This document discusses various oncologic emergencies that can arise as complications of malignancy. It covers emergencies such as upper airway obstruction, malignant pericardial tamponade, superior vena cava syndrome, acute spinal cord compression, hypercalcemia, hyperviscosity syndrome, and others. For each emergency, it describes the typical causative tumors, symptoms, diagnosis, and treatment approaches. The goal is to highlight life-threatening complications of cancer and how emergency physicians can recognize and initially manage these conditions.

1. Oncologic
Emergencies
Jim Holliman, M.D., F.A.C.E.P.
Professor of Military and Emergency Medicine
Uniformed Services University of the Health Sciences
Clinical Professor of Emergency Medicine
George Washington University
Bethesda, Maryland, U.S.A.

2. Oncologic Emergencies
Introduction
ƒ Malignancy is 2nd leading cause of
death in U.S.
ƒ Now cancer has 52 % 5 year
survival overall
ƒ Rx of complications can be life-
saving since causative tumor often
is curable
ƒ Rx of complications can, at a
minimum, improve quality of life

3. List of Major Emergency
Complications of
Malignancy
ƒ Upper airway obstruction
ƒ Malignant pericardial tamponade
ƒ Superior vena cava syndrome
ƒ Acute spinal cord compression
ƒ Hypercalcemia
ƒ Hyperviscosity syndrome
ƒ Hyperleukocytic syndrome
ƒ Acute tumor lysis syndrome
ƒ SIADH
ƒ Adrenal insufficiency / crisis
ƒ Thrombocytopenia / hemorrhage
ƒ Immunosuppression / infection

4. Upper Airway Obstruction
by Malignancy
ƒ Causative tumors :
–Laryngeal ca
–Thyroid ca
–Lymphoma
–Metastatic lung ca
ƒ Retropharyngeal abscess

5. Upper Airway Obstruction
by Malignancy
ƒ Symptoms
–Voice change
–Hoarseness
–Neck fullness
–Dysphagia
–Stridor
–Dyspnea
ƒ Usually progresses & presents subacutely,
unless food aspiration, infection, hemorrhage,
or inspissated secretions occur

6. Upper Airway Obstruction
by Malignancy
ƒ Diagnosis
–Lateral soft tissue neck film
–CXR
–Fiberoptic laryngoscopy

7. Tracheal deviation
from a substernal
goiter

8. Upper Airway Obstruction
by Malignancy
ƒ Treatment
–Oxygen
–Racemic epinephrine aerosol (1.0 to 1.5
cc)
–Helium / oxygen (Heliox) inhalation
–? IV steroids or diuretics
–Intubation over fiberoptic laryngoscope
–Consider tracheostomy
–? emergency radiation Rx

9. Malignant Pericardial
Tamponade
ƒ Causative tumors :
–Melanoma
–Hodgkin's lymphoma
–Acute leukemia
–Lung ca
–Breast ca
–Ovarian ca
ƒ Radiation pericarditis
ƒ Rare to be initial presentation of
malignancy

10. Malignant Pericardial
Tamponade
ƒ Sx and Signs :
–Dyspnea / weakness +/- chest pain
–Hypotension / narrow pulse pressure
–Friction rub rare
–Jugular venous distention
–Muffled (decreased) heart tones
–Pulsus paradoxicus > 10 mm Hg
–Low EKG QRS voltage +/- pulsus
alternans
–+/- cardiomegaly on CXR

11. Malignant Pericardial
Tamponade
ƒ Dx :
–Echocardiography
–Equalization of heart chamber pressures
ƒ Rx options :
–Needle catheter pericardiocentesis
–Pericardial window under local anesthesia
–Radiation Rx
–Pericardiectomy
–Intrapericardial chemoRx or sclerosis

