Key Facts

Oncological emergencies encompass a range of life-threatening conditions arising from the cancer itself or its treatment. Rapid recognition and protocolised management are essential to prevent death and permanent disability.

Epidemiology

• Neutropenic sepsis complicates approximately 15-25% of chemotherapy cycles (varies by regimen)
• MSCC affects 5-10% of cancer patients
• SVCO occurs in 2-4% of lung cancer patients
• Hypercalcaemia of malignancy affects 10-30% of cancer patients during their illness
• TLS most common with haematological malignancies (Burkitt lymphoma, ALL)

Aetiology

• Neutropenic sepsis: chemotherapy-induced bone marrow suppression
• MSCC: vertebral metastases with epidural compression (lung, breast, prostate most common)
• SVCO: mediastinal tumour compression/invasion (lung cancer 70%, lymphoma 15%)
• Hypercalcaemia: PTHrP secretion (humoral), osteolytic metastases, calcitriol production
• TLS: rapid tumour cell lysis releasing intracellular contents

Pathophysiology

• Neutropenic sepsis: impaired innate immunity allows overwhelming bacterial infection
• MSCC: tumour compresses spinal cord → oedema → ischaemia → irreversible neurological damage if untreated
• SVCO: obstruction of SVC → venous congestion in head, neck, arms, upper thorax
• Hypercalcaemia: PTHrP activates osteoclasts; excess calcium → renal impairment, cardiac arrhythmias, neurological dysfunction
• TLS: massive release of potassium, phosphate, uric acid, nucleic acids → renal failure, cardiac arrhythmias

Neutropenic Sepsis

• Fever ≥38°C (or ≥37.5°C sustained for >1 hour) in patient receiving chemotherapy
• May lack typical infection signs due to neutropenia
• Hypotension, tachycardia, rigors

Spinal Cord Compression

• Back pain (90%, often precedes neurology by weeks)
• Limb weakness (progressive)
• Sensory level
• Bladder/bowel dysfunction (late sign; poor prognostic indicator)

SVCO

• Facial and arm swelling
• Distended neck and chest wall veins
• Dyspnoea, stridor
• Headache worse on bending forward

Hypercalcaemia

• 'Stones, bones, groans, moans': renal stones, bone pain, abdominal pain, confusion
• Polyuria, polydipsia, dehydration
• Constipation, nausea
• Cardiac: shortened QT, arrhythmias

Red Flags

• Any temperature ≥38°C within 6 weeks of chemotherapy: assume neutropenic sepsis until proven otherwise
• New back pain in cancer patient: assume MSCC until excluded
• Rapid deterioration in conscious level: brain metastases, hypercalcaemia, or hyponatraemia

Bedside

• ABCDE assessment
• Observations: HR, BP, temperature, SpO2, RR
• Blood glucose
• ECG (hyperkalaemia, hypercalcaemia)
• Neurological examination (MSCC)

Bloods

• FBC (neutrophil count)
• U&Es (potassium, calcium, phosphate, urate, creatinine)
• LFTs, CRP, lactate
• Blood cultures (peripheral and from central line if present)
• Coagulation screen
• Blood gas

Imaging

• MSCC: MRI whole spine within 24 hours (NICE NG149)
• SVCO: CT chest with contrast (CT venogram)
• Brain metastases: CT head ± MRI brain
• CXR: baseline for sepsis assessment

Special Tests

• Urine culture, sputum culture (sepsis source)
• Adjusted calcium calculation: Corrected Ca = measured Ca + 0.02 × (40 - albumin)
• PTHrP: if humoral hypercalcaemia suspected

Non-pharmacological

• Sepsis 6 bundle implementation
• Spinal precautions (log-roll) if MSCC suspected
• IV fluid resuscitation

Pharmacological

• Neutropenic sepsis: IV piperacillin-tazobactam 4.5g TDS (or local protocol) within 1 hour of presentation (NICE NG151); add vancomycin if line infection suspected
• MSCC: dexamethasone 16mg IV stat then 16mg OD; PPI cover; specialist opinion within 24 hours
• SVCO: dexamethasone 16mg IV stat; anticoagulation if thrombosis; urgent oncology referral
• Hypercalcaemia: IV 0.9% saline 3-4L/24h rehydration → zoledronic acid 4mg IV over 15 minutes (onset 2-4 days; duration 3-4 weeks); denosumab 120mg SC if refractory
• TLS: aggressive IV hydration (3L/m²/day); rasburicase 0.2mg/kg IV (converts uric acid to allantoin; avoid in G6PD deficiency); allopurinol 300mg OD (prophylaxis); correct hyperkalaemia (calcium gluconate, insulin-dextrose, salbutamol nebuliser)
• Brain metastases: dexamethasone 16mg IV → 4mg QDS tapering; anticonvulsants if seizures (levetiracetam 250-500mg BD)

Surgical/Interventional

• MSCC: surgical decompression (if operable, single level, good performance status) ± RT; or RT alone
• SVCO: SVC stenting (interventional radiology) for rapid symptom relief
• Cardiac tamponade: pericardiocentesis (USS-guided)
• Obstructive uropathy: nephrostomy or ureteric stent

Referral Criteria

• All oncological emergencies: immediate oncology/acute medicine assessment
• MSCC: MSCC coordinator (every cancer network has one)
• Neutropenic sepsis: oncology assessment unit or A&E
• TLS: haematology/oncology + HDU/ITU if severe

• Neutropenic sepsis: mortality 5-10% with prompt treatment; up to 50% if delayed
• MSCC: ambulatory status at treatment predicts outcome; >80% remain ambulatory if mobile at diagnosis; <10% regain ambulation if paraplegic
• SVCO: depends on underlying cause; stenting provides rapid relief in >90%
• Hypercalcaemia: responds to treatment in >90%; median survival after first episode approximately 3-4 months (reflects advanced disease)
• TLS: mortality 5-15% with treatment; prevention is key

Oncological Emergency Management Summary

Cairo-Bishop TLS Classification