Oncologic emergencies that may necessitate ICU admission include superior vena cava syndrome (SVCS), cardiac tamponade, malignant spinal cord compression, hypercalcemia, tumor lysis syndrome (TLS), and leukostasis.
SVCS is primarily caused by lung cancer and lymphoma. Sudden death is observed only when there is airway compromise or cerebral edema. Management is directed toward restoring the patency of flow in the SVC and stabilizing the airway.
Pericardial effusions from malignancies accumulate slowly and may result in large effusions. Lung, breast, melanoma, and lymphoma are the most common malignancies associated with pericardial tamponade. Emergent drainage or pericardial window is the treatment of choice for pericardial tamponade.
Early recognition of malignant spinal cord compression with physical exam, magnetic resonance imaging, and angiography is vital to restoring neurologic function.
Malignancy-associated hypercalcemia occurs in 20% to 30% of patients and is more common in solid tumors such as breast and lung cancer. Volume repletion with isotonic saline is the initial treatment of choice. Bisphosphonates, calcitonin, and corticosteroids are also useful treatments.
TLS is characterized by electrolyte and metabolic derangements from the breakdown of malignant cells. TLS can occur spontaneously or after chemotherapy, radiation, and treatment with corticosteroids. Aggressive hydration and correction of electrolyte abnormalities (hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia) are keys to management.
Hyperleukostasis (WBC > 50,000-100,000/mm3) is common in patients with acute myelogenous leukemia. Respiratory symptoms include dyspnea, hemoptysis, respiratory distress, and hypoxemia as well as neurologic including dizziness, headache, blurry vision, confusion, and stroke or intracranial hemorrhage. Treatment consists of leukapheresis, hydroxyurea, and chemotherapy.
As the treatments for malignancies continue to improve, so does the long-term survival and prognosis of the oncologic patient. Consequently, an increasing number of patients with cancer face complications that can lead to severe illness and require admission to the intensive care unit (ICU). As in the general population, the majority of ICU admissions for patients with malignancy are due to sepsis and respiratory failure. Intensivists should be familiar with the specific issues relevant to the critically ill oncologic patient so that adequate treatment can be offered (Table 45–1). This chapter will focus on the classic clinical syndromes that represent oncologic emergencies: superior vena cava syndrome (SVCS), cardiac tamponade, spinal cord compression, tumor lysis syndrome, hypercalcemia, and leukostasis.
Table 45–1Oncologic emergencies. ||Download (.pdf) Table 45–1 Oncologic emergencies.
| ||Oncologic-Related Causes || |
|Hemoptysis || |
Tumor related (primary vs metastatic, including germ cell tumors)
DAHa (leukemias, multiple myeloma, HSCT,b pretransplant conditioning regimen, and other chemotherapies)
Infectious (aspergilloma, tuberculosis)
30% of all causes of hemoptysis are related to malignancy
Reversal of causes of bleeding diathesis
Response to recombinant factor VIIa administration in cases of DAH has been reported
|Status Epilepticus || |
Chemotherapy (cisplatin, cyclophosphamide, bevacizumab, busulfan, intrathecal methotrexate)
Electrolyte disorders (hyponatremia and hypercalcemia)