Oncologic Emergencies: Recognition and Initial Management

 

Am Fam Physician. 2018 Jun 1;97(11):741-748.

Author disclosure: No relevant financial affiliations.

Most oncologic emergencies can be classified as metabolic, hematologic, structural, or treatment related. Tumor lysis syndrome is a metabolic emergency that presents as severe electrolyte abnormalities. Stabilization is focused on vigorous rehydration, maintaining urine output, and lowering uric acid levels. Hypercalcemia of malignancy, which is associated with poor outcomes, is treated with aggressive rehydration, intravenous bisphosphonates, and subspecialty consultation. Syndrome of inappropriate antidiuretic hormone should be suspected if a patient with cancer has hyponatremia. This metabolic condition is treated with fluid restriction or hypertonic saline, depending on the speed of development. Febrile neutropenia is one of the most common complications related to cancer treatment, particularly chemotherapy. It usually requires inpatient therapy with rapid administration of empiric antibiotics. Hyperviscosity syndrome may present as spontaneous bleeding and neurologic deficits, and is usually associated with Waldenström macroglobulinemia. Treatment includes plasmapheresis followed by targeted chemotherapy. Structural oncologic emergencies are caused by direct compression of nontumor structures by metastatic disease. Superior vena cava syndrome presents as facial edema with development of collateral venous circulation. Intravascular stenting leads to superior patient outcomes and is used in addition to oncology-directed chemotherapy and radiation therapy. Malignant epidural spinal cord compression is managed in conjunction with neurosurgery, but it is classically treated using steroids and/or surgery and radiation therapy. Malignant pericardial effusion may be treated with pericardiocentesis or a more permanent surgical intervention. Complications of cancer treatment are becoming more varied because of the use of standard and newer immunologic therapies. Palliative care is increasingly appropriate as a part of the team approach for treating patients with cancer.

The National Cancer Institute estimates that 14.5 million persons in the United States have cancer, and that number could reach 19 million by 2024.1 Family physicians should be familiar with the most prevalent oncologic emergencies because stabilization is often necessary, in addition to referrals for managing the underlying malignancy and initiating palliative measures.2 Some oncologic emergencies are insidious and take months to develop, whereas others manifest over hours, causing devastating outcomes such as paralysis and death.3 In many patients, cancer is not diagnosed until a related condition emerges. A patient-focused approach that includes education; cancer-specific monitoring; and team-based care, including palliative care, with continuous communication is recommended.4  Most oncologic emergencies can be categorized as metabolic, hematologic, structural, or treatment related (Table 15).

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Concurrent palliative care consultation should be offered to patients with cancer at the time of diagnosis.

C

4

Emergent use of antibiotics in patients with cancer who present with febrile neutropenia improves survival rates.

B

22

New-onset back pain in patients with cancer should be evaluated as epidural spinal cord compression until it is ruled out.

C

3, 26

More permanent surgical solutions for management of malignant pericardial effusions, such as pericardial windows and indwelling pericardial catheters, are associated with improved patient outcomes compared with percutaneous pericardiocentesis alone.

B

2931

Complications from newer immunotherapy treatments often present as nonspecific and vague symptoms, such as flulike illness and rash, requiring a high level of suspicion in patients undergoing cancer treatment.

C

4042


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Concurrent palliative care consultation should be offered to patients with cancer at the time of diagnosis.

C

4

Emergent use of antibiotics in patients with cancer who present with febrile neutropenia improves survival rates.

B

22

New-onset back pain in patients with cancer should be evaluated as epidural spinal cord compression until it is ruled out.

C

3, 26

More permanent surgical solutions for management of malignant pericardial effusions, such as pericardial windows and indwelling pericardial catheters, are associated with improved patient outcomes compared with percutaneous pericardiocentesis alone.

B

2931

Complications from newer immunotherapy treatments often present as nonspecific

The Authors

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MARK L. HIGDON, DO, FAAFP, is the program director at the Novant Health Family Medicine Residency in Charlotte, North Carolina....

CHARLES J. ATKINSON, MD, FAAFP, is the assistant program director at the Novant Health Family Medicine Residency.

KELLEY V. LAWRENCE, MD, FAAFP, FABM, is an associate program director and team leader at the Novant Health Family Medicine Residency.

