Hematologic Syndromes

Thromboembolism is not uncommon in cancer patients and is due to a number of factors such as a hypercoagulable state; decreased proteins C, S, and antithrombin III; and the effect of metastases on activation of the coagulation pathway. Cancer patients are at increased risk for both deep venous thrombosis and pulmonary embolism. However, anticoagulation may result in bleeding at sites of metastatic disease, so that treatment options are more complex and may include placement of a filter in the inferior vena cava.

Polycythemia is enhanced production of red cells due to increases in sensitivity of erythropoietin. Any organ system can be affected by resulting thrombosis, bleeding, or hyperviscosity, but CNS effects are the most devastating. Celiac or mesenteric vessel ischemia, or Budd-Chiari syndrome, is seen when gastrointestinal vessels are involved. If the hematocrit is greater than 60 percent and symptoms are present, emergency phlebotomy is necessary.

Either acute or chronic leukemias can result in white blood cell counts greater than 100,000/pL. A leukocrit of greater than 10 percent is often associated with clinically significant hyperviscosity, and CNS dysfunction and respiratory distress can occur from capillary leukostasis. Diuretics worsen symptoms because they will increase the leukocrit. Treatment is directed at the underlying malignancy, and allopurinol should also be administered in anticipation of massive tumor lysis, to prevent acute gouty arthropathy and renal failure.

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