Oncologic Emergencies - C.Dee

Oncologic Emergencies Clinical Trials Office

Contents

1. Spinal Cord Compression
2. Superior Vena Cava Syndrome
3. Febrile Neutropenia
4. Hypercalcemia of Malignancy
5. Brain Metastasis
6. Cytokine Release Syndrome
7. Tumor Lysis Syndrome

What is An Oncologic Emergency?

Oncologic Emergencies:

• Acute
• Life-threatening
• Require immediate medical intervention!

1. Spinal Cord Compression

Definition

• Condition causing pressure on the spinal cord or its nerves.
• Leads to sensory and motor deficits.
• Can lead to permanent damage if not treated promptly!

Key Points:

• Occurrence = 5 to 30% of oncology patients
• Thoracic Spine = 60 to 80% of cases
• Most common cancers = prostate, breast, and lung
• Other cancers = multiple myeloma, renal cell, and non-Hodgkin lymphoma

Signs & Symptoms:

• New onset back pain
• Weakness (especially in the lower extremities)
• Late neurologic signs (e.g., confusion, imbalance, numbness, pain).

Evaluation

• Non-contrast MRI (whole spine)
• Biopsy

Treatment

• Surgical Decompression and Stabilization
• Radiation therapy
• Chemotherapy
• Steroids
• Strict bedrest

2. Superior Vena Cava Syndrome

Definition:

• A set of symptoms that result when blood flow through the superior vena cava is blocked

Key Points:

• Majority of cases = malignant tumors within the mediastinum
• Most common malignancies = lung cancer and non-Hodgkin Lymphoma
• Other causes = intravascular device thrombosis, aortic aneurysm, infections

Symptoms:

Early >

Late >

• Dyspnea
• Non-productive cough
• Headache
• Dysphagia
• Hoarseness
• Chest pain
• Edema face, neck, breast, and upper extremities

• Visual disturbances
• Syncope
• Cyanosis of the face or upper torso
• Irritability
• Mental status changes
• Seizures, stupor, coma

Evaluation

• Chest X-ray

MANAGEMENT

• Bed rest with head elevated
• Oxygen
• Corticosteroids
• Diuretic
• Stenting
• Warfarin or heparin

Specific Disease Management

• SCLC = Chemotherapy (may add radiation therapy)
• NSCLC = Radiation therapy and Chemotherapy
• NHL = Chemotherapy (may add radiation therapy)
• Catheter induced thrombosis = Thrombolysis

3. Febrile Neutropenia

Definition

• Fever
• Neutropenia

Evaluation

• History
• Physical Examination
• Investigation

4. Hypercalcemia of Malignancy

Definition

• Elevated level of calcium in the blood serum.

Clinical Features:

• General
• Neuromuscular
• Respiratory
• Gastrointestinal
• Cardiac

Key Points:

• Occurs in 10% of cancer patients.
• Malignancies associated with Hypercalcemia include:
• Multiple Myeloma
• Breast Cancer
• Lung Cancer
• Lymphomas
• Renal Cell Carcinoma
• Esophageal Cancer

"Stones, Bones, Groans, & Moans"

5. Brain Metastasis

Definition:

• Cancer that has metastasized to the brain from another location in the body and is therefore considered a secondary brain tumor.

Key Points:

• Most common cause of brain cancer.
• Most likely cancers: lung, breast, colon, kidney, and melanoma
• Occurs in 10 – 30% of adult cancer patients.
• About 100,000 new cases per year in the United States.
• More than 20% of patients with systemic disease have brain metastasis upon autopsy.

Signs & Symptoms

• Headache
• Nuchal rigidity
• Photophobia
• Cognitive dysfunction
• Motor dysfunction
• Seizures
• Nausea or vomiting

Work-Up

• Physical examination
• CT head
• MRI head
• Chest x-ray
• CBC, CMP, Coagulation screen, LFT

Management

Symptom directed

• Anticonvulsants
• Dexamethasone
• Mannitol

Treatment

Solitary Metastasis:

• Surgery followed by radiation therapy
• Whole brain radiation with boost
• Stereotactic radiation surgery/treatment

Multiple Brain Metastasis:

• Palliative WBRT

Prognosis

Improved Prognosis Factors:

• High Karnofsky score (>70%)
• Age younger than 70 years
• No systemic disease or systemic disease controlled
• No systemic metastases within 1 year of diagnosis of primary lesion
• Female patients

6. Cytokine Release Syndrome

Definition

• An acute, systemic inflammatory syndrome characterized by fever and multiple organ dysfunction that is most often caused by immunotherapy.

