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.
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
Most commonly associated with melanoma, leukaemias, lymphomas, lung, breast or oesophageal cancer.
May be the first symptom of cancer, develop as the disease progresses, or be an adverse effect of antineoplastic agents (immuno-oncological treatments, in particular) and radiotherapy; sometimes it is an asymptomatic imaging finding.
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.
Develops in the area of necrotic tumour mass or, in case of obstruction, above the obstruction. A rapid response to the treatment of intestinal wall lymphomas may also cause perforation.
Can occur as an adverse effect of antineoplastic agents (bevacizumab, complication of colic caused by treatment with immuno-oncological drugs)
Symptoms of peritonitis following perforation may be masked in patients who are on glucocorticoids or are neutropenic.
Various autoimmune inflammatory reactions associated with immuno-oncological agents
Patients may present to emergency services with symptoms suggesting undiagnosed cancer. If so, in addition to treating the symptoms, diagnostic tests should be initiated; consult an oncologist.
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]