Oncologic Emergencies
Life-threatening complications of malignancy requiring immediate recognition: SVC syndrome, cord compression, brain mets, hyperviscosity, and tumor lysis.
🔍 Overview
Overview
Oncologic emergencies are complications of cancer or its treatment that require immediate intervention to prevent death or irreversible organ damage. The key emergencies: (1) Superior vena cava (SVC) syndrome -obstruction of SVC, usually by lung cancer or lymphoma. (2) Malignant spinal cord compression (MSCC) -epidural metastasis compressing the cord. (3) Brain metastases with herniation -elevated ICP. (4) Hyperviscosity syndrome -Waldenström macroglobulinemia or multiple myeloma. (5) Tumor lysis syndrome -covered separately. (6) Febrile neutropenia -covered separately. (7) Malignant pericardial effusion/tamponade. The intern's role: recognize the pattern, start dexamethasone, and call oncology/radiation/surgery.
🧪 Workup
Workup
- SVC syndrome: CT chest with contrast (confirms obstruction + identifies cause). CXR may show widened mediastinum. Tissue diagnosis before radiation if patient is stable.
- Cord compression: MRI entire spine with contrast -gold standard. Order STAT. Must image ENTIRE spine (multiple levels in 10-38%). Check post-void residual (early bladder dysfunction).
- Brain mets: MRI brain with contrast. CT if MRI unavailable. Fundoscopy for papilledema. Assess for midline shift and herniation signs.
- Hyperviscosity: Serum viscosity (> 4-5 cP = symptomatic). Fundoscopy ("sausage-link" retinal veins). SPEP + serum free light chains. Peripheral smear (rouleaux).
- Malignant tamponade: Echocardiography (pericardial effusion + RA/RV diastolic collapse). Pulsus paradoxus > 10 mmHg. ECG: low voltage, electrical alternans.
🚨 Management
Management
- SVC syndrome: Elevate HOB. Dexamethasone 10 mg IV (if lymphoma suspected -exquisitely steroid-sensitive). Radiation therapy for NSCLC. Endovascular stenting for rapid relief. Anticoagulation if thrombus. Do NOT delay treatment for tissue diagnosis if severely symptomatic.
- Cord compression: Dexamethasone 10 mg IV STAT → 4 mg IV q6h. Must give within 24h of symptom onset -neurologic outcome correlates with pre-treatment function. Radiation (most common treatment). Surgery if: unknown primary (need tissue), radioresistant tumor, mechanical instability, or single-level disease with good prognosis. Patchell, Lancet 2005
- Brain mets: Dexamethasone 10 mg IV → 4 mg q6h (reduce edema). Anticonvulsants only if seizure has occurred (not prophylactic). Surgery for single resectable met with controlled primary. SRS (stereotactic radiosurgery) for ≤ 4 mets. WBRT for diffuse mets or poor prognosis.
- Hyperviscosity: Emergent plasmapheresis. Avoid pRBC transfusion before pheresis (increases viscosity further). Start definitive chemotherapy after pheresis.
- Tamponade: Pericardiocentesis (echo-guided). Pericardial window if recurrent. Intrapericardial chemotherapy or sclerotherapy for malignant effusions.
💊 Medications
Medications
| Drug | Dose | Route | Notes |
|---|---|---|---|
| Dexamethasone | 10 mg IV bolus → 4 mg q6h | IV | For cord compression, brain mets, SVC (lymphoma). Reduces vasogenic edema. Start immediately -do not wait for imaging. |
| Levetiracetam | 500-1000 mg BID | IV/PO | If seizure with brain mets. NOT for prophylaxis in brain mets without seizure. |
| Mannitol | 0.5-1 g/kg IV | IV | Impending herniation from brain mets. Osmotic diuresis reduces ICP. Bridge to dexamethasone effect. |
| Hypertonic saline 3% | 150-250 mL bolus | IV | Alternative to mannitol for acute ICP crisis. |
| Radiation therapy | Per radiation oncology | - | Mainstay for cord compression, SVC (solid tumors), brain mets (WBRT/SRS). |
| Heparin | Weight-based | IV | SVC syndrome with associated thrombus. |
Monitoring
- Neuro exam q4h -for cord compression and brain mets. Motor strength, sensory level, rectal tone, post-void residual. Deterioration = urgent re-imaging.
- Serum viscosity -before and after plasmapheresis. Target < 4 cP.
- Blood glucose -high-dose dexamethasone causes significant hyperglycemia. Sliding scale insulin + glucose checks q6h.
- Pericardial effusion reaccumulation -repeat echo at 24-48h post-pericardiocentesis. 40-70% recurrence rate with malignant effusions.
- Respiratory status -SVC syndrome patients at risk for airway compromise. Keep intubation equipment at bedside.
🏥 Rounds
Pimp Questions
❓ What is the most important prognostic factor in malignant cord compression?
Pre-treatment neurologic status. Patients who are ambulatory at diagnosis have ~80% chance of remaining ambulatory. Patients who are paraplegic at diagnosis have < 10% chance of regaining ambulation. This is why immediate dexamethasone and urgent imaging matter -every hour counts. Patchell, 2005
❓ Why do you NOT give prophylactic anticonvulsants for brain metastases?
Multiple RCTs show no benefit from prophylactic AEDs in brain mets without prior seizure, AND significant side effects (rash, drug interactions with chemo, sedation). AAN guidelines explicitly recommend against prophylaxis. Treat only if seizure has occurred. Levetiracetam preferred (fewer drug interactions than phenytoin).
