Oncologic Emergencies

Oncologic Emergencies is a topic covered in the Washington Manual of Medical Therapeutics.

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The most common oncology emergencies are febrile neutropenia (FN), TLS, malignant hypercalcemia, spinal cord compression, SVC syndrome, hyperleukocytosis, and brain metastases with increased intracranial pressure (Table 22-12).

Table 22-12: Oncologic Emergencies
EmergencyEtiologyPresentationManagement
Neutropenic feverInfectiousANC <500/ μL and Temp >38.3°C or >38°C twice (1 h apart), may present with sepsis and/or hypotensive shock
  • Infectious workup with complete physical exam, BCx (bacterial and fungal), UCx, CXR, RVP, and stool studies (if diarrhea)
  • Antibiotics: gram-negative anti-pseudomonal coverage; add gram-positive anti-MRSA coverage if: catheters, pneumonia, mucositis, Staphylococcus colonization, sepsis; add fungal coverage if clinically warranted
  • IV hydration, G-CSF and supportive care, as indicated
Tumor lysis syndrome (TLS)Massive lysis of cancer cells
High risk: leukemia, lymphoma, or bulky tumors		High LDH, uric acid, K and PO4, low Ca, AKI, cardiac arrhythmia, and/or seizures
  • Prevention: IV fluids and prophylactic allopurinol or rasburicase based on estimated risk of TLS
  • Treatment: IV fluids, allopurinol, rasburicase, dialysis if indicated
Malignant hyper­calcemiaPTH, PTHrP, calcitriol-mediated, osteolytic metastasisPolyuria/polydipsia, dehydration, confusion, constipation, weakness, cardiac arrhythmias
  • IV fluids
  • Bisphosphonates or denosumab (if low creatinine clearance)
  • Calcitonin (if severe, symptomatic)
  • Steroids can be useful in some cases
Spinal cord compressionCompression of spinal cord due to malignant involvementBack pain (most common), weakness, sensory loss, incontinence, ataxia
  • Total spine MRI
  • Glucocorticoids
  • Neurosurgery and Radiation Oncology consultation
  • Chemotherapy for chemosensitive tumors
Superior vena cava (SVC) syndromeObstruction of SVC by primary or metastatic cancerDyspnea, stridor (laryngeal edema), facial and upper extremity swelling, risk of respiratory failure, cerebral edema, and herniation
  • CT head, neck, and chest
  • Airway support, as indicated
  • Endovascular stent if comatose
  • Intubation if airway compromise
  • Treatment depends on tumor type: SCLC, lymphoma, germ cell: chemotherapy; NSCLC: RT; thymic tumors: surgery, etc.
Hyper-leukocytosis with leukostasisIntravascular accumulation of blasts, with or without TLS/DICChest pain, respiratory distress, altered mental status, bleeding and/or clotting (if DIC is present)
  • Leukapheresis: symptomatic patients (count threshold AML >50 × 103/μL, ALL and CML >150 × 103/μL, CLL >500 × 103/μL); asymptomatic patients (AML >100 × 103/μL, ALL >200 × 103/μL)
  • Hydroxyurea, glucocorticoids, empiric antibiotics, TLS/DIC management if present
Intracranial massIncreased intracranial pressure, cerebral edemaHeadache, altered mental status, focal neurologic deficits, potentially asymptomatic
  • CT head and/or MRI brain
  • Glucocorticoids
  • Neurosurgery and Radiation Oncology consultation
  • Consider antiepileptics, if indicated

AKI, acute kidney injury; ALL, acute lymphoblastic leukemia; AML, acute myeloid leukemia; CLL, chronic lymphocytic leukemia; CML, chronic myeloid leukemia; CNS, central nervous system; DIC, disseminated intravascular coagulation; G-CSF, granulocyte colony-stimulating factor; LDH, lactic dehydrogenase; MRSA, methicillin-resistant Staphylococcus aureus; NSCLC, non–small-cell lung cancer; PTHrP, parathyroid hormone-related protein; RT, radiotherapy; RVP, respiratory viral panel; SCLC, small-cell lung cancer.

