Cord Compression

• Results from spinal cord metastasis with mass effect causing symptoms pain and/or weakness.
• Should be suspected in cancer patients with back pain or complaining of new neurological deficits - definitive imaging and early treatment is essential.
• Urgent MRI of suspected area, dexamethasone, neurosurgical evaluation for possible operative management and radiation oncology evaluation are essential to preserving neurological function.
• Of note, if this is a patient’s first presentation of cancer and no other lesions are found, early neurosurgery is also important to make the pathological diagnosis, and should be strongly considered prior to the use of steroids or radiation therapy.
• See Neurology: Cord compression for more details. 

Cerebral Metastases

• Can present as headache, seizures, altered mental status, or focal deficit. Common in breast and lung cancer. 
• Evaluate with MRI, preferably with gadolinium if possible. Also consider LP with cytology if safe.
• Treat with dexamethasone, radiation, and consider neurosurgery. Patients with fewer lesions may benefit from stereotactic radiotherapy while those with more lesions may be more likely to require whole brain irradiation. With edema, mass effect, and/or midline shift, consider measures to control the rise in intracranial pressure (ICP) such as mannitol and hyperventilation. Little role for antiepileptics unless patient has seized.
• Again, if this is the first presentation of malignancy and no other more accessible lesion is found, consideration should be given to urgent neurosurgical biopsy prior to steroids or radiation.

Carcinomatous Meningitis

• May present as seizures, focal neurologic deficits (including cranial nerve deficits), peripheral neuropathy, or altered mental status. 
• Occurs most often with breast cancer, lymphoma, and leukemia. 
• Diagnose with spinal fluid cytology (repeat LP increases diagnostic accuracy if first LP is cytologically negative); MRI with gadolinium may also be helpful. 
• Treatments include systemic chemotherapy (e.g. high-dose methotrexate), and intrathecal chemotherapy.

Superior Vena Cava (SVC) Syndrome

• This is no longer considered an emergency, unless severe symptoms: stridor from laryngeal edema, CNS symptoms from cerebral edema, hemodynamic compromise/syncope from impaired venous return.
• Facial and/or upper extremity edema as well as dyspnea on exertion commonly with plethora. Results from a mediastinal mass impinging on SVC and limiting venous return. These are not life-threatening.
• Most commonly seen with lung cancer and lymphoma. 
• Diagnose with CT scan (gold standard) and work with pulmonary and radiology for best approach to obtain tissue. Catheter venogram is the best study for life-threatening SVC, can stent at same time.
• For life-threatening symptoms, best treatment is endovascular stent after venogram.
• Otherwise, treatment is non-urgent and can wait for tissue diagnosis. Stenting or radiation can then provide non-urgent symptomatic relief while waiting for cancer therapy to take effect. Chemo-responsive tumors (e.g. lymphoma, small cell lung cancer, germ cell tumors) usually only need chemo to treat SVC syndrome.
• Surgical resection is rarely used.

Hypercalcemia

• Presents gradually with fatigue, anorexia, constipation, polyuria, and confusion.
• Most commonly associated with breast cancer, lung cancer, and multiple myeloma. Most commonly due to PTHrp secretion, also lytic bone lesions (e.g. breast cancer, multiple myeloma) or 1-25 vitamin D production (lymphoma). Rarely tumors can secrete PTH.
• Treat with aggressive hydration (goal 100-150 ml/hr UOP), calcitonin and bisphosphonates (IV zolendronate preferred, dose reduction for renal dysfunction and dental evaluation are NOT required for this one-time dose), follow ionized calcium as a more accurate marker than serum calcium (even with correction for serum albumin) if needed. Diuresis only used for iatrogenic hypervolemia. Dialysis may be needed if life-threatening and not responsive to aggressive fluids.
• See section Acid-base/Electrolytes: Hypercalcemia.

Tumor Lysis Syndrome (TLS)

• Electrolyte abnormalities resulting from rapid turnover and/or destruction of tumor cell - findings include ↑ K+, ↑ Phos, ↑ uric acid, ↑ creatinine, and ↓ Ca2+, concerns are renal failure, arrhythmia, and seizure.
• Often occurs with bulky and chemosensitive tumors with high proliferative rate (commonly Burkitt’s lymphoma, acute leukemias, small cell lung cancer), and may be the presenting sign of malignancy or after initiation with cytotoxic therapy.
• Prevent with hydration and allopurinol. If TLS occurs, treat electrolyte abnormalities and continue hydration and allopurinol. Allopurinol generally takes 1-2 days to show effect and does not reduce preexisting serum uric acid, so rasburicase (50-100 U/kg/day) should be used early in a patient’s clinical course if ↑ uric acid despite standard approaches (usually use rasburicase if uric acid >8 mg/dL).  Prophylactic rasburicase may be used in selected case when the risk of TLS is high.
• Consider renal consult for HD if concern for renal damage.

Hyperviscosity

• Restricted CNS perfusion due to high levels of circulating paraproteins (in Waldenstrom macroglobulinemia far more often than multiple myeloma) or cells (e.g. polycythemia vera).
• Patients present with nonspecific neurologic symptoms such as headache, dizziness, somnolence, and blurry vision, as well as oronasal bleeding and heart failure.
• Most often occurs in patients with Waldenstrom macroglobulinemia; may also result from RBC overproduction in polycythemia vera. 
• Obtain head CT to rule out other CNS processes, less commonly LP. Serum viscosity may be directly measured, with normal typically <2 and symptoms occurring with viscosity >5. Correspondingly, IgG levels are usually >10 or IgM levels >4 in myeloma patients.
• Treat emergently with phlebotomy (for polycythemia vera), and plasmapheresis (for Waldenstrom macroglobulinemia) if the patient is symptomatic regardless of serum viscosity level.

Leukostasis

• Occurs with very high white blood cell count in acute leukemias. 
• Symptoms include hypoxia, renal insufficiency, altered mental status, and somnolence. Can worsen during induction chemotherapy. 
• Obtain CSF and head CT to rule out other diagnoses. 
• Emergent treatments include cytoreduction with hydroxyurea, and leukapheresis. Avoid blood product transfusions until adequate cytoreduction as this might worsen symptoms.   

DIC

• Consumptive coagulopathy commonly due to infection, cancer or trauma.
• Often occurs in patients with AML (especially M3 variant, acute promyelocytic leukemia) and adenocarcinoma. 
• Diagnose by platelet count (↓), PT/PTT (↑), fibrinogen (↓), and D-dimer (↑). Also obtain peripheral smear to evaluate for MAHA (schistocytes occasionally present).
• Treat by correcting deficits, especially if bleeding or at high risk for bleeding: platelet transfusions, FFP and cryoprecipitate (if fibrinogen <100), vitamin K if concomitant vitamin K deficiency suspected. Treat the underlying cause. Therapeutic heparin is recommended in patients with ongoing thrombosis, use unfractionated heparin when patients are also at high risk for bleeding.

Neutropenic Fever

See Hematology/Oncology: Neutropenic Fever.

Brigden ML.  Hematologic and oncologic emergencies.  Postgrad Med 2001;109:143-146, 151-154, 157-158.

Coiffier, B, Altman, A, Pui, CH, et al. Guidelines for the management of pediatric and adult tumor lysis syndrome: An evidence-based review. J Clin Oncol 2008. 26(16):2767-2778.

Levi M, Toh CH, Thachil J, Watson HG. Guidelines for the diagnosis and management of disseminated intravascular coagulation. British Committee for Standards in Haematology. Br J Haematol 2009 145(1):24-33.