12. Septum
Posterior
ventricular
wall
Pericardial
effusion
M mode echocardiogram showing malignant
pericardial effusion

13. M mode echo showing moderate size pericardial effusion (P)

14. Two dimensional echo in same patient showing pericardial
effusion (P)

15. Superior Vena Cava (SVC)
Syndrome
ƒ Causative tumors :
–Small cell (oat cell) lung ca
–Squamous cell lung ca
–Lymphoma
–Anaplastic mediastinal ca
ƒ SVC thrombosis from indwelling
catheter
ƒ Sx are due to SVC compression or
occlusion

16. SVC Syndrome
SYMPTOM FREQUENCY (%)
Dyspnea 83
Cough 70
Orthopnea 64
Nasal congestion 35
Hoarseness 35
Stridor 33
Dizziness 29
Stupor / coma 20
Other sx : syncope, headache, dysphagia,
epistaxis

17. SVC Syndrome
SIGN FREQUENCY (%)
Neck vein distention 92
Facial swelling / fullness 86
Arm vein distention 68
Mentation changes 27
Tongue edema 24
Laryngeal edema 24
Rhinorrhea 18

18. SVC Syndrome
ƒ Less common signs :
–Facial plethora / telangiectasia
–Supraclavicular palpable mass
–Horner's syndrome
–Papilledema
ƒ If present, represents a true
emergency

19. Patient with SVC
Syndrome

20. Another patient with SVC Syndrome

21. SVC Syndrome from small cell lung cancer

22. SVC Syndrome from lung adenocarcinoma

23. SVC Syndrome
ƒ Diagnosis
–CXR abnormal in 84 %
–Confirm with (one of ) :
ƒ Chest CT with contrast
ƒ MRI
ƒ Contrast venography
ƒ Tc99m radionuclide venography

24. Anaplastic cancer of
the mediastinum
causing SVC
Syndrome

25. Mediastinal widening and pulmonary venous obstruction from
lung cancer

26. Chest computed tomography showing right sided mediastinal
lung cancer compressing the contrast filled SVC

27. Another CT cut of the same patient showing tumor
compression of the SVC

30. 37 year old male who presented with sudden onset of venous
stasis, hoarseness, and hemoptysis

31. Chest X-ray of same patient who proved to have squamous cell
cancer of the lung blocking the left subclavian vein

32. SVC Syndrome
ƒ Treatment :
–Keep in head-up position
–IV steroids
–IV diuretics
–? anticoagulants or thrombolytics
–Emergent mediastinal radiation Rx
–Remove central IV catheter if present

33. Acute Spinal Cord
Compression
ƒ Causative tumors :
–Breast ca
–Lung ca
–Prostate ca
–Lymphomas
–Multiple myeloma
–Renal cell ca
–Sarcomas
ƒ Epidural abscess / hematoma
ƒ 18,000 cases per year in U.S.

34. Acute Spinal Cord
Compression
ƒ Symptoms :
–Localized back pain +/- tenderness
ƒ May be absent with lymphomas
–Paraparesis / paraplegia
–Distal sensory deficits
–Urinary incontinence

35. Acute Spinal Cord
Compression
ƒ Cervical, thoracic, or lumbar spine films : 85 %
abnormal
–May not be needed if CT or MRI planned
anyway
ƒ Radionuclide bone scan
–Sensitivity > 90 % except for multiple myeloma
ƒ Spine CT with contrast
ƒ MRI
ƒ Myelography
ƒ NOTE : any studies done should be in emergent
time frame & with early involvement of

36. MRI scan showing multiple myeloma destroying the C6 vertebra
and surrounding the spinal cord

37. 40 year old male who
presented with neck pain ;
he had a metastatic
hypernephroma which
destroyed the odontoid

38. Myelogram showing
breast cancer metastasis
pressing on the L5 nerve
root, and also pushing
the thecal sac posteriorly
at L4

39. T1 MRI of same patient showing compression of the L5 nerve
root

40. Acute Spinal Cord
Compression
ƒ Treatment
–Spine immobilization
–Foley catheter
–? IV steroids / diuretic / mannitol
–Emergent decompressive laminectomy
or radiation Rx

