Oncologic Emergencies and Complications
Oncologic emergencies: recognize and act
Oncologic emergencies are time-critical. Candidates must recognize febrile neutropenia, tumor lysis syndrome, hyperleukocytosis and leukostasis, superior vena cava syndrome, spinal cord compression, increased intracranial pressure, hemorrhage and DIC, anaphylaxis, sepsis, typhlitis, and CAR-T-related cytokine release syndrome or neurotoxicity. Fever in a neutropenic patient requires cultures and empiric broad-spectrum antibiotics promptly, without waiting for results. Tumor lysis syndrome produces hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia, and rising creatinine; management includes vigorous hydration, frequent labs, uric-acid-lowering therapy, and avoidance of potassium and phosphate supplementation. Hyperleukocytosis can cause leukostasis and requires urgent hematology involvement. Spinal cord compression may present as back pain, weakness, or bowel and bladder dysfunction and needs urgent imaging and steroids. CAR-T toxicity can escalate quickly; use protocol grading tools.
Traps include waiting for a positive culture before treating febrile neutropenia, giving potassium-containing fluids in tumor lysis, attributing back pain to minor strain, and missing subtle neurotoxicity. A normal-looking child can deteriorate rapidly. Reassess vital signs, urine output, electrolytes, and neurologic status.
Worked example: a child with newly diagnosed Burkitt lymphoma has potassium 6.2 mEq/L, phosphorus 7.0 mg/dL, calcium 7.2 mg/dL, uric acid 12 mg/dL, and rising creatinine. This is tumor lysis syndrome until proven otherwise. Hold potassium and phosphate in IV fluids, hydrate per protocol, give uric-acid-lowering therapy, monitor urine output and electrolytes, and notify the provider immediately.
Rule of thumb: in tumor lysis, hydrate and lower uric acid-do not add potassium or phosphate.