What is the initial management approach for a patient presenting with an oncology emergency, such as febrile neutropenia (FN), tumor lysis syndrome (TLS), spinal cord compression (SCC), superior vena cava syndrome (SVCS), hypercalcemia of malignancy (HCM), malignant pericardial tamponade (MPT), brain metastases with increased intracranial pressure (ICP), or massive hemoptysis/airway compromise?

Initial Management of Oncology Emergencies

For patients presenting with oncology emergencies, immediate stabilization takes priority with specific interventions tailored to each emergency type, following a systematic approach that addresses airway, breathing, circulation, and neurologic status before definitive cancer-directed therapy.

Febrile Neutropenia

Administer broad-spectrum antibiotics within 1 hour of presentation in any cancer patient with fever (≥38.3°C or ≥38°C for >1 hour) and neutropenia (absolute neutrophil count <500 cells/μL or <1000 cells/μL with expected decline) 1, 2.

• Start empiric antibiotics immediately without waiting for culture results, as delays increase mortality 1
• Common pitfall: Admitting febrile neutropenic patients to COVID-19 screening areas can delay appropriate antibiotic administration and increase infection risk 1
• Do not use prophylactic G-CSF after fever develops; it is indicated only for primary prophylaxis in high-risk regimens 1

Tumor Lysis Syndrome (TLS)

Begin aggressive IV hydration (3 L/m²/day) immediately upon diagnosis or high-risk identification, with rasburicase 0.2 mg/kg IV for patients with established or high-risk TLS 3, 4.

Risk Stratification and Monitoring

• Monitor uric acid, potassium, phosphorus, calcium, creatinine, BUN, and LDH every 6 hours for the first 24 hours, then daily 3
• Laboratory TLS is defined by: uric acid >8 mg/dL or 25% increase, potassium >6 mEq/L, phosphorus >4.5 mg/dL, or calcium <7 mg/dL 3
• Clinical TLS requires laboratory TLS plus renal failure, cardiac arrhythmia, or seizure 3

Critical Management Points

• Do not give rasburicase to patients with G6PD deficiency (screen African and Mediterranean ancestry patients first) 4
• Collect blood samples in pre-chilled heparin tubes and immediately place in ice water bath; assay within 4 hours (rasburicase degrades uric acid in room temperature samples) 4
• Do not alkalinize urine if using rasburicase 3
• Do not give calcium gluconate for mild hypocalcemia unless symptomatic 3

Spinal Cord Compression (SCC)

Immediately administer high-dose dexamethasone (16-100 mg/day in divided doses) and obtain emergent MRI of entire spine within hours of presentation 1, 5.

Diagnostic Approach

• Obtain sagittal T1-weighted MRI of entire spine for any cancer patient with new back pain 1
• MRI is superior to CT and must image the entire spine (multiple levels involved in 10-38% of cases) 1

Treatment Algorithm

• Asymptomatic epidural metastases: High-dose dexamethasone plus radiotherapy 1
• Symptomatic compression with good performance status: Immediate neurosurgical consultation for decompression surgery followed by radiotherapy 1
• Start dexamethasone at 16 mg/day for moderate symptoms; up to 100 mg/day for severe acute neurologic deterioration 5
• Taper steroids slowly after radiotherapy to minimize toxicity (personality changes, immunosuppression, metabolic derangements) 5

Superior Vena Cava Syndrome (SVCS)

Obtain tissue diagnosis before treatment unless life-threatening symptoms require immediate intervention; treatment depends on histology 1.