41. Hypercalcemia of
Malignancy
ƒ Causative tumors
–Metastatic breast, lung, or prostate ca
–Multiple myeloma
–Non-Hodgkin's lymphoma
–Adult T-cell lymphoma / leukemia
–Renal cell ca
–Head & neck squamous cell ca

42. Malignancy Hypercalcemia
ƒ Symptoms
–Vague malaise / weakness
–Polydipsia
–Lethargy / confusion
–Constipation
–Vomiting
–Back pain
–Can have coma or seizures

43. Malignancy Hypercalcemia
ƒ Diagnosis
–Total & ionized serum calcium
–Serum albumin sometimes helpful
–EKG shows short QT interval
ƒ May show low voltage, long PR
–Discrete skeletal lesions not
demonstrable in 30 % of patients
ƒ Serum levels > 12 mg % dangerous

44. EKG showing short QT interval (0.28 seconds) in a patient with
a serum calcium of 14 mg/dl

45. Malignancy Hypercalcemia
Treatment
ƒ IV hydration with normal saline
ƒ Diuresis with IV furosemide
–Only after fluid loading ; avoid thiazides
ƒ IV steroids
ƒ Etidronate (7.5 mg/kg/day IV for 3 days)
ƒ Mithramycin (15 to 25 mcg/kg/day IV x 3
days)
ƒ Radiation Rx to tumor site(s)
ƒ Rarely may need hemodialysis

46. Considerations for Use of Etidronate
(Didronel) for Rx of Malignant
Hypercalcemia
ƒ Acts mainly to reduce bone resorption
ƒ Mainly excreted renally
ƒ Causes some degree of hyperphosphatemia
ƒ Should be withheld if creatinine > 5 mg %
ƒ Dose (must be diluted in 250 cc NS) :
–7.5 mg/kg/day IV for 3 days
–Dose should be given over 2 hours
ƒ Followup Rx with oral tablets
–20 mg/kg/day for 30 days

47. Use of Mithramycin (Plicamycin) for
Rx of Malignancy Hypercalcemia
ƒ Acts as antineoplastic agent
ƒ Method of action on hypercalcemia
not known
ƒ Main complication is bleeding
ƒ GI side effects common
ƒ Can cause thrombocytopenia
ƒ Most useful as second agent for
cases not responsive to etidronate

48. Hyperviscosity Syndrome
ƒ Basic cause is elevation of serum
proteins producing sludging &
reduction in microcirculatory
perfusion
ƒ Serum viscosity is normally 1.4 to
1.8 times that of water
ƒ Symptoms develop at viscosity > 5

49. Hyperviscosity Syndrome
ƒ Causative tumors
–Multiple myeloma
–Waldenstrom's macroglobulinemia
–Chronic myelocytic leukemia

50. Hyperviscosity Syndrome
Symptoms
ƒ Fatigue / malaise
ƒ Headache
ƒ Anorexia
ƒ Somnolence
ƒ If microthromboses occur :
–Deafness
–Visual deficits
–Seizures

51. Hyperviscosity Syndrome
Diagnosis
ƒ Anemia
ƒ Rouleaux formation on peripheral blood
smear
ƒ Retinal hemorrhages / exudates
ƒ "Sausage-link" appearance of retinal vessels
ƒ Factitious hyponatremia (due to H2O
displacement)
ƒ Measurement of serum viscosity & serum
protein electrophoresis (SPEP) confirm Dx

52. Hyperviscosity Syndrome
Treatment
ƒ If comatose :
–Emergent 2 unit phlebotomy & saline
infusion
ƒ Rehydration with IV saline
ƒ Emergency plasmapheresis
ƒ If patient has CML & massive
leucocytosis : leukopheresis &
concurrent chemoRx

