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KEY POINTS
Oncologic emergencies can be classified into tumor obstruction or compression, metabolic, cardiopulmonary, and hematologic malignancy-related emergencies.
Management of malignant spinal cord compression includes pain control and preservation of neurologic function with glucocorticoids, surgical decompression, and external beam radiation therapy.
Treatment priorities for severe superior vena cava syndrome include rapid stabilization of the airway in the setting of laryngeal/vocal cord edema and relief of obstruction with endovenous recanalization (e.g., mechanical or pharmacologic thrombolysis, balloon angioplasty) and SVC stenting.
Tumor lysis syndrome (TLS) occurs as a result of breakdown of malignant cells commonly after initiation of cytotoxic chemotherapy and is characterized by hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia.
Treatment of TLS includes aggressive intravenous hydration with close monitoring of electrolytes, rasburicase, and hemodialysis or continuous veno-venous hemofiltration for severe hyperphosphatemia and renal failure (uremia, volume overload, hyperkalemia, and acidosis).
Malignancy-associated hypercalcemia (MAH) can occur in up to 30% of patients with cancer. Treatment includes aggressive IV hydration with 0.9% saline along with the use of bisphosphonates (zoledronic acid favored over pamidronate), denosumab, and corticosteroids.
Echocardiography-guided pericardiocentesis is the preferred treatment modality for pericardial tamponade in an unstable patient to restore hemodynamics.
Hematologic malignancy-related emergencies include blast crisis, hyperleukocytosis, leukostasis, and hemophagocytic lymphohistiocytosis (HLH).
The HLH-2004 diagnostic criteria requires five of the following eight criteria: fever, cytopenia, splenomegaly, hypertriglyceridemia and/or fibrinogenemia, hemophagocytosis in bone marrow, low or absent NK cell activity, hyperferritinemia, and elevated levels of soluble interleukin (IL)-2 receptor. First-line therapy includes the administration of corticosteroids and etoposide.
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Cancer remains the second leading cause of death worldwide, including the United States, where 1.8 million new cases of cancer and 606,520 deaths from cancer were estimated in 2020.1 In recent years, there have been major therapeutic advances in oncology, including the use of targeted agents, immune checkpoint blockade, and chimeric antigen receptor T-cell therapy, as well as innovations in cancer surgery and radiotherapy. These developments have improved not only patient outcomes but also their quality of life (QOL). However, oncology patients remain at high risk of developing acute critical illness requiring admission to the intensive care unit (ICU). Many of these patients are admitted to the ICU due to either the malignancy itself, cancer treatment-related side effects or complications, or an underlying medical condition unrelated to the cancer.2
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Oncologic emergencies can occur at any time during the course of a malignancy, from initial presentation to late recurrence to end-stage disease.3 This chapter will focus on the unique life-threatening syndromes resulting from tumor obstruction or compression, metabolic derangements, cardiopulmonary emergencies, and hematologic malignancy-related emergencies that ICU clinicians will most likely encounter (Table 96-1). More recently identified complications from cancer immunotherapy including cytokine release syndrome, immune-effector cell-associated neurotoxicity syndrome (ICANS), and immune-related adverse events (irAEs) are addressed in a separate chapter (Chapter 98). Similarly, other common entities that can occur in cancer patients and require ...