Address correspondence to Mark L. Higdon, DO, FAAFP, Novant Health, 19475 Old Jetton Rd., Ste. 200, Cornelius, NC 28031 (e-mail: mlhigdon@novanthealth.org). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. National Cancer Institute. Cancer statistics. https://www.cancer.gov/about-cancer/understanding/statistics. Accessed February 16, 2017....

2. McCurdy MT, Shanholtz CB. Oncologic emergencies. Crit Care Med. 2012;40(7):2212–2222.

3. Lewis MA, Hendrickson AW, Moynihan TJ. Oncologic emergencies: pathophysiology, presentation, diagnosis, and treatment [published correction appears in CA Cancer J Clin. 2011;61(6):420]. CA Cancer J Clin. 2011;61(5):287–314.

4. Smith TJ, Temin S, Alesi ER, et al. American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care. J Clin Oncol. 2012;30(8):880–887.

5. Higdon ML, Higdon JA. Treatment of oncologic emergencies. Am Fam Physician. 2006;74(11):1873–1880.

6. Wilson FP, Berns JS. Tumor lysis syndrome: new challenges and recent advances. Adv Chronic Kidney Dis. 2014;21(1):18–26.

7. Howard SC, Jones DP, Pui CH. The tumor lysis syndrome. N Engl J Med. 2011;364(19):1844–1854.

8. Wagner J, Arora S. Oncologic metabolic emergencies. Emerg Med Clin North Am. 2014;32(3):509–525.

9. Cairo MS, Bishop M. Tumour lysis syndrome: new therapeutic strategies and classification. Br J Haematol. 2004;127(1):3–11.

10. Takai M, Yamauchi T, Ookura M, et al. Febuxostat for management of tumor lysis syndrome including its effects on levels of purine metabolites in patients with hematological malignancies—a single institution's, pharmacokinetic and pilot prospective study. Anticancer Res. 2014;34(12):7287–7296.

11. Rosner MH, Dalkin AC. Onco-nephrology: the pathophysiology and treatment of malignancy-associated hypercalcemia. Clin J Am Soc Nephrol. 2012;7(10):1722–1729.

12. Pettifer A, Grant S. The management of hypercalcaemia in advanced cancer. Int J Palliat Nurs. 2013;19(7):327–331.

13. Clines GA. Mechanisms and treatment of hypercalcemia of malignancy. Curr Opin Endocrinol Diabetes Obes. 2011;18(6):339–346.

14. Hu MI, Glezerman IG, Leboulleux S, et al. Denosumab for treatment of hypercalcemia of malignancy. J Clin Endocrinol Metab. 2014;99(9):3144–3152.

15. Minisola S, Pepe J, Piemonte S, Cipriani C. The diagnosis and management of hypercalcaemia. BMJ. 2015;350:h2723.

16. Balachandran K, Okines A, Gunapala R, Morganstein D, Popat S. Resolution of severe hyponatraemia is associated with improved survival in patients with cancer. BMC Cancer. 2015;15:163.

17. Castillo JJ, Vincent M, Justice E. Diagnosis and management of hyponatremia in cancer patients. Oncologist. 2012;17(6):756–765.

18. U.S. Food and Drug Administration. FDA drug safety communication: FDA limits duration and usage of Samsca (tolvaptan) due to possible liver injury leading to organ transplant or death. https://www.fda.gov/Drugs/DrugSafety/ucm350062.htm. Accessed December 7, 2017.

19. Salahudeen AK, Ali N, George M, Lahoti A, Palla S. Tolvaptan in hospitalized cancer patients with hyponatremia: a double-blind, randomized, placebo-controlled clinical trial on efficacy and safety. Cancer. 2014;120(5):744–751.

20. Koinis F, Nintos G, Georgoulias V, Kotsakis A. Therapeutic strategies for chemotherapy-induced neutropenia in patients with solid tumors. Expert Opin Pharmacother. 2015;16(10):1505–1519.

21. Castagnola E, Mikulska M, Barabino P, Lorenzi I, Haupt R, Viscoli C. Current research in empirical therapy for febrile neutropenia in cancer patients: what should be necessary and what is going on. Expert Opin Emerg Drugs. 2013;18(3):263–278.

22. Rosa RG, Goldani LZ. Cohort study of the impact of time to antibiotic administration on mortality in patients with febrile neutropenia. Antimicrob Agents Chemother. 2014;58(7):3799–3803.

