Acute Management of Oncological Emergencies

Malignant Hypercalcaemia

This is defined as a corrected serum calcium > 2.60 mmol/L.

N.B. Presents with stones, bones, groans, and psychiatric moans.

Investigations:

• History

• Assessment of Fluid status (BP, HR, CRT)

• Bloods – Bone profile, U&Es, LFTs, Magnesium

• ECG

The mainstay of management is with Aggressive IVF and Bisphosphonates (Zoledronic Acid 4mg). When this is given is determined by the grade of hypercalcaemia:

• IV Fluids - 0.9% saline every 4-6 hours for 24 hours

• Bisphosphonates - Zoledronic Acid 4mg in 50ml of 0.9% saline over 15 mins

Metastatic Spinal Cord Compression (MSCC)

The 2 main presenting symptoms of this are Acute UMN signs and Sensory disturbance below the level of the lesion. Other symptoms include:

• Stabbing radicular sensory disturbance at the level of the lesion

• Bladder and bowel involvement

Management:

For treatment, Radiotherapy is crucial. It can either be done with or without surgical decompression. Radiotherapy reduces the tumour burden and alleviates pressure on the spinal cord, and can be given:

• For palliative patients with a poor prognosis

• Urgently to prevent further deterioration

• After surgery (usually within 2 weeks) with aim to reduce local recurrence

  
  

N.B. Radiotherapy on its own is associated with fewer complications than surgery, but may not be as effective.

Neutropenic Sepsis

Neutropenic sepsis is an oncology emergency Defined as a temperature of 38⁰C+, or temperature of 37.5⁰C+ on two occasions recorded 1 hour apart PLUS a neutrophil count < 1.0 × 10*9/L or other clinical signs of sepsis in a cancer patient who recently received systemic chemotherapy or is immunosuppressed.

• Severe Neutropenia < 0.5 × 1 0*9/L

• Very severe neutropenia < 0.2 × 10*9/L

This is assessed and managed using the Sepsis 6. Patients with neutropenia should always have a low threshold for a comprehensive assessment and Abx.

N.B. If left untreated can result in death within 48 hours in up to 50% of patients.

Management:

• Prompt initiation of broad spectrum Abx

  
  

• Supportive - Fluids, oxygen

  
  

• Blood cultures

• Lactate

• Urine output

Superior Vena Cava Obstruction (SVCO)

This becomes an oncological emergency when the patient has difficulty breathing. It presents with:

• Dyspnoea, Tachypnoea,

  Stridor, Cyanosis

• Facial plethora

• Dilated chest and neck veins

• Facial/neck/arm swelling

• Non-pulsatile JVP

Investigations:

• Bloods – FBC, U&E, Clotting

• Imaging – CT Chest

Management:

• Dexamethasone

• Once patient is stabilised, other options like stenting may be considered