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Oncology Cancer Emergencies Hypercalcemia Treatment: Treatment of the underlying cancer is the definitive management. Otherwise, treatment of severe or symptomatic hypercalcemia includes: o isotonic saline volume expansion r loop diuretics are not recommended unless kidney failure or heart failure is present r calcitonin is recommended for immediate management of symptomatic hypercalcemia . bisphosphonates are preferred to denosumab for longer-term control Hyponatremia See Nephrologz, Hyponatremia. Treatment: Initially treat asymptomatic or mildly symptomatic patients with SIADH with fluid restriction. Give 3% sodium chloride to patients with altered mental status or other neurologic findings. Deep Venous Thrombosis Treatment: Begin long term LMWH for initial treatment and secondary prevention of thromboembolic disease in patients with underlying cancer. DOACs are a reasonable alternative but may be associated with an increased risk for gastrointestinal bleeding. Metastatic Brain Tumor See also Neurolory, Metastatic Brain Tumors. Characteristic fi ndings: . headache . vomiting . altered mental status o focal neurologic deficits . loss ofconsciousness . new onset seizure Testing and treatment: Obtain emergent assessment with CT or MRI Oral glucocorticoids are appropriate for minimally symptomatic disease; osmotic diuresis (mannitol or hypertonic saline) and IV glucocorticoids are used for more advanced disease. When intracranial pressure is controlled, an isolated brain metastasis can be treated with surgical excision followed by radiation. Multiple brain metastases are treated with radiation therapy (solid tumors) and chemotherapy (leukemia, lymphoma). Spinal Cord Compression See also Neurologz, Myelopathy. Diagnosis: Characteristic findings include: . localized spinal or radicular pain . sensory loss .t 332

Oncology . muscle weakness o change in bowel or bladder function . autonomic dysfunction Testing: The diagnosis is established by gadolinium-enhanced MRI of the entire spine (more than one site of compression is common). DON'T BE TRICKED o Do not order plain x-rays or bone scans to diagnose spinal cord compression Treatment: Treat immediately with glucocorticoids and decompressive surgery followed by radiation therapy. Systemic chemo therapy is useful in patients with highly chemosensitive tumors such as lymphoma or breast cancer. Prescribe opioid therapy as needed for pain. Superior Vena Cava Syndrome Diagnosis: Characteristic findings are shortness ofbreath, cough, facial edema, plethora, swollen arms, jugularvenous distention, stridor (tracheal obstruction), and prominent collateral veins on the anterior chest wall. Testing and treatment: Chest CT with intravenous contrast confirms the diagnosis. Tissue biopsy is essential for establishing a histologic diagnosis and guiding therapy for the specific cancer type. Options for obtaining diagnostic tissue include mediastinoscopy, bronchoscopy, thoracentesis (ifa pleural effusion is present), or biopsy ofa peripheral area of lymphadenopathy. Cancers that are highly responsive to chemotherapy, such as SCLC, lymphoma, and germ cell cancers, are treated with initial chemo- therapy. NSCLC may be treated with initial chemotherapy, radiation therapy, or both. DOil'T BETRICKED . Most patients with SVC syndrome do not require emergency intervention; a tissue diagnosis should be obtained first with treatment directed by the type ofcancer. Cardiac Tamponade Superior Vena Cava Syndrome: Significantly dilated superficial veins See also Cardiovascular Medicine, Cardiac Tamponade and Constrictive transporting blood from the upper body to the lower caval vein herald the Pericarditis. onset of SVC syndrome. By EMAHkempny-0wn work, Public Domain, https:// commons.wikimedia.org/wiki/File:Superior.vena.cava.syndrome.aak.jpg Diagnosis: Characteristic fi ndings are

Cardiac Tamponade Superior Vena Cava Syndrome: Significantly dilated superficial veins See also Cardiovascular Medicine, Cardiac Tamponade and Constrictive transporting blood from the upper body to the lower caval vein herald the Pericarditis. onset of SVC syndrome. By EMAHkempny-0wn work, Public Domain, https:// commons.wikimedia.org/wiki/File:Superior.vena.cava.syndrome.aak.jpg Diagnosis: Characteristic fi ndings are . dyspnea, orthopnea, and clear lungs o jugular venous distention and hepatic engorgement . sinus tachycardia, hypotension, narrow pulse pressure, distant heart sounds, and pulsus paradoxus Treatment: Life threatening hemodynamic compromise is treated with immediate drainage of fluid by pericardiocentesis or pericardiotomy. Pleural Effusion See also Pulmonary and Critical Care Medicine, Pleural Effusion. 333