Oncologic Emergencies

Definition:

Oncologic emergencies are life-threatening complications of cancer or its treatment that require urgent diagnosis and intervention to prevent morbidity or death.

Emergency	Red Flags	First Steps
Neutropenic Fever	Fever, low ANC, hypotension	Blood cultures + IV cefepime + vancomycin
Spinal Cord Compression	Back pain, weakness, bowel/bladder dysfunction	IV steroids + urgent MRI
SVC Syndrome	Facial swelling, dyspnea, neck vein distension	Elevate HOB, CT chest, oncology consult
Tumor Lysis Syndrome	Weakness, arrhythmia, AKI	IV fluids, rasburicase or allopurinol
Hypercalcemia	Confusion, dehydration, constipation	IV fluids, bisphosphonates
Pericardial Tamponade	Hypotension, JVD, muffled heart sounds	Bedside echo, pericardiocentesis
SIADH	Confusion, seizures, weakness	Fluid restriction, slow Na+ correction

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1. Neutropenic Fever

• Why it Happens: Chemotherapy suppresses bone marrow production, resulting in profound neutropenia and impaired ability to fight infection¹.
• Associated Cancers: Most common with hematologic malignancies (e.g., leukemia, lymphoma) and solid tumors undergoing chemotherapy¹.
• Common Symptoms: Fever, chills, fatigue, sore throat, cough, dyspnea, abdominal pain.
• Red Flags: Temp >38.0°C (100.4°F), ANC <500, hypotension, respiratory distress.
• First Steps:
  • Blood cultures x2 sets (peripheral and central line if present).
  • Start broad-spectrum IV antibiotics ideally within 60 minutes:
    • Adults: Cefepime 2 g IV q8h + Vancomycin 15–20 mg/kg IV q8–12h².
    • Pediatrics: Cefepime 50 mg/kg IV q8h (max 2 g/dose) + Vancomycin 15 mg/kg IV q6–8h².
  • Admit all neutropenic fever cases regardless of initial appearance.

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2. Spinal Cord Compression

• Why it Happens: Epidural tumor extension compresses the spinal cord, impairing blood flow and causing neurologic dysfunction³.
• Associated Cancers: Breast, lung, prostate, multiple myeloma, lymphoma³.
• Common Symptoms: Back pain (especially thoracic), weakness, gait instability, numbness, urinary retention, bowel incontinence.
• Red Flags: New severe back pain, limb weakness, saddle anesthesia, bowel/bladder dysfunction.
• First Steps:
  • High-dose steroids: Dexamethasone 10 mg IV bolus, then 4 mg IV every 6 hours³.
  • Note: Steroids are indicated in malignant spinal cord compression to preserve neurologic function, unlike traumatic spinal injuries, where steroid use is controversial and generally not recommended⁴.
  • Emergent MRI of the entire spine (thoracic most common).
  • Urgent oncology or neurosurgical consultation.

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3. Superior Vena Cava (SVC) Syndrome

• Why it Happens: Obstruction of the SVC by tumor (most often lung cancer or lymphoma) or thrombus reduces venous drainage from the head, neck, and arms⁵.
• Associated Cancers: Small-cell lung cancer, non-small cell lung cancer, lymphoma⁵.
• Common Symptoms: Facial swelling, periorbital edema, dyspnea, cough, chest pain, hoarseness, orthopnea.
• Red Flags: Head fullness, cyanosis, venous distension of neck/chest.
• First Steps:
  • Elevate head of bed (improve venous return).
  • Urgent imaging: CT chest with contrast.
  • Emergent therapy to consider if unstable:⁶
    • Immediate radiation therapy for radiosensitive tumors (e.g., lymphoma, small cell lung cancer).
    • Intravascular stenting in select cases.
  • Oncology consult immediately.

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4. Tumor Lysis Syndrome

• Why it Happens: Rapid tumor cell death releases large amounts of potassium, phosphate, and uric acid into the blood, overwhelming renal clearance⁷.
• Associated Cancers: High-grade lymphomas (e.g., Burkitt lymphoma) and acute leukemias, especially after chemotherapy.
• Common Symptoms: Nausea, vomiting, diarrhea, muscle cramps, arrhythmias, lethargy.
• Red Flags: Acute kidney injury, arrhythmias, seizures.
• First Steps:
  • Labs: electrolytes, phosphate, calcium, uric acid, creatinine.
  • Aggressive IV hydration (2–3 L/m²/day with normal saline).
  • Consider rasburicase if high uric acid or allopurinol for prophylaxis.
  • Cardiac monitoring.
• Common EKG Findings:
  • Hyperkalemia: Peaked T waves, widened QRS.
  • Hypocalcemia: QT prolongation, Torsades de Pointes risk⁷.

