11. Oncologic emergencies

• In case of oncological emergencies oncotherapy can be initiated without knowing the histology of the cancer
• Increased intracranial pressure
  • Due to brain metastases or primary brain tumor
  • Urgent MRI should be made
  • ASAP treatment includes dexamethasone, forced diuresis (fluid + loop diuretics) and mannitol to reduce oedema
  • Then treat tumor
• Spinal cord compression
  • Due to enlarging vertebral metastasis or pathologic vertebral fracture due to metastasis
  • Often from breast, lung, prostate, etc.
  • Most often involves thoracic spine
  • X-ray will show blastic or lytic lesions
  • MRi will show localization of spinal cord compression
  • ASAP treatment includes dexamethasone and spinal decompression surgery
  • Then treat tumor
• Superior vena cava syndrome
  • Can be due to lung cancer, lymphoma etc, but also due to non-cancer conditions
  • X-ray will show mediastinal widening
  • CT with contrast will give more detailed picture
  • Hyperfractionated radiation therapy given to provide rapid tumor reduction and symptom relief
• Malignant pleural effusion
  • Exudate, not transudate
  • Due to tumor cell implants on pleura
  • Due to metastatic breast, lung or lymphoma
  • Chest x-ray shows effusion
  • Thoracentesis shows exudate, also drains fluid
  • Chest tube can be inserted to continually drain fluid
  • Pleurodesis – procedure where the visceral and parietal pleurae are adhered together to prevent fluid accumulation
    • A sclerosing agent like doxycycline, bleomycin or talc is added to the pleural cavity
    • These agents cause the pleurae to adhere to each other
• Airway obstruction
• Ileus
• Hypercalcaemia of malignancy
  • In breast, lung, or multiple myeloma
  • Due to osteolytic metastases, or due to PTH-related peptide secretion
  • Symptoms include fatigue, vomiting, altered mental status
  • Treatment involves hydration and furosemide + bisphosphonates
• Hyponatraemia
  • Due to syndrome of inappropriate ADH, due to SCLC or other neuroendocrine tumor
  • ASAP slow infusion of hypertonic saline
• Tumor lysis syndrome
  • Due to chemo of chemosensitive, high cell-turnover tumours, especially leukaemias, lymphomas
  • Massive cell death release causes hyperkalaemia, hyperuricaemia, hyperphosphataemia, secondary hypocalcaemia
  • Prevention is essential, by hydrating patients, possibly giving allopurinol
  • Manifest tumor lysis syndrome may require dialysis
• Febrile neutropaenia
  • Defined as a single measurement of > 38,3°C oral or a sustained temperature of 38,0°C for 1 hour + neutropaenia (< 500/µL)
  • Take two sets of blood culture ASAP, then immediately start empiric broad-spectrum AB therapy
  • Aminoglycoside + antipseudomonal beta-lactam
• Disseminated intravascular coagulation
  • Due to acute promyelocytic leukaemia (APML)
  • Signs of haemorrhage and thrombosis
  • All-trans retinoic acid treats APML
  • Replacement of platelets and coagulation factors may be necessary
• Hyperviscosity syndrome
  • Due to myeloproliferative disease or ALL
  • Hyperviscous blood causes symptoms of impaired microcirculation
  • Treatment includes phlebotomy