, Clinical trials databases and hand search were done to identify randomized controlled trials (RCTs) investigating the use of Loratadine for prevention of G-CSF bone pain. Studies were appraised using the Cochrane Collaboration tool. Using the random effects model, pooled Odds ratios (ORs) with 95% confidence intervals (CI), results were analyzed. Two RCTs were included ( N=814). Patients in the Loratadine group reported lesser bone pain as compared to the control group, 57% and 60% respectively (OR 0.95, CI [0.81, 1.10). However, the result was not statistically significant (P=0.52). Histamine blockade with Loratadine in the prevention of bone pain induced by G-CSF did not show statistically significant advantage over placebo or no prophylaxis.

Acute Myeloid Leukemia: Advanced Practice Management From Presentation to Cure.

Acute myeloid leukemia (AML) is the most common acute leukemia in adults, diagnosed in approximately 21,450 individuals annually in the US with nearly 11,000 deaths attributable to this disease (National Cancer Institute, 2020). Acute myeloid leukemia is a disease of the elderly, with the average age of diagnosis being 68 years old (Kouchkovsky & Abdul-Hay, 2016). It is a heterogeneous disease with widely varying presentations but universally carries a poor prognosis in the majority of those affected. Unfortunately, the 5-year overall survival rate remains poor, at less than 5% in patients over 65 years of age (Thein, Ershler, Jemal, Yates, & Baer, 2013). The landscape of AML is beginning to change, however, as new and improved treatments are emerging. Advanced practitioners (APs) are often involved in the care of these complex patients from the time of initial symptoms through diagnosis, treatment, and potentially curative therapy. It is vitally important for APs to understand and be aware of the various presentations, initial management strategies, diagnostic workup, and treatment options for patients with AML, especially in the elderly population, which until recently had few treatment options. This Grand Rounds article highlights the common presenting signs and symptoms of patients with AML in the hospital, including a discussion of the upfront clinical stability issues, oncologic emergencies, diagnostic evaluation, and current treatment options for elderly patients and those with poor performance status.

Abstracts from the 2020 Oncological Emergencies Conference at MD Anderson in Houston, TX

Abstracts from the 2020 Oncological Emergencies Conference at MD Anderson in Houston, TX

COVID-19: The Impact in Oncology Care.

The COVID-19 pandemic has imposed a critical challenge to the current oncology care and practices including late diagnoses, delayed anti-cancer treatment, and static clinical trials. With the increasing risk of cancer patients acquiring infection during receiving the essential care, the debate ensues on how to balance the risk factors and benefits out of the oncologic emergencies in cancer patients. In this review article, we have focused on the current global re-organization of the integrity and effectiveness of the treatment modalities depending on the patient and cancer-specific urgencies while minimizing exposure to the infection. In this review, we addressed how the worldwide oncology community is united to share therapy schemes and the best possible guidelines to help cancer patients, and to strategize and execute therapy/trial protocols. This review provides collective knowledge on the current re-structuring of the general framework that prioritizes cancer care with the available exploitation of the reduced resources and most importantly the unparalleled levels of companionship as a large health care community towards the need to offer the best possible care to the patients.