Oncological Emergencies : clinical presentation and management
NEUTROPENIC SEPSIS / FEVER
Fever of 38°C for over 1 hour in a patient with a neutrophil count < 1.0 × 109/l indicates possible septicaemia . This is most commonly a complication of myelosuppressive chemotherapy but can be a complication of the underlying disease, particularly in leukaemias or very occasionally in metastatic solid tumours with extensive bone marrow replacement. It is life-threatening and requires urgent assessment and therapy. Presenting symptoms include obvious infection (fever, chills, influenza-like myalgia, headache), non-specific malaise and profound shock . Those with shock and multi-organ failure should be managed in a specialist or intensive care unit, using agreed protocols for antibiotics that reflect local sensitivity patterns.
SPINAL CORD COMPRESSION
This is an emergency that is difficult to treat effectively. The spinal cord resides within a confined bony framework, so that tumour tissue quickly expands to damage nerve tissue directly by pressure or indirectly by interfering with blood supply. Pain, sensorimotor and sphincter symptoms vary according to the level of the cord compressed .
Immediate diagnosis and therapy are essential as the neurological deficit following treatment is closely related to the severity prior to treatment. Plain X-rays may show bony destruction, but magnetic resonance imaging (MRI) is essential to demonstrate tumour detail. Needle biopsy may be appropriate to establish histology. Treatment should be commenced with dexamethasone 16 mg i.v. then 4 mg 6-hourly. Urgent radiotherapy is the mainstay of therapy, but surgical decompression may be appropriate in some patients. Useful function can be regained if treatment starts within 24 hours of the development of weakness or sphincter disturbance. Tragically, warning signs of a band-like pain just below the lesion, or early evidence of neurological damage distal to the lesion, are often missed by patients and clinicians alike.
As a consequence of direct bone involvement with metastatic disease or ectopic tumour production of a hormone (almost always parathormone-related peptide, PTHrP), increased osteoclast activity produces a rise in serum calcium, which cannot be compensated for by the normal homeostatic mechanisms. The clinical manifestations are essentially the same as for any other cause of elevated serum calcium , except that the duration is usually shorter and renal stone formation consequently rare. The basic physiological problem is dehydration, consequent upon the diuretic effect of the elevated urinary calcium, and so the key to successful management is fluid replacement as well as prevention of further calcium release with bisphosphonate therapy.
Occlusion of the pericardial space with fluid causes cardiac compression, which results in a dramatic reduction in cardiac output . Patients present with breathlessness, collapse, tachycardia and hypotension. Chest X-ray may reveal an enlarged and globular heart, and echocardiography confirms the presence of a significant pericardial effusion. Treatment involves aspiration of the pericardial fluid through a catheter placed under echocardiographic guidance, and a sample of fluid should be sent for cytological examination . Recurrent pericardial tamponade is fortunately uncommon. If it occurs, surgical intervention with drainage into the left pleural cavity or peritoneal cavity may be necessary.
SUPERIOR VENA CAVAL OBSTRUCTION
Obstruction of the superior vena cava (SVCO) in the mediastinum reduces the filling of the right atrium and ventricle and causes venous engorgement and later oedema in the head, neck, arms and upper thorax. The symptoms are breathlessness, blackouts, and headaches which are worse on leaning forwards. Clinically, the venous engorgement is usually obvious, with fixed dilated external jugular veins