aware of the common complications associated with malignancies and available treatments. These complications can be broadly divided into those created by local tumor effects, complications from hematologic derange ­

 

Tintinalli's Emergency Medicine: A Comprehensive Study

Guide. 7th ed. New York, NY: McGraw-Hill, 20 l l,pp. l453-1456.

Peacy SR, Guo CY, Robinson AM, et al. Glucocorticoid replace ­

ment therapy: are patients over treated and does it matter? Clin

Endocrinol (Oxf). 1 997;46:255.

Stewart PM, Krone NP. The adrenal cortex. In: Kronnenberg H,

Melmed S, Polonsky K, Larson PR, eds. Williams Textbook

of Endocrinology. 1 2th ed. Philadelphia, PA: Saunders

Elsevier, 20 11, Pages 479-544.

Oncologic Emergencies

Biswadev Mitra, MD

Key Points

• Spinal cord compression should be considered in any

patient presenting to the emergency department with a

neurologic complaint and a history of malignancy.

• Electrolyte abnormal ities should be considered in all

patients with malignancy and nonspecific symptoms.

INTRODUCTION

Improvements in the management of cancer have lead to

an aging population presenting to emergency departments

(EDs) with complications related to malignant disease.

Oncologic emergencies occur in patients with recurrence

of a previously diagnosed malignancy, complications of

cancer treatment, or signs and symptoms that may lead to

a new diagnosis of cancer. Emergency clinicians must be

aware of the common complications associated with

malignancies and available treatments. These complications can be broadly divided into those created by local

tumor effects, complications from hematologic derange ­

ments and biochemical abnormalities, and complications

related to cancer treatment. When caring for patients with

oncologic related emergencies in the ED, consideration

should always be given to the nature of medical therapy

warranted in view of progression of the disease. Early

consultation with family members and stakeholders is

advised.

Emergencies related to local tumor invasion include

spinal cord compression and superior vena cava (SVC)

syndrome. Both are oncologic emergencies that require

prompt intervention. The most common primary tumors

that metastasize to the spine are lung (29%), prostate (19%),

and breast (13%). The thoracic spine is the most common

site involved (77%). The lumbar spine is affected 29% of

• Patients undergoing chemotherapy who present with

fever should be considered neutropenic until proven

otherwise.

the time with the cervical ( 12%) and sacral (7%) regions

being affected least often.

SVC syndrome is defined as obstruction of flow through

the superior vena cava due to tumor-related compression.

Lung cancer and non-Hodgkin lymphoma together cause

about 95% of cancer-related SVC syndrome. The incidence

of SVC syndrome in patients with lung cancer and nonHodgkin lymphoma is 2-4%. Thrombosis related to central

venous catheters can also cause SVC syndrome in patients

with cancer as a result of their prothrombotic state.

Emergencies related to biochemical derangements in

the cancer patient include hypercalcemia and tumor lysis

syndrome. Hypercalcemia has been reported to occur in

20-30% of patients with cancer at some time during the

course of their disease. It occurs most commonly in cancers associated with bone (multiple myeloma), bony

metastasis (breast, lung, prostate, renal), or cancers that

secrete parathyroid-like substance (lung) or osteoclastic

factors (lymphomas). The detection of hypercalcemia in a

patient with cancer signifies a very poor prognosis, with

death often occurring within months.

Tumor lysis syndrome is the most common diseaserelated emergency encountered in patients with hematologic

cancers. The syndrome occurs when tumor cells release their

contents into the bloodstream, either spontaneously or in

response to therapy, leading to the characteristic findings of

hyperuricemia, hyperkalemia, hyperphosphatemia, and

295