Oncologic Emergencies

21.03.2024

ONCOLOGICAL EMERGENCIES DURING THE CANCER TREATMENT

Oncological emergencies are serious health problems that can be observed in cancer patients and require urgent intervention. These conditions may result from the direct effects of cancer or the side effects of cancer treatments. Examples include conditions such as severe infections, tumor lysis syndrome, spinal cord compression, and hypercalcemia. These emergencies can rapidly worsen the patient's general health condition and even pose a life-threatening risk. The importance of such emergencies stems from the need for a rapid and effective response. Therefore, early recognition of oncological emergencies, accurate evaluation, and rapid implementation of appropriate treatment strategies are vital. High awareness of cancer patients and physicians on this issue can significantly improve patients' quality of life and treatment outcomes.

Image 1: Many emergencies may occur during the cancer diagnosis and treatment process. It is necessary to be careful to detect emergency situations.

The most common oncological emergencies and treatment methods:

Spinal Cord Compression: Spinal Cord Compression (SCC) is a serious condition that is especially common in cancer patients and usually occurs as a result of spinal metastases. This condition is characterized by pressure on the spinal cord or nerve roots and requires urgent intervention. The most common symptoms of SCC include back or neck pain, difficulty moving, loss of sensation, difficulty controlling urine or stool, and weakness in the legs. Diagnosis is made through patient history, physical examination, and magnetic resonance imaging (MRI). Treatment varies depending on the patient's general condition and the cause of the compression; Symptomatic relief is usually achieved with high-dose corticosteroids, followed by radiotherapy or surgery. The aim of treatment is to relieve symptoms, preserve neurological functions and improve the patient's quality of life. When SCC is managed with early diagnosis and effective treatment, its negative effects on the patient's neurological functions can be reduced and the quality of life can be significantly improved.

Febrile Neutropenia: Febrile Neutropenia is a common condition, especially in cancer patients receiving chemotherapy, and increases the risk of serious infections. Neutropenia means that the number of neutrophil granulocytes in the bloodstream is abnormally low; This condition may be a result of suppression of the bone marrow by chemotherapy or disease. Febrile neutropenia describes the presence of signs of neutropenia along with fever and is considered a sign of a potentially life-threatening infection. Symptoms are generally nonspecific and appear as fever and general malaise. Diagnosis is made by blood tests with a low neutrophil count and body temperature of 38°C or above. Treatment should be immediate and aggressive. It is often necessary to start broad-spectrum antibiotics immediately because it may not always be possible to identify the specific focus of infection. Additionally, antifungal (fungal) and antiviral (virus) medications may be added depending on the patient's condition. Hematopoietic growth factors (e.g., granulocyte colony-stimulating factors) can be used to increase neutrophil count and shorten the duration of infection. Management of febrile neutropenia should be individualized depending on factors such as the patient's general health, underlying cancer type, and response to treatment. Prompt and effective treatment can reduce infection complications and ensure continuity of cancer treatment.

Hypersalivation Crisis: Hypersalivation crisis is a condition characterized by excessive saliva production and can often be caused by a variety of reasons, such as neurological disorders, oral infections, side effects of certain medications, or gastroesophageal reflux. It can also be seen in patients receiving cancer treatment, especially in those receiving radiotherapy to the head and neck area, or due to some chemotherapeutic agents. Symptoms of hypersalivation include constant salivation from the mouth, difficulty speaking and swallowing, skin irritation around the mouth and jaw, and potentially airway obstruction. Treatment is based on determining the underlying cause and removing it if possible. Anticholinergic medications are often used to reduce salivation. In special cases, such as radiotherapy or surgery, specific approaches may be necessary to manage hypersalivation associated with these treatments. It is also important to maintain patients' oral hygiene and involve other specialists, such as a dentist or gastroenterologist, when necessary. Effective management of hypersalivation can improve patients' comfort and quality of life and prevent respiratory complications. This condition is a complex medical problem that requires a multidisciplinary approach and requires treatment tailored to each patient's individual needs.