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The most common oncology emergencies are febrile neutropenia (FN), TLS, malignant hypercalcemia, spinal cord compression, SVC syndrome, hyperleukocytosis, and brain metastases with increased intracranial pressure (Table 22-12).

Table 22-12: Oncologic Emergencies
EmergencyEtiologyPresentationManagement
Neutropenic feverInfectiousANC <500/ μL and Temp >38.3°C or >38°C twice (1 h apart), may present with sepsis and/or hypotensive shock
  • Infectious workup with complete physical exam, BCx (bacterial and fungal), UCx, CXR, RVP, and stool studies (if diarrhea)
  • Antibiotics: gram-negative anti-pseudomonal coverage; add gram-positive anti-MRSA coverage if: catheters, pneumonia, mucositis, Staphylococcus colonization, sepsis; add fungal coverage if clinically warranted
  • IV hydration, G-CSF and supportive care, as indicated
Tumor lysis syndrome (TLS)Massive lysis of cancer cells
High risk: leukemia, lymphoma, or bulky tumors		High LDH, uric acid, K and PO4, low Ca, AKI, cardiac arrhythmia, and/or seizures
  • Prevention: IV fluids and prophylactic allopurinol or rasburicase based on estimated risk of TLS
  • Treatment: IV fluids, allopurinol, rasburicase, dialysis if indicated
Malignant hyper­calcemiaPTH, PTHrP, calcitriol-mediated, osteolytic metastasisPolyuria/polydipsia, dehydration, confusion, constipation, weakness, cardiac arrhythmias
  • IV fluids
  • Bisphosphonates or denosumab (if low creatinine clearance)
  • Calcitonin (if severe, symptomatic)
  • Steroids can be useful in some cases
Spinal cord compressionCompression of spinal cord due to malignant involvementBack pain (most common), weakness, sensory loss, incontinence, ataxia
  • Total spine MRI
  • Glucocorticoids
  • Neurosurgery and Radiation Oncology consultation
  • Chemotherapy for chemosensitive tumors
Superior vena cava (SVC) syndromeObstruction of SVC by primary or metastatic cancerDyspnea, stridor (laryngeal edema), facial and upper extremity swelling, risk of respiratory failure, cerebral edema, and herniation
  • CT head, neck, and chest
  • Airway support, as indicated
  • Endovascular stent if comatose
  • Intubation if airway compromise
  • Treatment depends on tumor type: SCLC, lymphoma, germ cell: chemotherapy; NSCLC: RT; thymic tumors: surgery, etc.
Hyper-leukocytosis with leukostasisIntravascular accumulation of blasts, with or without TLS/DICChest pain, respiratory distress, altered mental status, bleeding and/or clotting (if DIC is present)
  • Leukapheresis: symptomatic patients (count threshold AML >50 × 103/μL, ALL and CML >150 × 103/μL, CLL >500 × 103/μL); asymptomatic patients (AML >100 × 103/μL, ALL >200 × 103/μL)
  • Hydroxyurea, glucocorticoids, empiric antibiotics, TLS/DIC management if present
Intracranial massIncreased intracranial pressure, cerebral edemaHeadache, altered mental status, focal neurologic deficits, potentially asymptomatic
  • CT head and/or MRI brain
  • Glucocorticoids
  • Neurosurgery and Radiation Oncology consultation
  • Consider antiepileptics, if indicated

AKI, acute kidney injury; ALL, acute lymphoblastic leukemia; AML, acute myeloid leukemia; CLL, chronic lymphocytic leukemia; CML, chronic myeloid leukemia; CNS, central nervous system; DIC, disseminated intravascular coagulation; G-CSF, granulocyte colony-stimulating factor; LDH, lactic dehydrogenase; MRSA, methicillin-resistant Staphylococcus aureus; NSCLC, non–small-cell lung cancer; PTHrP, parathyroid hormone-related protein; RT, radiotherapy; RVP, respiratory viral panel; SCLC, small-cell lung cancer.

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