Introduction

Each oncology patient possesses a narrative of strength, fear, hope, and uncertainty. The oncology patient's cancer diagnosis represents merely the beginning of a very difficult journey filled with treatment plans, emotional ups and downs, and the nerve-wracking waiting for what happens next. Often during a patient's fight with cancer, there are times when the cancer does not allow the stipulated pause until the next scan or appointment and takes control. These are the times defining oncologic emergencies.

Oncologic emergencies are acute, often life-threatening emergencies due to malignancy or its treatment which leads to the need for immediate medical attention. Oncologic emergencies can develop from malignancy; for example a tumor compressing a spinal cord or obstructing major vein, or from the host response to rapidly dying cells, examples of which are tumor lysis syndrome, etc. Oncologic emergencies may also come from the side effects of therapies used to save a life; or the consequences of incapacitating electrolyte imbalances, kidney shutting down, or sudden neurological deficits.

These emergencies are not infrequent. They can happen at any type and stage of cancer, and when they do, require immediate attention to life and/or permanent function. Worse of all, these emergencies frequently mimic other medical states, which can lead to a delay in the urgent diagnosis and treatment. Without an emergency intervention, many of these emergencies could accumulate irreversible injury or be fatal within hours or days. However, if identified in a timely fashion and treated appropriately, the outcomes can be extraordinarily favorable; even bringing back a person’s quality of life and survival.

This article will delve into four major categories of oncologic emergencies:

•                   superior Vena Cava (SVC) Syndrome

•                   Spinal Cord Compression (SCC)

•                   Metabolic emergencies (e.g., hypercalcemia, tumor lysis syndrome)

•                   Urologic emergencies (e.g., obstructive uropathy, hemorrhagic cystitis.)

For each of these emergency types we will explore etiology, clinical presentation, treatment options, and ultimately the human aspects of the emergency which are: mortality rate, survival rate, and recovery. Oncologic emergencies represent a strong reminder that cancer is not only a long-term battle, but also a fierce encounter where quick decision-making often makes the  difference between triumph and calamity.

Methods

This study was performed as a short review with comparative analysisand presenting the incidence of clinical presentation, and outcomes related to few medical emergencies that arise in the relation of cancer: superior vena cava (SVC) syndrome; spinal cord compression; metabolic emergencies (inclusive of hypercalcemia of malignancy and tumor lysis syndrome); and urological emergencies (inclusive of obstructive uropathy and hemorrhagic cystitis). A comprehensive search of the peer-reviewed literature was conducted on PubMed, Scopus, Google Scholar, and ScienceDirect databases from January 2010 through April 2024. Keywords searched included courses of "oncologic emergencies," "tumor lysis syndrome," "spinal cord compression," "hypercalcemia in cancer," and "obstructive uropathy in malignancy." Inclusion criteria consisted of studies completed in an adult population (≥ 18 years) that reported quantitative outcomes (e.g. number of patients with the incidence per the country/region/area, mortality, hospitalization, or clinical recovery), and included national data or limited to a country. All data for this research study was collected using a standardized data extraction form which included the type of emergency; country of origin; type of malignancy; symptoms presented; treatment; and clinical outcome. Descriptive analysis was performed to look for trends and differences in the data internationally or by region, especially focusing on mortality rates, survival outcomes, and the level of health care infrastructure.

1. Superior Vena Cava Syndrome (SVC Syndrome)

Overview & Pathophysiology

SVCS (Superior Vena Cava Syndrome) occurs when the superior vena cava, which returns deoxygenated blood from the head, neck, arms and upper chest back to the heart, is occluded or compressed, with the most common underlying etiology being a malignant tumor in the mediastinum, most often small cell lung cancer and non-Hodgkin lymphoma (greater than 85%).

Obstruction of the superior vena cava will result in increased pressure within the vein, and thus increased venous pressure (venous congestion and edema). This venous congestion is evident both externally, by changes in external appearance, and internally as impairment to internal functions, i.e. breathing, and to potentially cause cerebral edema. Vascular obstruction caused by SVCS can be detrimental to life, particularly when significant swelling occurs in rapid fashion, and it may also cause elevated cranial pressures, compromising function, and possibly resulting in herniation in truly catastrophic cases.

Clinical Presentation

Predominantly, a patient will present with:

·         Swelling of the head and neck, including facial swelling, which may be exacerbated in the morning.

·         Thickened neck and chest wall veins.