53. Hyperleukocytic Syndrome
ƒ Usually occurs in new onset acute
myelocytic leukemia
ƒ Can occur in CML with blast crisis
ƒ WBC > 100 k in AML is dangerous
ƒ WBC > 250 k in CML is dangerous
ƒ Myeloblasts invade & damage vessel walls,
esp. in brain & lung
ƒ Serum analyses show pseudohypoxia,
pseudohyperkalemia, & pseudohypoglycemia

54. Hyperleukocytic Syndrome
ƒ Symptoms
–Marked dyspnea
–Headache, confusion
ƒ Signs
–Hypoxia
–Diffuse lung infiltrates
–Neuro deficits

55. Hyperleukocytic Syndrome
Treatment
ƒ Temporizing with leukopheresis
ƒ Load with allopurinol (600 mg/M2)
ƒ Then give hydroxyurea 3 to 5
gm/M2
ƒ Brain radiation Rx for CNS
leukostasis
ƒ Definitive chemoRx once WBC
decreased

56. Acute Tumor Lysis
Syndrome
ƒ Usually occurs 6 to 72 hours after
initiation of chemoRx or radiation
Rx
ƒ Due to rapid release of cell contents
into bloodstream
ƒ Most common tumor causes :
–Leukemias (with high WBC counts)
–Lymphomas
–Small cell ca
–Metastatic adenoca

57. Acute Tumor Lysis
Syndrome
Etiologic Factors
ƒ Large tumor burden
ƒ High growth fraction
ƒ High preRx serum LDH or uric acid
ƒ Preexisting renal insufficiency

58. Acute Tumor Lysis
Syndrome
ƒ Main life-threatening problems :
–Hyperkalemia
–Hyperuricemia (causes uric acid
nephropathy)
–Hyperphosphatemia with secondary
hypocalcemia
ƒ Can result in acute renal failure &
arrhythmias

59. Acute Tumor Lysis
Syndrome
Treatment
ƒ Stop the chemoRx
ƒ Aggressive IV hydration / diuresis
ƒ +/- alkalinize urine to pH 7
–Decreases urate but may worsen hypocalcemic tetany
ƒ CaCl2, NaHCO3, glucose / insulin, kayexalate
for hyperkalemia
ƒ Emergency hemodialysis
–If K > 6, urate > 10, creat. > 10, or unable to tolerate
diuresis
ƒ Can use allopurinol for prevention

60. Syndrome of Inappropriate
Antidiuretic Hormone Secretion
(SIADH)
ƒ Causative tumors :
–Small cell lung ca most common (ectopic ADH)
–Pancreatic ca
–Bowel ca
–Thymus ca
–Prostate ca
–Lymphosarcoma
–Any brain tumor
ƒ Vincristine or cyclophosphamide
ƒ Other meds (narcotics, phenothiazines, etc.)

61. SIADH
Symptoms
ƒ Altered mental status
–lethargy
–confusion
ƒ Anorexia, nausea, vomiting
ƒ Peripheral edema
ƒ If severe, coma or seizures

62. SIADH
Diagnosis
ƒ Normal renal, thyroid, adrenal, &
cardiac function
ƒ Absence of diuretic Rx
ƒ Euvolemia or hypervolemia
ƒ Hyponatremia with less than
maximally dilute urine
ƒ Excessive urine Na excretion (> 30
meq/liter)

63. SIADH
Treatment
ƒ Serum Na > 125 usually not require Rx
ƒ Fluid restriction only, if mild
ƒ Furosemide with NS bolus (increases free water
clearance)
ƒ Hypertonic saline (3 %) only needed for :
–seizures
–coma
–cardiovascular compromise
ƒ Only correct at about 1 meq/liter/hour (if too fast can
cause central pontine myelinolysis)
ƒ Seizure control with benzodiazepines

64. Malignancy - Caused Adrenal
Crisis
ƒ Causative tumors :
–Melanoma
–Lung ca
–Breast ca
–Renal & other retroperitoneal ca's
ƒ Withdrawl of chronic steroid Rx
ƒ Infection of adrenals
ƒ Adrenal hemorrhage
ƒ Aminoglutethamide chemoRx

