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- Patients with malignancy are subject to life-threatening complications of the primary disease, its treatment, or coexisting medical diseases.
- Oncologic emergencies should be treated when they are associated with higher acute morbidity and mortality than the underlying malignancy.
- In patients who are terminally ill from their malignancy, restraint should be exercised in the diagnosis and management of oncologic complications.
- A high index of suspicion must be maintained for oncologic complications to be recognized because they often share features with other common medical illnesses.
- Frequent examination of critically ill patients is necessary because such patients (often intubated, bed-bound, hypotensive) are often unable to verbalize changes in their condition.
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This chapter details the epidemiology, pathophysiology, clinical presentation, diagnostic approaches, and treatment modalities of the most common oncologic emergencies. Because of the systemic nature of cancer, these emergencies often affect organ systems remote from the original cancer, making diagnosis challenging. To recognize these disorders, it is important to develop a differential diagnosis for common signs and symptoms that occur in critically ill patients (Table 72-1). Given the long natural history of many advanced cancers, the successful diagnosis and management of these emergencies may be rewarded with prolonged survival. However, when cancer patients become end stage, the same invasive diagnostic procedures and aggressive treatments may be onerous. Decisions regarding management of these patients may be best made through discussions among the patient, the primary oncologist, the family, and the treating physician.
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Superior Vena Cava Syndrome
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Superior vena cava (SVC) syndrome is the clinical manifestation of SVC obstruction and occurs through external compression, thrombosis, or invasion of the vein. While previously in the realm of nonneoplastic entities such as syphilitic aortitis or histoplasmosis, SVC syndrome is now almost exclusively (>90%) secondary to malignancy.1 The syndrome complicates 2% to 8% of primary thoracic malignancies, most frequently small cell carcinoma of the lung, followed by other lung cancer histologies, non-Hodgkin's lymphoma, and mediastinal germ cell tumors.2–5 Studies estimate the risk of clinically evident subclavian vein thrombosis to be approximately 5%6,7 in cancer patients with indwelling central venous catheters, and some small percentage of these apparently evolve to SVC syndrome.8–10
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To understand the clinical manifestations of the syndrome, an appreciation of the regional anatomy is necessary (Fig. 72-1). Because the venous drainage from ...