Malignant Pleural Effusion: Malignant Pleural Effusion is a condition that occurs as a result of some types of cancer, especially lung, breast, and ovarian cancers, metastasizing into the pleural cavity. The spread of cancer cells to the pleural membrane causes inflammation of the membrane and accumulation of abnormal amounts of fluid. This condition manifests itself with symptoms such as shortness of breath, cough, chest pain and sometimes fatigue. Malignant pleural effusion is usually diagnosed with a chest X-ray, computed tomography (CT) scan, and pleural fluid analysis. Treatment is generally aimed at relieving symptoms and improving quality of life. Pleural effusion drainage is the most commonly performed method to provide symptomatic relief. During this procedure, excess fluid in the chest cavity is removed through a tube. As a more permanent solution, a procedure called pleurodesis can be applied; Here, the pleural membranes are adhered to prevent fluid accumulation again. Additionally, chemotherapy or radiotherapy as cancer treatments may also play a role in controlling this effusion. An individualized approach is required in the treatment of malignant pleural effusion, taking into account factors such as the patient's general health condition, the stage of the cancer and the severity of the effusion. Effective management can reduce the patient's symptoms and significantly improve quality of life.

Superior Vena Cava Syndrome:Superior Vena Cava Syndrome (SVCS) occurs as a result of blockage or narrowing of the superior vena cava, the main vein that carries blood from the upper body to the heart. This condition is usually caused by cancers in the chest area (especially lung cancer and lymphoma) or non-cancerous conditions (for example, catheters placed in a vein or thrombosis causing a blockage). Symptoms of SVCS include swelling of the face, neck and upper body, headache, dizziness, feeling of fullness in the chest, cough and difficulty breathing. Skin redness and swelling of the eyelids may also occur. Treatment varies depending on the cause of the obstruction and the general condition of the patient. In case of cancer-related SCVC, radiotherapy and/or chemotherapy are usually the first treatment options. These treatments can help reduce the size of the tumor and relieve blockage of the vena cava. In emergency situations, corticosteroids and diuretics can be used to quickly reduce symptoms. In more advanced cases, surgical interventions such as intravenous stent placement may be necessary. Treatment of SVCS aims to relieve the patient's symptoms and address the underlying cause. Treatment of this condition requires a multidisciplinary approach and can significantly affect the patient's quality of life. Early diagnosis and appropriate treatment can prevent complications of SVCS and improve the patient's overall prognosis.

Image 2: Emergencies in cancer treatment may disrupt the main treatment process. For this reason, rapid response to emergencies is essential.

Hypercalcemia: Cancer-associated hypercalcemia is a common condition, especially in some types of cancer with bone metastases (e.g., lung, breast, and prostate cancer) or due to paraneoplastic syndromes. Hypercalcemia is characterized by excessively high blood calcium levels and occurs both as a result of direct damage to bones by cancer cells and overproduction of hormones that regulate calcium (for example, parathyroid hormone-like proteins). Symptoms include fatigue, thirst, loss of appetite, nausea, vomiting, constipation, confusion, and mental status changes. In severe cases, more severe complications such as kidney failure and coma may develop. Treatment of hypercalcemia is immediate and aggressive. The first step is usually to provide hydration with intravenous fluids, thereby increasing calcium excretion through the kidneys. Additionally, medications such as bisphosphonates help lower blood calcium levels by reducing the release of calcium from bones. In some cases, other faster-acting medications, such as calcitonin, may be used. Treatment also aims to control the underlying cancer and prevent hypercalcemia from recurring. Management of hypercalcemia is individualized depending on the patient's general condition and the stage of the cancer. Effective treatment can quickly control symptoms and reduce the risk of complications, which can significantly improve the patient's quality of life and overall survival.

Thromboembolic events: Cancer-related Thromboembolic Events (TEE) are common complications in cancer patients and carry an increased risk due to factors such as the cancer itself, chemotherapy, surgical interventions, and bed rest. Cancer cells can increase the susceptibility to thrombosis by affecting the blood clotting mechanism. This condition most commonly manifests as deep vein thrombosis (DVT) and pulmonary embolism (PE). While DVT causes symptoms such as pain, swelling and redness in the legs, PE may cause shortness of breath, chest pain and rapid heartbeat. In the treatment of cancer-related TEE, anticoagulant drugs are the main treatment method. In acute cases, intravenous or subcutaneous heparin is usually initiated and then switched to oral anticoagulants (e.g., warfarin). In recent years, the use of low molecular weight heparins (LMWH) and direct oral anticoagulants (DOACs) has increased because these drugs are better tolerated and easier to use. Prophylactic treatment is important, especially for high-risk patients, in terms of preventing thromboembolic events. This can be applied in the post-surgical period or during chemotherapy, taking into account the patient's general condition and bleeding risk. In the treatment of cancer-related TEE, an individual approach should be adopted, taking into account the patient's cancer type, treatment regimen and general health condition. Effective treatment and monitoring are vital in reducing these serious complications and their associated risks.