What Are Cytokines?

• Small Proteins that act as messengers to help direct the body’s immune response.
• High levels of cytokines may cause increased inflammation throughout the body.
• This cam be harmful, interfere with bodily functions, and in severe cases, cause organ failure and even death.

Key Points:

• CRS usually develops within 3 to 14 days after T cell-based immunotherapy.
• Often begins with fever and flu-like symptoms.
• Can worsen quickly and lead to serious illness.
• Most patients improve within 1-2 weeks.
• Most patients do not have long-term problems from CRS.

General Symptoms:

• Fever
• Chills
• Fatigue
• Weakness
• Anorexia
• Nausea
• Vomiting
• Diarrhea
• Joint/muscle aches
• Rash

Cardiac Symptoms:

• Hypotension
• Tachycardia
• Arrythmias
• Decreased heart function
• Edema

Brain & Nervous System:

• Headache
• Confusion
• Dizziness
• Seizures
• Hallucinations
• Motor Deficits

Respiratory System:

• Cough
• Shortness of breath
• Decreased lung function
• Hypoxia

Monitoring:

• Body temperature
• Breathing rate
• Blood pressure
• Heart rate
• Oxygen levels
• Neurological exam to watch for changes in brain and nervous system function
• CBC, CMP, LFTs, Cytokines

Treatment

• Supportive care
• Symptom management

7. Tumor Lysis Syndrome

Definition

• The constellation of metabolic disturbances that occurs when large numbers of neoplastic cells are killed rapidly, leading to the release of intracellular ions and metabolic byproducts into the systemic circulation.

Key Points

• Most common with acute leukemias and high-grade non-Hodgkin lymphomas.
• Most common after start of initial chemotherapeutic treatment.
• Rapid development of metabolic disorders.

Signs & Symptoms

• Fatigue
• Confusion
• Nausea
• Vomiting
• Diarrhea
• Muscle weakness, cramps, or spasms
• Tingling around mouth or in hands and feet
• Cardiac Arrythmias
• Seizures

Treatment

• Allopurinol – reduces the occurrence of elevated uric acid.
• Kayexalate – reduces level of increasing potassium content in the blood.
• Rasburicase – treatment of hyperuricemia and controls serum potassium, creatinine, phosphate and calcium levels (takes effect in as quickly as four hours).
• Calcium Supplements – prevent tetany, muscle cramps, and seizure cause by hypocalcemia.
• Diuretics – facilitate proper renal excretion and decrease uric acid levels in renal tubules to prevent crystal formation..
• Electrolyte Replacement – for control and balance.

References

Fico V, Altieri G, Di Grezia M, Bianchi V, Chiarello MM, Pepe G, Tropeano G, Brisinda G. Surgical complications of oncological treatments: A narrative review. World J Gastrointest Surg. 2023 Jun 27;15(6):1056-1067. doi: 10.4240/wjgs.v15.i6.1056. PMID: 37405101; PMCID: PMC10315125.

Gri N, Longhitano Y, Zanza C, Monticone V, Fuschi D, Piccioni A, Bellou A, Esposito C, Ceresa IF, Savioli G. Acute Oncologic Complications: Clinical-Therapeutic Management in Critical Care and Emergency Departments. Curr Oncol. 2023 Aug 2;30(8):7315-7334. doi: 10.3390/curroncol30080531. PMID: 37623012; PMCID: PMC10453099.

Klemencic S, Perkins J. Diagnosis and Management of Oncologic Emergencies. West J Emerg Med. 2019 Mar;20(2):316-322. doi: 10.5811/westjem.2018.12.37335. Epub 2019 Feb 14. PMID: 30881552; PMCID: PMC6404710.

Regnier L, Wilkinson AN. Common oncologic emergencies. Can Fam Physician. 2023 Jan;69(1):28-32. doi: 10.46747/cfp.690128. PMID: 36693744; PMCID: PMC9873297.