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Chapter 139: Emergency Complications of Malignancy

Ross J. Fleischman

INTRODUCTION

Oncologic emergencies arise from the underlying malignancy or as complications of therapy.

AIRWAY OBSTRUCTION

Patients with tumors of the upper and lower respiratory tract may experience acute airway compromise due to edema, bleeding, infection, or loss of protective mechanisms. Presenting symptoms and signs include dyspnea, tachypnea, wheezing, and stridor. Imaging involves plain radiographs, CT scan, and/or endoscopic visualization. Emergency measures include humidified oxygen, optimal patient positioning, and possibly administration of a helium–oxygen mixture. If intubation is required, an “awake look” with a fiber optic bronchoscope with a 5-0 or 6-0 endotracheal tube is preferred. A surgical airway such as cricothyroidotomy, transtracheal jet ventilation, or tracheotomy may be needed.

BONE METASTASES AND PATHOLOGIC FRACTURES

Patient with solid tumors, most commonly in breast, lung, and prostate, may present with bony metastases and pathologic fractures, usually in the axial skeleton and proximal limbs. Plain radiographs may only identify half of metastases, so negative films should be followed by CT with contrast or MRI. Control pain with opioid analgesia. Most pathologic fractures require surgical intervention. Painful bone metastases are treated with radiotherapy.

SPINAL CORD COMPRESSION

Spinal cord compression from metastases to the vertebral bodies may cause weakness, radicular pain, and bowel or bladder dysfunction. MRI is the imaging study of choice. The presentation, evaluation, and management of malignant spinal cord compromise are described in Table 139-1.

Table 139-1

Malignant Spinal Cord Compression

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Table 139-1

Malignant Spinal Cord Compression
Suspect

  • Most common cancers: lung, breast, prostate.

  • Thoracic location: 70%.

  • Progressive pain and worse when supine.

  • Motor weakness: proximal legs.

  • Sensory changes and bladder or bowel dysfunction: late findings.
Imaging

  • MRI: modality of choice, image entire vertebral column.

  • Plain radiographs: may detect vertebral body metastases but less sensitive and specific for malignant spinal cord compression.

  • CT myelography: used when MRI is not available.
Corticosteroids

  • Dexamethasone, 10 mg IV followed by 4 mg PO or IV every 6 h.

  • Consider starting in ED if imaging is delayed.
Radiotherapy

  • Beneficial in approximately 70% of cases.

  • Prognosis highly dependent on pretreatment neurologic function.
Surgery

  • Consider in highly selected cases, such as:

    • Patient in good general condition and able to undergo extensive surgery

    • Appropriate prognostic life expectancy

    • Rapidly progressive symptoms

    • Clinical worsening during radiotherapy

    • Unstable vertebral column

Consider giving corticosteroids if imaging will be delayed. Malignant spinal cord compression is a radiotherapy emergency.

MALIGNANT PERICARDIAL EFFUSION

Malignant pericardial effusions are usually asymptomatic but can progress to life-threatening cardiac tamponade. Symptoms depend on the rate of accumulation (see Chapter 24, “The Cardiomyopathies, Myocarditis, and Pericardial Disease”). Patients with symptomatic effusions may present with chest heaviness, dyspnea, cough, and syncope. Physical examination findings include tachycardia, narrowed pulse pressure, hypotension, distended neck veins, muffled heart tones, ...

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