Malign Pericardial Effusion: Malignant Pericardial Effusion occurs when cancer cells infiltrate the pericardium (the membrane surrounding the heart) and accumulate abnormal amounts of fluid in the pericardial space. This condition is usually seen in types of cancer such as lung cancer, breast cancer, lymphoma and leukemia. Pericardial effusion may occur as a result of direct invasion of cancer cells into the pericardium, lymphatic obstruction, or tumor metastasis. Symptoms include chest pain, shortness of breath, cough, fatigue and sometimes swelling in the legs. In severe cases, cardiac tamponade may develop, which prevents the heart from pumping blood effectively. Treatment of malignant pericardial effusion involves rapid drainage of accumulated fluid, providing symptomatic relief and reducing the risk of cardiac tamponade. In a procedure known as pericardiocentesis, fluid is removed through a needle or catheter. As a more permanent solution, surgical interventions such as pericardial fenestration or pericardiectomy can be applied. Treatments such as chemotherapy or radiotherapy are also important to control the progression of cancer. A personalized approach should be adopted in the treatment of malignant pericardial effusion, taking into account the patient's general health condition and the stage of the cancer. Effective treatment and management can relieve the patient's symptoms and significantly improve quality of life.

Brain Metastases: Brain metastases occur when cancer cells from other parts of the body spread to the brain. It is most commonly caused by lung, breast, kidney, skin (melanoma) and colorectal cancers. The basic mechanism of this condition is that cancer cells move to the brain through the blood and form new tumors there. Symptoms of brain metastases include headache, neurological deficits (e.g., speech or movement disorders), seizures, nausea, vomiting, and personality changes. Symptoms vary depending on the location of the tumor and its size. In the treatment of brain metastases, surgical intervention, radiotherapy (especially stereotactic radiosurgery) and chemotherapy are commonly used. Surgical intervention is often preferred to reduce the size of the tumor and relieve symptoms. Stereotactic radiosurgery attempts to control the tumor without damaging healthy brain tissue by focusing high doses of radiation directly on the tumor. While systemic chemotherapy targets cancer cells in other parts of the body, it may also be effective against brain tumors in some cases. Treatment is individualized depending on factors such as the patient's general health condition, the number and size of metastases, and the type and stage of the cancer. Management of metastatic brain tumors is complex and requires a multidisciplinary approach. Effective treatment can help preserve the patient's neurological functions and improve quality of life. This condition is a serious health problem that can achieve better results with early diagnosis and treatment.

Tumor Lysis Syndrome: Tumor Lysis Syndrome (TLS) occurs when tumors, especially those that grow rapidly (e.g., some leukemias and lymphomas), respond rapidly to aggressive chemotherapy or radiotherapy. During treatment, cancer cells break down in large quantities and release their contents into the bloodstream. This leads to electrolyte imbalances such as hyperuricemia (high uric acid levels), hyperphosphatemia (high phosphate levels), hypocalcemia (low calcium levels), and hyperkalemia (high potassium levels). Symptoms of TLS can include nausea, vomiting, loss of appetite, muscle cramps, weakness, confusion, and even kidney failure. In the treatment of TLS, the primary aim is to reduce the risk and prevent complications. Hydration is used to accelerate the removal of uric acid and other toxins from the body. Uric acid-lowering medications such as allopurinol or rasburicase help keep uric acid levels under control. It is also important to correct electrolyte imbalances and support kidney function. Additionally, careful adjustment of the chemotherapy regimen may help prevent TLS, especially in high-risk patients. Management of TLS should be individualized based on the patient's health status, type of cancer, and response to treatment. With early diagnosis and appropriate treatment, serious complications of TLS can be prevented, resulting in positive effects on the patient's overall survival and quality of life. This condition is a serious medical problem that must be carefully addressed in aggressive cancer treatments.