·         Dyspnea, cough, hoarseness.

·         Headache, dizziness, or visual disturbances (cerebral edema) may be due to decreased blood flow and possibly due to cranial swelling.

·         In more unfortunate circumstances: stridor, confusion, or coma.

Diagnosis

·         CT scan with contrast enhancement chest- the gold standard test.

·         Biopsy - required to evidence the malignancy.

Prognosis & Mortality

·         Mortality can be 30-40% if untreated, especially with aggressive tumors.

·         With timely therapy, symptoms can often abate within 24-72 hours, and mortality can be significantly reduced.

Treatment

• Corticosteroids (e.g., dexamethasone) to reduce inflammation

• Radiation therapy or chemotherapy, depending on tumor type

• Endovascular stenting placed for immediate relief in critical cases

• Anticoagulation if thrombus is present

2. Spinal Cord Compression (SCC)

Overview and Mechanism

SCC occurs when a metastatic tumor invades, impinges on, or encroaches on the spinal cord or cauda equina. SCC can be defined as a true neurologic emergency. The most common cancers resulting in SCC are breast, lung, and prostate cancers, which comprise over 60% of cases.

Compression leads to spinal ischemia, ultimately demyelination, and irreversible paralysis by compression, if not treated promptly.

Clinical Features

·         Continous back pain, worse in recumbent position and with cough

·         Motor weakness (eg, "foot drop"; loss of grip)

·         Sensory deficits

·         Bowel or bladder dysfunction

·         Gait or ambulation difficulty

Diagnosis

·         MRI spine is the imaging modality of choice

·         Urgent imaging is critical in cases of SCC suspicion and requires imaging all components of the spine.

Prognosis & Mortality

·         Median survival after SCC diagnosis is 2 to 6 months depending on tumor type and neurologic function at presentation.

·         Prognosis drops dramatically if treatment is delayed and paraplegia is present for more than 48 hours.

Management

·         High-dose corticosteroids (dexamethasone) to decrease edema

·         Radiation therapy or surgery to relieve compression, depending on the tumor's radiosensitivity and the patient's stability

·         Rehabilitation is a major component of functional recovery

3. Metabolic Emergencies

Overview and Types

Metabolic emergencies related to cancer result from dysregulation of electrolytes and organ systems. The conditions are as follows:

·         Hypercalcemia of malignancy (common)

·         Tumor lysis syndrome (TLS)

·         Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

·         Hypoglycemia

Hypercalcemia of Malignancy

Observed in 10 – 30% of all cancer patients, notably with breast, lung and multiple myeloma.

·         Symptoms: fatigue, confusion, constipation, renal failure

·         Treatment: IV hydration, bisphosphonates, calcitonin

Tumor Lysis Syndrome (TLS)

TLS occurs due to acute lysis of malignant cells (predominantly with chemotherapy for leukemia/lymphoma), leading to release of large quantities of potassium, phosphate and uric acid into the bloodstream.

·         Symptoms: Nausea, seizures, arrhythmias, renal failure

·         Treatment: hydration, allopurinol or rasburicase, dialysis if necessary

·         SIADH

Frequently observed in small-cell lung cancer.

·         Results in hyponatremia, which can cause seizures or coma.

·         Treatment: fluid restriction, salt tablets or vasopressin antagonists

Prognosis

·         It Varies and bases on type and severity of metabolic disturbance

·         if not treated aggressively, TLS can lead to death within 72 hours

4. Urologic Emergencies

An Overview

Urologic oncologic emergencies can occur from direct tumor invasion, obstruction, or any treatment side effects, and the most common Urologic oncologic emergencies is bladder cancer, prostate cancer, kidney cancer, and pelvic tumors.

Types of urologic oncologic emergencies

Obstructive Uropathy

·         Tumor compression or invasion of the ureters can cause obstructive uropathy for example presents hydronephrosis and renal failure.

·         Management includes nephrostomy tubes or ureteral stent placement.

Hemorrhagic Cystitis

·         Chemotherapy (specifically cyclophosphamide) or radiation therapy following treatment can result in hemorrhagic cystitis

·         Can cause abnormal urination, blood clots, and anemia

·         Management includes continuous bladder irrigation, bladder instillation of alum, formalin, or hyperbaric oxygen.

Prognosis

o   Renal recovery depends on early intervention.

o   Hemorrhagic cystitis is potentially life-threatening when severe.