Summary

Oncological emergencies can occur at presentation or during end-of-life care. Prompt recognition and management can significantly improve quality of life and prevent catastrophic disability. The "Big Three" structural/metabolic emergencies are:

1. Metastatic Spinal Cord Compression (MSCC).
2. Superior Vena Cava Obstruction (SVCO).
3. Hypercalcaemia of Malignancy. Other critical events include Catastrophic Haemorrhage and Neutropenic Sepsis. [1,2]

Clinical Pearls

MSCC Warning: The earliest symptom of spinal cord compression is Back Pain, typically "Radicular" (band-like) and Worse on Lying Down (due to venous distension/instability). Do NOT wait for weakness/bladder issues to diagnose MSCC – by then, function is often permanently lost.

Pemberton's Sign: Used for SVCO. Ask patient to lift arms above head. If positive, face turns red/cyanosed and veins distend within 1 minute (the "thyroid/mass plunges" into the thoracic inlet).

Corrected Calcium: Always interpret Calcium levels relative to Albumin. In Palliative patients (who are often hypoalbuminaemic/malnourished), the total calcium may look normal while the ionised/corrected calcium is dangerously high.

Pathophysiology

• Tumour (metastasis) in the vertebral body expands posteriorly to compress the Thecal Sac.
• Common primaries: Breast, Lung, Prostate, Renal, Lymphoma.
• Occurs in 5-10% of cancer patients.

Presentation

• Pain: 90%. Precedes neuro signs by weeks. Worse at night/lying flat.
• Motor: Weakness (Pyramidal), Heavy legs.
• Sensory: Sensory level on trunk.
• Autonomic: Urinary retention / Constipation (Late signs).

Management Algorithm

1. Suspect: New back pain in cancer patient?
2. Steroids: Dexamethasone 16mg PO/IV Stat. (Then 16mg daily with PPI). Reduces oedema, buys time.
3. Image: MRI Whole Spine within 24 hours.
4. Treat:
   • Surgery: Decompression/Stabilisation (if fit and single level).
   • Radiotherapy: 20 Gy in 5 fractions (Standard for most).
   • Nursing: Flat bed rest (log roll) until stability confirmed.

Pathophysiology

• Compression of the SVC by a mediastinal mass (e.g., Lung Cancer - NSCLC/SCLC, Lymphoma).
• Reduces venous return from head/neck/arms.

Presentation

• Symptoms: Dyspnoea, Facial Swelling (worse in morning), Headache.
• Signs: Distended neck veins (non-pulsatile), Plethoric face, Pemberton's sign positive.

Management

1. Steroids: Dexamethasone 8mg BD.
2. Definitive:
   • Endovascular Stenting: (Interventional Radiology). Provides rapid relief (hours). Preferred.
   • Chemotherapy: If chemosensitive tumour (SCLC/Lymphoma).
   • Radiotherapy: If stent not possible.

Pathophysiology

• Mechanism: Tumour secretion of PTHrP (Parathyroid Hormone related Protein) - e.g., Squamous cell lung cancer. Or direct osteolysis (Myeloma/Breast).

Presentation

• "Bones, Stones, Abdominal Groans, Psychic Moans".
• Confusion, Thirst (Polyuria/Polydipsia), Constipation, Vomiting.

Management

1. Rehydration: IV 0.9% Saline (e.g. 3-4 Litres in 24h). Essential first step.
2. Bisphosphonates: IV Zoledronic Acid (4mg) or Pamidronate. Give after rehydration. Takes 2-3 days to work.
3. Refractory: Denosumab (Rank-L inhibitor).

Scenario

• Erosion of a major artery by tumour.
• Classic: Carotid artery blow-out in Head & Neck cancer. Or Haematemesis in Gastric CA.

Management (Comfort Focus)

1. Do Not Resuscitate: Usually a terminal event. CPR futile.
2. Calm: Stay with the patient. Reassure.
3. Visuals: Use dark (green/blue) towels to soak up blood (red on white looks traumatic).
4. Drugs: Midazolam 10mg IV/IM (Anxiolytic/Sedative) + Morphine/Diamorphine (Analgesia).
5. Crisis Packs: These meds should be pre-prescribed (PRN) for at-risk patients.

Imaging

• MRI Spine: Gold standard for MSCC.
• CT Chest/Abdo: For SVCO or source of primary.

Bloods

• Calcium Profile: Hypercalcaemia.
• FBC: Neutropenia (Sepsis risk).
• U&E: Hyponatraemia (SIADH is another emergency - treat with fluid restriction).

Reversibility?

• Always ask: "Is this patient dying now regardless of intervention?"
• If the patient is essentially terminal and unconscious, aggressive treatment of Hypercalcaemia/SVCO may be inappropriate. Focus on symptom control (Syringe Driver).

Communication

• These events are terrifying for families. Clear, calm explanation is vital.

Key Guidelines

Landmark Evidence

1. Patchell Study (Lancet 2005)

• Demonstrated that Surgery + Radiotherapy was superior to Radiotherapy alone for MSCC in terms of maintaining ability to walk. Changed practice to favour surgical decompression in fit patients.

What is Spinal Cord Compression?

The cancer has spread to the bones of the back (vertebrae). It is pressing on the spinal cord nerves. Symptoms: New and severe back pain (especially lying down), leg weakness, or numbness. Action: Urgent MRI scan. If found, we give strong steroids and usually radiation to shrink the tumour and save leg function.

What is High Calcium?

Cancer can release chemicals that leach calcium out of bones into the blood. This makes patients very thirsty, confused, and constipated. We treat it with fluids and a special bone-strengthening drip (Bisphosphonate) which lowers the levels.

What if a bleed happens?

In some cancers, there is a risk of sudden bleeding. If this happens, we have strong sedatives ready to keep the patient calm and asleep, so they do not suffer.

Common Exam Questions

1. Prescribing: "Dose of Dex for MSCC?"
   • Answer: 16mg daily (stat dose then morning dose).
2. Emergency: "Stridor + Facial Swelling?"
   • Answer: SVCO. Give Steroids + O2 + Call for Stenting.
3. Pharmacology: "Treatment for Hypercalcaemia?"
   • Answer: Fluids + Bisphosphonates.
4. Signs: "Pemberton's Sign?"
   • Answer: SVCO.

Viva Points

• Why avoid fluids in SVCO?: The patient has venous congestion in the head/neck. Overloading with fluids can worsen laryngeal oedema. Use fluids cautiously.
• Opioid Toxicity: Another emergency. Pinpoint pupils + RR less than 8. Treat with Naloxone (carefully - can cause rapid pain crisis).

Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.