Chapter 182. Oncologic Emergencies

1. What clinical presentations in cancer patients necessitate immediate action?

2. Which of these emergencies are consequences of the patient's underlying malignancy and which are caused, directly or indirectly, by antineoplastic therapy?

3. Do certain cancers confer a higher risk of developing particular oncologic emergencies than others?

4. When is it necessary for these conditions to be managed in a multidisciplinary fashion? Who are the consultants whose timely involvement is essential for optimal treatment?

5. Are there situations in which it is safe to manage these patients in the outpatient setting?

6. Are there preventive measures one can take to reduce the risk of a patient's encountering one of these acute complications of malignant disease?

A diagnosis of cancer places patients at risk for a number of acute life-threatening complications. Such an event may herald the initial presentation of a malignant condition, represent the underlying progression of a known malignancy, or be a result of a rapid response to treatment; it may be obstructive, metabolic, or infectious in nature. Prompt recognition of these potentially lethal events is essential to timely life-sustaining intervention and preservation of organ function. Several oncologic emergencies will be outlined in this chapter, separated into those entities caused by the cancer itself and those which are related to the treatments delivered.

Spinal Cord Compression

Carrying an imminent threat of irreversible neurologic disability, malignant spinal cord compression (MSCC) is perhaps the most dramatic of the oncologic emergencies. It is critical that one approach a new symptom of back pain somewhat differently in a patient with a current diagnosis or history of cancer from the way in which one would approach a patient without such a history.

Clinical Presentation

Back pain is the initial symptom in the vast majority of patients. The pain is usually localized initially, but may later develop a radicular component, which can be unilateral or bilateral. The presence of a Lhermitte sign, parasthesias radiating down the spine on flexion of the neck, may also point to a spinal cord process.

Inquiries must be made as to symptoms of neurologic compromise, though they typically follow the onset of back pain over a period of weeks to months. If present on initial assessment, however, they significantly raise the level of urgency with which a definitive diagnosis must be pursued. These include weakness, spasticity, or loss of sensation in the lower limbs; the patient may complain of difficulty rising from a chair or climbing stairs. Motor and sensory symptoms usually precede autonomic dysfunction, but it is essential to inquire about urinary hesitancy or retention, perhaps accompanied by overflow incontinence.