Acute oncology 1: oncological emergencies

Abstract

Introduction An oncological emergency is an acute medical problem related to cancer or its treatment which may result in serious morbidity or mortality if not treated quickly. It may be secondary to a structural/obstructive, metabolic or treatment-related complication (Cervantes and Chirivella, 2004). The emergency may be the first manifestation of malignant disease, particularly for superior vena cava obstruction (SVCO) and malignant spinal cord compression (MSCC). Around 20–30% of all cancer patients suffer from hypercalcaemia. Spinal cord compression is the commonest neurological complication of cancer, occuring in approximately 5–10% of all cancer patients. Thrombotic events are the second leading cause of death in cancer patients after death from cancer itself. Types of emergency Metabolic emergencies include: • hypercalcaemia, • syndrome of inappropriate antidiuretic hormone (SIADH). Structural/obstructive emergencies include: • MSCC and cauda equina compression, • SVCO, • raised intracranial pressure, • acute airway obstruction, • bleeding, • urinary obstruction, • cardiac tamponade, • pain: this has been named the ‘fifth vital sign’ following pulse, blood pressure, temperature and respiration; when pain is present it should evoke an immediate response. Treatment of pain is considered in Chapter 10 . • thromboembolic disease. Treatment-related emergencies include: • neutropenic fever/sepsis, • anaphylaxis related to a chemotherapeutic agent, • tumour lysis syndrome, • extravasation of a chemotherapeutic agent . Treatment overview As with any acute medical emergency, resuscitation measures may be needed to ensure that airway, breathing and circulation are maintained. Adequate hydration, oxygen and monitoring of fluid balance are particularly important in patients with sepsis or tumour lysis syndrome. Steroids are used in patients with SVCO and suspected spinal cord compression, although the evidence base supporting their use is poor. Mannitol infusions may be needed for severe symptomatic raised intracranial pressure that does not respond to steroids. Pain, breathlessness and distress should be treated as priorities, especially in patients presenting with end-stage cancer and an oncological emergency. The WHO pain ladder is a suitable framework to guide appropriate analgesic use. Some seriously ill patients may need to be transferred to a high-dependency unit (HDU) or intensive therapy unit (ITU), especially those with a treatable malignancy and a good prognosis and those who develop complications of curative chemotherapy. Liaison with specialist colleagues at an early stage is recommended.