Pain: Cancer pain is a common symptom caused by the cancer itself or cancer treatments. Causes of pain may include tumor compression of nerves, bones or other organs, metastasis, inflammation or infection, and treatment-related side effects (e.g. neuropathy or mucositis). The character of cancer pain may vary depending on the location and underlying causes; It may be continuous or intermittent, aching, stinging or burning. Pain can significantly impact a patient's quality of life and have negative consequences on sleep, mood, and overall health. A multifaceted approach is adopted in the treatment of cancer pain. Pain management can be done with medications such as NSAIDs (nonsteroidal anti-inflammatory drugs), opioid analgesics, other painkillers (antidepressants, anticonvulsants) and local anesthetics. Treatments directed at the source of the pain are also important; For example, radiotherapy or surgery may be necessary for pain caused by the tumor. In addition, complementary and alternative treatment methods such as physical therapy, massage, acupuncture and psychological support can also be effective in pain management. In the treatment of cancer pain, a personalized plan is developed taking into account the individual needs of the patient, the severity and type of pain, underlying causes and other accompanying symptoms. Effective pain management can improve cancer patients' quality of life and increase overall compliance with treatment. Therefore, pain management is a vital component in cancer treatment.

Hyponatremia: Cancer-related hyponatremia is an electrolyte imbalance frequently seen in cancer patients and is often characterized by an abnormally low serum sodium level. This condition can occur for a variety of reasons, including as a side effect of cancer treatment (for example, fluid retention from chemotherapy or radiotherapy), the tumor producing antidiuretic hormone (ADH) (known as paraneoplastic syndrome), excessive water intake, or kidney dysfunction. Symptoms of hyponatremia can range from mild dizziness to severe confusion and coma, and may also include loss of appetite, nausea, vomiting, headache and muscle weakness. The main goal in treating hyponatremia is to return serum sodium levels to the normal range in a careful and controlled manner. Treatment varies depending on the factors causing hyponatremia. In mild cases, fluid restriction and treatment of the underlying cause is usually sufficient. In more severe cases, carefully administered intravenous sodium chloride solutions may be required. Additionally, if the tumor stimulates ADH production, specific medications such as demeclocycline or tolvaptan may be used. When treating hyponatremia, it is important not to raise sodium levels too quickly, as this can lead to serious neurological complications such as central pontine myelinolysis. Each patient's condition should be evaluated according to the specific factors causing hyponatremia, general health status and other accompanying health problems, and treatment should be planned accordingly. With effective management, the risks associated with hyponatremia can be reduced and patient comfort and safety can be ensured.

Image 3: Oncological emergencies often require hospitalization.

Paraneoplastic Complications: Paraneoplastic complications are rare conditions that occur in patients with cancer, without the direct effect of the cancer, usually as a result of an abnormal response of the immune system or the production of hormone-like substances by the tumor. These complications can affect a wide variety of systems, such as neurological disorders, endocrine changes, skin changes and rheumatological problems. For example, neurological paraneoplastic syndromes such as Lambert-Eaton myasthenic syndrome can cause muscle weakness and fatigue, while endocrine disorders such as Cushing syndrome can lead to hormone imbalances. Treatment of paraneoplastic complications focuses primarily on controlling the underlying cancer. Successful treatment of the tumor may help relieve or completely eliminate paraneoplastic symptoms. Supportive treatments are also administered to relieve symptoms. For example, treatments such as corticosteroids, immunosuppressive drugs, or plasmapheresis may be used for neurological symptoms. In the management of endocrine disorders, drugs that correct hormone imbalances are preferred. In the treatment of paraneoplastic complications, an individual approach should be adopted, taking into account the general condition of the patient, the type and stage of the cancer, and the severity of the symptoms. These complications can be complex in terms of diagnosis and treatment and may require a multidisciplinary approach. Effective treatment can improve the patient's quality of life and play an important role in dealing with general health problems caused by cancer.

Oncological emergencies refer to serious and potentially life-threatening medical conditions seen in cancer patients, and early intervention is critical in the management of these conditions. Oncological emergencies can include conditions such as spinal cord compression, febrile neutropenia, hypercalcemia, malignant pleural effusion, etc., and these conditions, if not treated quickly and effectively, can seriously compromise the patient's health and deteriorate rapidly. Early intervention can prevent symptoms from worsening, reduce the risk of complications, and sometimes save the patient's life. For example, in cases such as febrile neutropenia, starting antibiotic treatment quickly can prevent the infection from spreading and developing into more serious health problems. Similarly, early diagnosis and treatment of spinal cord compression can prevent serious consequences such as permanent paralysis. Therefore, early recognition of oncological emergencies, prompt appropriate medical evaluation, and initiation of effective treatment play a vital role in the treatment process of cancer patients and can improve overall survival rates and quality of life. Treatment methods may vary depending on the general condition of the patient, the type of cancer and the severity of the emergency.