23. Stone MJ, Bogen SA. Evidence-based focused review of management of hyperviscosity syndrome. Blood. 2012;119(10):2205–2208.

24. Khan UA, Shanholtz CB, McCurdy MT. Oncologic mechanical emergencies. Emerg Med Clin North Am. 2014;32(3):495–508.

25. Wilson LD, Detterbeck FC, Yahalom J. Clinical practice. Superior vena cava syndrome with malignant causes [published correction appears in N Engl J Med 2008;358(10):1083]. N Engl J Med. 2007;356(18):1862–1869.

26. Furlan JC, Sakakibara BM, Miller WC, Krassioukov AV. Global incidence and prevalence of traumatic spinal cord injury. Can J Neurol Sci. 2013;40(4):456–464.

27. Loblaw A, Mitera G. Malignant extradural spinal cord compression in men with prostate cancer. Curr Opin Support Palliat Care. 2011;5(3):206–210.

28. Fehlings MG, Nater A, Holmer H. Cost-effectiveness of surgery in the management of metastatic epidural spinal cord compression: a systematic review. Spine (Phila Pa 1976). 2014;39(22 suppl 1):S99–S105.

29. Çelik S, Lestuzzi C, Cervesato E, et al. Systemic chemotherapy in combination with pericardial window has better outcomes in malignant pericardial effusions. J Thorac Cardiovasc Surg. 2014;148(5):2288–2293.

30. Tsang TS. Echocardiography-guided pericardiocentesis for effusions in patients with cancer revisited. J Am Coll Cardiol. 2015;66(10):1129–1131.

31. El Haddad D, Iliescu C, Yusuf SW, et al. Outcomes of cancer patients undergoing percutaneous pericardiocentesis for pericardial effusion [published correction appears in J Am Coll Cardiol. 2015;66(20):2269]. J Am Coll Cardiol. 2015;66(10):1119–1128.

32. Pérez Fidalgo JA, García Fabregat L, Cervantes A, Margulies A, Vidall C, Roila F; ESMO Guidelines Working Group. Management of chemotherapy extravasation: ESMO-EONS clinical practice guidelines. Ann Oncol. 2012;23(suppl 7):vii167–vii173.

33. Al-Benna S, O'Boyle C, Holley J. Extravasation injuries in adults. ISRN Dermatol. 2013. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3664495/. Accessed December 7, 2017.

34. Kreidieh FY, Moukadem HA, El Saghir NS. Overview, prevention and management of chemotherapy extravasation. World J Clin Oncol. 2016;7(1):87–97.

35. Mayer DK, Travers D, Wyss A, Leak A, Waller A. Why do patients with cancer visit emergency departments? Results of a 2008 population study in North Carolina. J Clin Oncol. 2011;29(19):2683–2688.

36. Andreyev HJ, Davidson SE, Gillespie C, Allum WH, Swarbrick E; British Society of Gastroenterology; Association of Colo-Proctology of Great Britain and Ireland; Association of Upper Gastrointestinal Surgeons; Faculty of Clinical Oncology Section of the Royal College of Radiologists. Practice guidance on the management of acute and chronic gastrointestinal problems arising as a result of treatment for cancer. Gut. 2012;61(2):179–192.

37. Gibson RJ, Keefe DM, Lalla RV, et al.; Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO). Systematic review of agents for the management of gastrointestinal mucositis in cancer patients. Support Care Cancer. 2013;21(1):313–326.

38. Berkey FJ. Managing the adverse effects of radiation therapy. Am Fam Physician. 2010;82(4):381–388.

39. Gedye C, van der Westhuizen A, John T. Checkpoint immunotherapy for cancer: superior survival, unaccustomed toxicities. Intern Med J. 2015;45(7):696–701.

40. Weber JS, Yang JC, Atkins MB, Disis ML. Toxicities of immunotherapy for the practitioner. J Clin Oncol. 2015;33(18):2092–2099.

41. Michot JM, Bigenwald C, Champiat S, et al. Immune-related adverse events with immune checkpoint blockade: a comprehensive review. Eur J Cancer. 2016;54:139–148.

42. Morrissey KM, Yuraszeck TM, Li CC, Zhang Y, Kasichayanula S. Immunotherapy and novel combinations in oncology: current landscape, challenges, and opportunities. Clin Transl Sci. 2016;9(2):89–104.

 

 

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