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, and brain metastases with increased intracranial pressure (Table 22-14).

Table 22-14: Oncologic Emergencies
Neutropenic feverInfectiousTemperature >38.3°C or >38°C two times 1 h apart
  1. Antibiotic coverage: gram-negative with pseudomonal activity, and gram-positive if risk factors (catheters, pneumonia, mucositis, Staphylococcus colonization, sepsis), and also fungal if unstable
  2. IV hydration and supportive care as appropriate
Tumor lysis syndrome (TLS)Massive lysis of cancer cells (mostly with chemotherapy)Hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia, AKI, cardiac arrhythmias, and/or seizures
  1. Prevention with IV fluids and prophylactic allopurinol or rasburicase based on estimated risk of TLS
  2. Treatment: Aggressive hydration, rasburicase, dialysis
HypercalcemiaHumoral, PTHrP, bone metastasis, calcitriol mediated (lymphomas)Dehydration, CNS symptoms, constipation, ileus, weakness, cardiac (bradycardia, short QT, prolonged PR, etc.)
  1. IV hydration
  2. Bisphosphonates or denosumab (if low creatinine clearance)
  3. Calcitonin (if symptomatic, rapid onset)
  4. Steroids can be useful
Spinal cord compression (SCC)Metastatic or involvement of spine in SCCPain, weakness, sensory loss, incontinence, ataxia
  1. Steroids
  2. Neurosurgery consultation
  3. RT
  4. Chemotherapy can be considered in few cases of SCC
Superior vena cava (SVC) syndromeObstruction of SVC by primary or metastatic cancer (mostly intrathoracic)Dyspnea, stridor (laryngeal edema), facial and upper extremity swelling, risk of cerebral edema and herniation
  1. Histologic diagnosis is important
  2. Consider upfront endovascular stent and RT if comatose or respiratory compromise
  3. Treatment depends on tumor type: SCLC, lymphoma, germ cell: chemotherapy; NSCLC: RT; thymic tumors: surgery
Hyperleukocytosis with leukostasisIntravascular accumulation of blasts, with or without DICChest pain, respiratory distress, stupor, TLS, DIC
  1. Leukapheresis: symptomatic patients (count threshold AML >50 × 10/μL, ALL and CML >150 × 10/μL, CLL >500 × 10/μL); asymptomatic patients (AML >100 × 10/μL, ALL >200 × 10/μL)
  2. Hydroxyurea for cytoreduction

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; NSCLC, non–small-cell lung cancer; PTHrP, parathyroid hormone-related protein; RT, radiotherapy; SCLC, small-cell lung cancer.

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