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Editors
Oncological Emergencies
Essentials
- In the course of their treatment, cancer patients may be faced several times with emergencies due to the cancer itself or to its treatment.
- Most cancer treatment is provided on an outpatient basis, and as there are often no oncological emergency services available, patients will turn to general emergency services.
- Do not hesitate to consult the responsible oncological department in such cases.
- When treating any such emergency, take the line of the patient's treatment into consideration; whether the aim is curative or to delay disease progression, or whether it is palliative, with the aim of treating the symptoms, or whether the disease is in the terminal stage.
Neurological emergencies
- Primary brain tumours, meningeal or other metastases, and antineoplastic agents may cause headaches, convulsions, nausea, vomiting or visual disturbances, or impair consciousness, for example.
- Of the various imaging modalities, MRI is the most accurate.
- In patients with metastatic cancer, particularly at the end stage of the disease, organic delirium may occur Delirium in the Elderly.
- About 5% of patients with metastatic cancer develop spinal cord compression.
- This is most often associated with breast, lung or prostate cancer but can also be seen in patients with myeloma or renal cancer.
- Thoracic vertebrae are most often affected.
- In 75% of cases, spinal cord compression is caused by an epidural soft tissue tumour and in 25% by a collapsed, fractured vertebra.
- Spinal cord compression may be an asymptomatic finding on imaging. Symptoms may include pain, motor weakness (a leg giving way, stiff movement), hypaesthesia, impaired sphincter tonus (urinary retention, faecal incontinence).
- Examine the neurological status, perform a digital rectal examination, find out how long the symptoms have been present.
- For first aid, start high-dose glucocorticoid treatment (oral/intravenous dexamethasone 6-10 mg 3 times daily).
- MRI is the primary imaging method and should cover the whole spine (in 20-35% of patients, several vertebrae are affected).
- The longer the duration of symptoms, the less likely it is that mobility will be restored.
- Consult a neurosurgeon and radiation oncologist.
- Depending on the prognosis and overall situation, the condition should be treated urgently either by surgery with subsequent radiotherapy or by radiotherapy alone.
Cardiovascular emergencies
- Superior vena cava syndrome
- Obstruction of the superior vena cava can be caused by tumour growth within or outside the vessel or by a thrombus.
- The symptoms include dyspnoea, facial and neck oedema, chest pain, cough and pronounced veins on the neck and chest.
- In 80% of cases the underlying disease is lung cancer, in 10-20% lymphoma and in about 10% other types of cancer, such as breast cancer.
- CT should be used as the diagnostic examination.
- For first aid, give a high-dose glucocorticoid (oral/intravenous dexamethasone 6-10 mg 3 times daily).
- Initiate anticoagulation, unless there are contraindications.
- The treatment is urgent radiotherapy; consult a radiation oncologist. In patients with lymphoma, it may be enough to start cancer treatment.
- Cardiac tamponade
- Deep vein thrombosis (DVT) Deep Vein Thrombosis and pulmonary embolism Pulmonary Embolism are common in cancer patients.
Metabolic emergencies
- Hypercalcaemia Hypercalcaemia and Hyperparathyroidism
- Tumour lysis syndrome
- Tumour lysis syndrome develops when antineoplastic medication or radiotherapy rapidly destroys large numbers of tumour cells, the released substances causing metabolic imbalance and renal damage.
- The risk of the syndrome is highest in the case of cancers with rapidly dividing cells and a large tumour mass, such as aggressive lymphomas.
- The most important form of treatment is prevention, i.e. fluid administration, allopurinol, monitoring of diuresis and weight, pausing medication with renal toxicity, and treatment of electrolyte disturbances. For curative treatments, consult a nephrologist on the need for dialysis.
Gastrointestinal emergencies
Skeletal emergencies
- Pathological fractures occur in 8-30% of cancer patients. They are most common in patients with myeloma, breast cancer or prostate cancer.
- The most common fracture sites are ribs, the pelvis, long bones, such as the femur or the humerus, and vertebrae.
- For fractures of weight-bearing bones, operative treatment and postoperative adjuvant radiotherapy of the fracture area; otherwise, radiotherapy, only
- Prophylactic radiotherapy or prosthetic surgery of any foci with risk of fracture
- Bone medication: calcium-vitamin D supplementation, denosumab, bisphosphonates
- Spinal cord compression, see above here
Haematological and other emergencies
References
- Thandra K, Salah Z, Chawla S. Oncologic Emergencies-The Old, the New, and the Deadly. J Intensive Care Med 2020;35(1):3-13. [PubMed]