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  Spinal cord compression should be considered in any patient presenting to the emergency department with a neurologic complaint and a history of malignancy.

  
  
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  Electrolyte abnormalities should be considered in all patients with malignancy and nonspecific symptoms.

  
  
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  Patients undergoing chemotherapy who present with fever should be considered neutropenic until proven otherwise.

Improvements in the management of cancer have lead to an aging population presenting to emergency departments (EDs) with complications related to malignant disease. Oncologic emergencies occur in patients with recurrence of a previously diagnosed malignancy, complications of cancer treatment, or signs and symptoms that may lead to a new diagnosis of cancer. Emergency clinicians must be aware of the common complications associated with malignancies and available treatments. These complications can be broadly divided into those created by local tumor effects, complications from hematologic derangements and biochemical abnormalities, and complications related to cancer treatment. When caring for patients with oncologic related emergencies in the ED, consideration should always be given to the nature of medical therapy warranted in view of progression of the disease. Early consultation with family members and stakeholders is advised.

Emergencies related to local tumor invasion include spinal cord compression and superior vena cava (SVC) syndrome. Both are oncologic emergencies that require prompt intervention. The most common primary tumors that metastasize to the spine are lung (29%), prostate (19%), and breast (13%). The thoracic spine is the most common site involved (77%). The lumbar spine is affected 29% of the time with the cervical (12%) and sacral (7%) regions being affected least often.

SVC syndrome is defined as obstruction of flow through the superior vena cava due to tumor-related compression. Lung cancer and non-Hodgkin lymphoma together cause about 95% of cancer-related SVC syndrome. The incidence of SVC syndrome in patients with lung cancer and non-Hodgkin lymphoma is 2–4%. Thrombosis related to central venous catheters can also cause SVC syndrome in patients with cancer as a result of their prothrombotic state.

Emergencies related to biochemical derangements in the cancer patient include hypercalcemia and tumor lysis syndrome. Hypercalcemia has been reported to occur in 20–30% of patients with cancer at some time during the course of their disease. It occurs most commonly in cancers associated with bone (multiple myeloma), bony metastasis (breast, lung, prostate, renal), or cancers that secrete parathyroid-like substance (lung) or osteoclastic factors (lymphomas). The detection of hypercalcemia in a patient with cancer signifies a very poor prognosis, with death often occurring within months.

Tumor lysis syndrome is the most common disease-related emergency encountered in patients with hematologic cancers. The syndrome occurs when tumor cells release their contents into the bloodstream, either spontaneously or in response to therapy, leading to the characteristic findings of hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia. These electrolyte and metabolic disturbances can progress to clinical toxic effects, including renal insufficiency, cardiac arrhythmias, seizures, and death due to organ failure. It is most common in cancers with high cell turnover (leukemia and lymphoma).

One of the most common hematologic emergencies is neutropenic fever, which is the presence of a fever >38°C with an absolute neutrophil count of <500/μL. Febrile neutropenia is a result of bone marrow suppression, a common side effect of chemotherapy. Patients with neutropenia are susceptible to life-threatening bacterial infections. Older age has been shown to be an independent risk factor for the development of neutropenia and febrile neutropenia. A history of previous chemotherapy-induced neutropenia predicts recurrent neutropenia and neutropenic fever.

History

Pain is the presenting symptom of spinal cord compression in 90–95% of patients. The pain is usually constant and close to the site of the lesion. Patients complain of a band or girdle of pain/tightness radiating from back to front, exacerbated by recumbency, movement, coughing and sneezing. Symptoms may include numbness and tingling, which usually precedes weakness. Weakness often presents with “stiffness,” dragging of a limb, or unsteadiness.