65. Malignancy - Caused Adrenal
Crisis
ƒ Symptoms
–weakness, lethargy
–thirst
ƒ Signs
–Dehydration
–Hypotension
–Hyponatremia, hyperkalemia,
hypoglycemia, azotemia, +/-
eosinophilia

66. Malignancy - Caused Adrenal
Crisis
ƒ Diagnosis
–Serum electrolytes, BUN
–Serum cortisol (draw prior to Rx)
–Computed tomography of
retroperitoneum (+/- MRI)
ƒ Start Rx prior to full workup

67. Malignancy - Caused Adrenal
Crisis
Treatment
ƒ IV fluid bolus (NS)
ƒ IV steroids (at least 300 mg
equivalents of hydrocortisone per
day initially)
ƒ +/- calcium, NaHCO3, glucose /
insulin for hyperkalemia
ƒ IV glucose
ƒ Evaluate for source of infection
ƒ Maintain steroid coverage

68. Hemorrhagic Syndromes in
Malignancy *
ƒ Thrombocytopenia
ƒ Disseminated intravascular coagulation
(DIC)
ƒ Decreased clotting factors
ƒ Primary fibrinolysis
ƒ Platelet dysfunction
ƒ Vascular defects
ƒ Circulating anticoagulants
(* in decreasing
order of
probability)

69. Mechanisms of
Thrombocytopenia in
Malignancy
ƒ ChemoRx
ƒ Radiation Rx
ƒ Bone marrow tumor infiltration
ƒ Hypersplenism
ƒ DIC
ƒ Infection - induced
ƒ ITP

70. Thrombocytopenia in
Malignancy
ƒ Avoid all NSAID's
ƒ Spontaneous bleeds can occur if
platelets < 10 K
ƒ Platelet transfusion indications :
–count < 5000
–Any CNS bleed (even if count > 10 k)
–Avoid in consumptive states
–Use HLA matched single donor
platelets if sensitized

71. Malignancy - Related DIC
ƒ Possible with any tumor but usually due to :
–acute leukemia (esp. promyelocytic)
–pancreas ca
–prostate ca
ƒ Can be acute or chronic
–Acute : platelets, PT, PTT, FDP, fibrinogen
ƒ Rx with platelets & clotting factors
ƒ May need tumor debulking
–Chronic : lab results may be near normal ; Rx
intravascular thrombosis with heparin

72. Malignancy - Related Primary
Fibrinolysis
ƒ Some tumors cause spontaneous
fibrinolytic activity :
–Sarcomas
–Breast ca
–Colon ca
–Gastric ca
–Thyroid ca
ƒ Show increased FDP's
ƒ Rx with epsilon aminocaproic acid

73. Treatment- Related
Bleeding Disorders in
Malignancy
ƒ Due to specific chemoRx agents :
–Plicamycin : thrombocytopenia, DIC
–L-asparaginase : hypofibrinogenemia
–Mitomycin : microangiopathic
hemolytic anemia
–Actinomycin D : vitamin K antagonist
–Daunorubicin : primary fibrinolysis
ƒ Initiation of DIC by cytotoxic
effects

74. Malignancy - Related
Immunosuppression / Infection
ƒ Causative tumors
–Almost all
–Also due to chemoRx or radiation Rx
directly
ƒ If fever & neutrophil plus band count is
< 500 per mm3, presume serious
infection present
–Most common source is endogenous
microbes
–Rx with antipseudomonal med plus 3rd
generation cephalosporin +/- amphotericin

75. Oncologic Emergencies
Summary
ƒ Have low threshold for workup of
vague symptoms in the cancer
patient
ƒ Consider direct effects of meds
ƒ Treat complications aggressively if
primary tumor still treatable
ƒ Have prearranged referral
arrangements for special emergent
Rx's