Introduction: Oncological emergencies are life-threatening emergencies that can occur as result of cancer or cancer treatment. These emergencies can be obstructive, metabolic, or infiltrative.
1. Obstructive emergencies :
· Caused by tumour obstruction of an organ or blood vessel.
· Include superior vena cava syndrome, spinal cord compression syndrome, third space syndrome and intestinal obstruction.
A. Superior vena cava syndrome
· Considered a serious medical problem
· Results from obstruction of the superior vena cava by a tumour or thrombosis.
· The clinical manifestations include facial oedema, periorbital oedema, and distention of veins of the head, neck, and chest, headache, and seizures.
· A mediastinal mass is often visible on chest x-ray
· The most common causes are lung cancer, non-Hodgkin's lymphoma, and metastatic breast cancer.
· Management involves radiation therapy to the site of obstruction.
· Chemotherapy may be administered for tumours more sensitive to this form of therapy.
B. Spinal cord compression : A neurologic emergency caused by the presence of a malignant tumour in the epidural space of the spinal cord
Tumours causing spinal cord compression
· Breast Cancer
· Prostate cancer
· Renal tumours
· lung cancer
· GI cancer
· Localized, persistent and Intense back pain
· vertebral tenderness and aggravated by the Valsalva maneuver
· motor weakness and dysfunction
· Sensory paraesthesia
· Autonomic dysfunction.
· Radiation therapy in conjunction with prompt initiation of corticosteroids
· Activity limitations
· Pain management
· Surgical decompressive laminectomy
C. Third Space Syndrome
Involves a shifting of fluid from the vascular space to the interstitial space.
Occurs secondary to extensive surgical procedures, biologic therapy, or septic shock.
Signs and symptoms
· low central venous pressure
· Decreased urine output
· Hypotension .
Treatment: Fluid, electrolyte, and plasma protein replacement and Fluid balance monitoring
D. Intestinal Obstruction
Mechanical obstruction due to tumours in the bowel.
Symptoms include: nausea, vomiting, abdominal pain, distension, inability to pass flatus.
Management: Emergency surgery for strangulated bowel, NPO, Insertion of Ryle’s tube and abdominal decompression, IV fluid resuscitation.
2. Metabolic Emergencies
Caused by the production of ectopic hormones directly from the tumour or are secondary to metabolic alterations caused by the presence of the tumour or cancer treatment.
Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
Tumour lysis syndrome (TLS)
disseminated intravascular coagulation (DIC)
A. Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)
Results from abnormal or sustained production of antidiuretic hormone (ADH)
Results in water retention and hyponatremia
Most frequently in carcinoma of the lung but can also occur in cancer of the pancreas, duodenum, brain, oesophagus, colon, ovary, prostate, bronchus, and nasopharynx; leukaemia, mesothelioma,reticulum cell sarcoma, Hodgkin's lymphoma and thymoma( a tumour originating from the epithelial cells of the thymus).
Signs and symptoms: Weight gain, weakness, anorexia, nausea, vomiting, personality changes,seizures, and coma
Treatment: treating the underlying malignancy and measures to correct the sodium-water balance, fluid restriction and in severe cases, IV administration of 3% sodium chloride solution.
B. Hypercalcemia: Occur in the presence of cancer that involves metastatic disease of the bone or multiple myeloma, or when a parathyroid hormone-like substance is secreted by cancer cells. Occurs in patients with lung, breast, kidney, colon, ovarian, or thyroid cancer, squamous cell carcinoma of the lung; head and neck, cervical, and oesophageal cancer; lymphomas; and leukaemia.
Signs and symptoms
Apathy, depression, fatigue, muscle weakness, ECG changes, polyuria and nocturia, anorexia, nausea and vomiting.
· Treat the primary disease
· hydration & bisphosphonates
· bisphosphonates, (inhibits the action of osteoclasts)
C. Tumour Lysis Syndrome (TLS)
· A metabolic complication characterized by rapid release of intracellular components in response to chemotherapy.
· Associated with tumours that have high growth rate
· Releases a host of intracellular components into the bloodstream including potassium, phosphate, and DNA and RNA components
Sign and symptoms
· The four hallmark signs are hyperuricemia, hyperphosphatemia, hyperkalemia, and hypocalcaemia
· Usually occurs within the first 24 to 48 hours after the initiation of chemotherapy and may persist for approximately 5 to 7 days
· Goal is to prevent renal failure and severe electrolyte imbalances.
· Hydration therapy
· Decreasing uric acid concentrations using allopurinol.
D. Septic shock and disseminated intravascular coagulation (DIC)
· Septic shock is a systemic disease associated with the presence and persistence of pathogenic microorganisms or their toxins in the blood.
· It is characterized by hemodynamic instability, abnormal coagulation, and altered metabolism
· Antibiotics are started immediately; broad-spectrum antibiotics are given until organism is identified.
· I.V. fluids and plasma expanders are used to restore circulating volume.
· Colony-stimulating factors are administered to increase neutrophil count.
· Vasopressors are administered to support blood pressure.
· Oxygen is administered as needed to prevent tissue hypoxia.
3. Infiltrative Emergencies
· occur when malignant tumours infiltrate major organs or secondary to cancer therapy.
· The most common infiltrative emergencies are cardiac tamponade and carotid artery rupture.
A. Crdiac Tamponade : Results from fluid accumulation in the pericardial sac, constriction of the pericardium by tumour, or pericarditis secondary to radiation therapy to the chest
Signs and symptoms : Heavy feeling over the chest, shortness of breath, tachycardia, cough, dysphagia, hoarseness, nausea,vomiting,decreased level of consciousness, excessive perspiration, pulsus paradoxus, distant or muted heart sounds, and extreme anxiety.
Emergency management is aimed at reduction of fluid around the heart
Surgical establishment of a pericardial window or an indwelling pericardial catheter,
Administration of oxygen therapy, intravenous hydration and vasopressor therapy
B. Carotid Artery Rupture : Occurs most frequently in patients with cancer of the head and neck secondary to invasion of the arterial wall by tumour or to erosion therapy
Signs and symptoms: Bleeding can manifest as minor oozing or spurting of blood in the case of a "blowout" of thc artery.
In the presence of a blowout, pressure should be applied to the site with a finger.
Intravenous fluid and blood products
Stabilize the patient for surgery.
Surgical management involves ligation of the carotid artery above and below the rupture site and reduction of local tumour.