Management of hematological patients requiring emergency chemotherapy in the intensive care unit

Abstract

Hematological malignancies may require rapid-onset treatment because of their short doubling time, notably observed in acute leukemias and specific high-grade lymphomas. Furthermore, in targeted onco-hematological scenarios, chemotherapy is deemed necessary as an emergency measure when facing short-term, life-threatening complications associated with highly chemosensitive hematological malignancies. The risks inherent in the disease itself, or in the initiation of treatment, may then require admission to the intensive care unit (ICU) to optimize monitoring and initial management protocols. Hyperleukocytosis and leukostasis in acute leukemias, tumor lysis syndrome, and disseminated intravascular coagulation are the most frequent onco-hematological complications requiring the implementation of emergency chemotherapy in the ICU. Chemotherapy must also be started urgently in secondary hemophagocytic lymphohistiocytosis. Tumor-induced microangiopathic hemolytic anemia and plasma hyperviscosity due to malignant monoclonal gammopathy represent infrequent yet substantial indications for emergency chemotherapy. In all cases, the administration of emergency chemotherapy in the ICU requires close collaboration between intensivists and hematology specialists. In this review, we provide valuable insights that aid in the identification and treatment of patients requiring emergency chemotherapy in the ICU, offering diagnostic tools and guidance for their overall initial management.

Keywords: Acute leukemia; Chemotherapy; Emergency; ICU; Lymphoma.

Fig. 1

Inaugural complications of acute myeloid leukemia requiring emergency chemotherapy. A Pulmonary leukostasis, with bilateral alveolar and interstitial opacities, related to hyperleukocytic (230 × 10⁹/L) acute monocytic leukemia (ex FAB-M5) at the time of diagnosis. B Pulmonary leukostasis, with ground-glass opacity in the right upper lobe, secondary to hyperleukocytic (200 × 10⁹/L) acute myelomonocytic leukemia (ex FAB-M4). C Fundus image with fluorescein angiography revealing hyperviscosity-related retinopathy with disseminated retinal hemorrhages and vascular dilation. D, E T2*-weighted and T2-flair MRI sequences revealing inaugural left fronto-temporal hemorrhage and cerebral edema linked to hyperleukocytic (330 × 10⁹/L) acute monocytic leukemia (ex FAB-M5). F Acute monocytic leukemia (ex FAB-M5): peripheral blood smear with numerous promonocytes that have folded and convoluted nuclei and a finely granulated cytoplasm and vacuoles. DIC disseminated intravascular coagulation, FAB French–American–British classification, MRI magnetic resonance imaging