❓ Why should you avoid pRBC transfusion before plasmapheresis in hyperviscosity?
Transfusing pRBCs increases blood viscosity further by raising hematocrit. In a patient already symptomatic from hyperviscosity (IgM paraprotein causing sludging), this can precipitate stroke, retinal vein occlusion, or cardiac failure. Do plasmapheresis FIRST, then transfuse if needed afterward.
❓ Name the classic triad of SVC syndrome.
Facial/upper extremity edema + dyspnea + distended neck/chest wall veins. Worse when leaning forward or lying flat. Pemberton sign: facial plethora + cyanosis when arms raised above head. Most common cause: lung cancer (especially right-sided). Second: lymphoma (more steroid-responsive).
❓ What imaging do you order for suspected cord compression and why must you image the entire spine?
MRI entire spine with gadolinium contrast -gold standard. Must image the ENTIRE spine because 10-38% of patients have multiple levels of compression. Treating only the symptomatic level while missing another will lead to treatment failure. CT myelography is an alternative if MRI contraindicated.
❓ When is surgery preferred over radiation for cord compression?
Surgery (decompressive laminectomy ± stabilization) is preferred when: (1) unknown primary (need tissue for diagnosis), (2) radioresistant tumor (renal cell, melanoma), (3) mechanical spinal instability, (4) single level of disease with good overall prognosis, (5) progression during or after radiation. Patchell, 2005 showed surgery + RT was superior to RT alone for single-level compression.
Sample Presentation
Mr. Johnson is a 62-year-old man with known Stage IV NSCLC (right upper lobe, 3 cycles of pembrolizumab) presenting with 2 days of progressive lower extremity weakness and urinary retention. Exam: 4/5 hip flexors bilateral, absent ankle reflexes, T10 sensory level, post-void residual 400 mL. No saddle anesthesia. VS stable. MRI spine: T9-T10 epidural mass with cord compression.
Key Points: This is MSCC -give dexamethasone 10 mg IV STAT, consult radiation oncology AND spine surgery. Motor function at presentation is the strongest predictor of outcome. Ambulatory at diagnosis → 80% remain ambulatory. Non-ambulatory → only 10-20% regain walking.
📋 Summary
Summary
The Ones That Cannot Wait
Spinal cord compression, superior vena cava syndrome with airway compromise, raised intracranial pressure from brain metastases, tumor lysis syndrome, hypercalcemia of malignancy, neutropenic fever, hyperviscosity and leukostasis. Several present before the cancer is known, so the absence of an oncology history is not reassuring.
Cord Compression: Steroids Before Imaging
Back pain precedes neurologic deficit by weeks in most patients, and it is the point at which the outcome is still recoverable. Give dexamethasone 10 mg IV immediately, then 4 mg q6h, and get an urgent MRI of the whole spine (whole spine, because multilevel disease is common). Function at the time of treatment is the strongest predictor of function afterward, so a patient who can still walk is an emergency, not a next-morning MRI.
SVC Syndrome Is Rarely a True Airway Emergency
Facial and upper limb swelling, distended neck and chest veins, orthopnea. Get tissue before treating when the patient is stable, because steroids or radiation can make a lymphoma unbiopsiable and lymphoma is curable. Stridor, airway compromise or depressed consciousness change that: those need immediate intervention, endovascular stenting being the fastest option. Anticoagulate if there is associated thrombus.
Brain Metastases and Raised ICP
Dexamethasone reduces vasogenic edema and often improves symptoms within hours. Mannitol 0.5 to 1 g/kg or hypertonic saline for impending herniation, then urgent neurosurgical and radiation oncology input. Do not give prophylactic antiepileptics to a patient who has not had a seizure: they do not prevent the first seizure and add interactions and toxicity. Treat seizures that occur, with levetiracetam preferred.
Tumor Lysis Syndrome
High potassium, high phosphate, high uric acid and low calcium, with acute kidney injury. Prevent rather than treat: aggressive fluids plus allopurinol, and rasburicase for high-risk disease or an already raised uric acid (contraindicated in G6PD deficiency). Labs every 6 to 8 h during the first cycle. Do not correct asymptomatic hypocalcemia, because calcium-phosphate precipitation worsens the renal injury.
Hypercalcemia of Malignancy
Aggressive isotonic saline first, then a bisphosphonate (zoledronic acid), which takes 2 to 4 days to work, with calcitonin as the bridge for the first 48 h. Denosumab when renal function precludes a bisphosphonate. Avoid loop diuretics unless the patient is volume overloaded: that is old teaching, and diuresing a dehydrated patient worsens the calcium. It signals a poor prognosis, so it is also a prompt for a goals-of-care conversation.
Neutropenic Fever Is a One-Hour Antibiotic
A single temperature of 38.3°C, or 38.0°C sustained for an hour, with ANC below 500. Blood cultures then broad-spectrum antipseudomonal antibiotics within 1 hour, before imaging and before a source is identified. These patients cannot mount inflammation, so the usual localizing signs may be entirely absent and a benign examination does not mean a benign infection.
Hyperviscosity and Leukostasis
Bleeding, visual change and neurologic symptoms with a paraprotein (usually IgM in Waldenstrom) or an extreme white count. Paraprotein → plasmapheresis. Leukostasis → leukapheresis plus hydroxyurea and urgent cytoreduction. Do not transfuse red cells before the viscosity is lowered: raising the hematocrit worsens sludging and can precipitate stroke or infarction.
Related Topics
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