Management by Histology

• Small cell lung cancer: Chemotherapy is first-line treatment 1
• Non-small cell lung cancer: Radiotherapy and/or stent insertion 1
• Refractory cases: Vascular stenting for patients failing chemotherapy or radiotherapy 1

Critical Considerations

• Secure tissue diagnosis (histologic or cytologic) before starting treatment whenever possible 1
• When using stenting, consider anticoagulation requirements and impact on future cancer management 1
• Endoscopy useful for diagnosis and endobronchial treatment 1

Hypercalcemia of Malignancy (HCM)

Initiate aggressive IV saline hydration (200-300 mL/hour) immediately, followed by IV bisphosphonate (pamidronate 60-90 mg or zoledronic acid 4 mg) over 2-24 hours 6, 7, 8.

Severity-Based Dosing

• Moderate hypercalcemia (corrected calcium 12-13.5 mg/dL): Pamidronate 60-90 mg IV over 2-24 hours 6
• Severe hypercalcemia (corrected calcium >13.5 mg/dL): Pamidronate 90 mg IV over 2-24 hours 6
• Use longer infusions (>2 hours) to reduce renal toxicity risk, especially with pre-existing renal insufficiency 6

Calculation and Monitoring

• Calculate corrected calcium: serum calcium (mg/dL) + 0.8 × (4.0 - serum albumin g/dL) 6
• Avoid overhydration in patients with cardiac failure risk 6
• Consider glucocorticoids for hematologic malignancies 6
• Allow minimum 7 days before retreatment 6

Malignant Pericardial Tamponade (MPT)

Perform emergent pericardiocentesis for hemodynamically unstable patients; obtain pericardial fluid for cytology to confirm malignancy 9, 8.

• Echocardiography confirms diagnosis and guides pericardiocentesis 9
• Surgical pericardial window may be required for recurrent effusions 9
• Hemodynamic instability (hypotension, tachycardia, elevated jugular venous pressure) requires immediate drainage 8

Brain Metastases with Increased Intracranial Pressure (ICP)

Start dexamethasone 4 mg/day (or 16 mg/day for moderate-severe symptoms) immediately; obtain contrast-enhanced brain MRI to determine number and location of lesions 1, 5.

Treatment Algorithm by Number of Metastases

• Single metastasis (RPA class I-II): Stereotactic radiosurgery (SRS) or surgical resection 1
• 2-3 metastases (RPA class I-II): SRS preferred 1
• >3 metastases: Whole brain radiotherapy (WBRT) 1
• ≥5 metastases: WBRT is recommended therapy 1

Steroid Management

• Dexamethasone 4 mg/day for most symptomatic patients with cerebral edema 1
• Higher doses (16-100 mg/day) for acute severe symptoms 5
• Taper early after radiotherapy to minimize toxicity 1, 5
• Avoid enzyme-inducing anticonvulsants (affect chemotherapy metabolism) 5

Special Considerations

• Asymptomatic brain metastases: Defer radiotherapy; treat at progression 1
• RPA class III (Karnofsky <70%): Do not treat given dismal prognosis 1
• Systemic therapy reasonable for patients with minor symptoms 1
• Large space-occupying metastases (>3 cm): Surgical resection if surgical candidate 1

Massive Hemoptysis/Airway Compromise

Secure airway with single-lumen endotracheal tube immediately; perform emergent bronchoscopy to identify bleeding source 1.

Management by Bleeding Volume

• Large volume hemoptysis:

  • Secure airway first with single-lumen endotracheal tube 1
  • Emergent bronchoscopy to identify source 1
  • Endobronchial management: argon plasma coagulation, Nd:YAG laser, or electrocautery for visible central lesions 1

• Non-large volume hemoptysis:

  • Bronchoscopy to identify source 1
  • Endobronchial management for visible central lesions 1
  • External beam radiotherapy for distal or parenchymal lesions 1
  • Consider bronchial artery embolization if above measures unsuccessful 1

Additional Interventions

• Endoscopic debulking (laser, cryotherapy, stent) for symptomatic major airway obstruction 1
• Endovascular embolization guided by endoscopy 1
• Radiotherapy effective for hemoptysis control 1

Critical Pitfall

• Do not delay airway management while obtaining imaging or consulting specialists 1