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5. Hypercalcemia of Malignancy

• Why it Happens: Tumor secretion of parathyroid hormone-related protein (PTHrP) or bone resorption leads to elevated calcium levels⁸.
• Associated Cancers: Breast cancer, lung cancer, multiple myeloma, renal cell carcinoma.
• Common Symptoms: Confusion, weakness, constipation, polyuria, nausea, vomiting.
• Red Flags: Dehydration, arrhythmias, altered mental status.
• First Steps:
  • IV hydration with normal saline.
  • Consider bisphosphonates (e.g., zoledronic acid 4 mg IV).
• Common EKG Findings:
  • Hypercalcemia: Shortened QT interval, bradycardia⁸.

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6. Pericardial Tamponade (Malignant)

• Why it Happens: Malignant infiltration causes pericardial effusion leading to restricted cardiac filling⁹.
• Associated Cancers: Lung cancer, breast cancer, lymphoma, leukemia.
• Common Symptoms: Dyspnea, chest pain, fatigue, peripheral edema.
• Red Flags: Hypotension, jugular venous distension, muffled heart sounds (Beck’s triad).
• First Steps:
  • Immediate bedside echocardiogram.
  • Pericardiocentesis if unstable.
  • Cardiology and oncology consult urgently.

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7. SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion)

• Why it Happens: Tumor secretion of ADH or ectopic ADH-like substances results in water retention and dilutional hyponatremia¹⁰.
• Associated Cancers: Small-cell lung cancer, head and neck cancers¹⁰.
• Common Symptoms: Nausea, vomiting, headache, weakness, confusion, seizures.
• Red Flags: Severe hyponatremia, seizures, altered mental status.
• First Steps:
  • Fluid restriction.
  • Correct sodium slowly (≤8 mEq/L per 24 hours) to prevent osmotic demyelination syndrome.

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References

1. Freifeld AG, Bow EJ, Sepkowitz KA, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update. Clin Infect Dis. 2011;52(4):e56–e93. doi:10.1093/cid/cir073
2. Flowers CR, Seidenfeld J, Bow EJ, et al. Antimicrobial prophylaxis and outpatient management of fever and neutropenia in adults treated for malignancy: American Society of Clinical Oncology guideline. J Clin Oncol. 2013;31(6):794–810. doi:10.1200/JCO.2012.45.8661
3. Loblaw DA, Perry J, Chambers A, et al. Systematic review of the diagnosis and management of malignant extradural spinal cord compression: the Cancer Care Ontario Practice Guidelines Initiative’s Neuro-Oncology Disease Site Group. J Clin Oncol. 2005;23(9):2028–2037. doi:10.1200/JCO.2005.06.086
4. Hurlbert RJ. Methylprednisolone for acute spinal cord injury: an inappropriate standard of care. J Neurosurg. 2000;93(1 Suppl):1–7. doi:10.3171/spi.2000.93.1.0001
5. Wilson LD, Detterbeck FC, Yahalom J. Superior vena cava syndrome with malignant causes. N Engl J Med. 2007;356(18):1862–1869. doi:10.1056/NEJMcp067190
6. Parish JM, Marschke RF Jr, Dines DE, Lee RE. Etiologic considerations in superior vena cava syndrome. Mayo Clin Proc. 1981;56(7):407–413. PMID: 7229992.
7. Cairo MS, Bishop M. Tumour lysis syndrome: new therapeutic strategies and classification. Br J Haematol. 2004;127(1):3–11. doi:10.1111/j.1365-2141.2004.05094.x
8. Stewart AF. Clinical practice. Hypercalcemia associated with cancer. N Engl J Med. 2005;352(4):373–379. doi:10.1056/NEJMcp042806
9. Maisch B, Seferović PM, Ristić AD, et al. Guidelines on the diagnosis and management of pericardial diseases. Eur Heart J. 2004;25(7):587–610. doi:10.1016/j.ehj.2004.02.002
10. Ellison DH, Berl T. The syndrome of inappropriate antidiuresis. N Engl J Med. 2007;356(20):2064–2072. doi:10.1056/NEJMra070256

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For Further Reading:

Managing Patients with Oncologic Complications in the Emergency Department