Summary of Oncologic Emergencies Neutropenic fever: - Fever + ANC < 500 → start cefepime ± vancomycin (if SSTI or port infection suspected) - CT chest; CT abdomen if abdominal pain; full infectious work-up - If febrile > 4 days → add fungal work-up + empiric antifungal - 70 % of patients will have no identifiable source - When afebrile 24-48 h and ANC rising > 500 → may stop antibiotics TLS (tumor-lysis syndrome): - Hematologic malignancies, “rapid-turnover” SCLC - Lab changes: high K, high Phos, high uric acid, high LDH, low Ca - q8 h TLS labs, aggressive fluids, allopurinol 300 mg BID, sevelamer PRN - Consider rasburicase if uric acid > 8 mg/dL or > 25 % rise from last lab (check G6PD first) DIC (disseminated intravascular coagulation): - Simultaneous clotting and bleeding; high d-dimer, low fibrinogen - Treat underlying cause - Give cryoprecipitate if fibrinogen < 100 - Consider TEG to guide replacement Cord compression: - Lower-extremity weakness, urinary retention, bowel incontinence - High-dose steroids + urgent neurosurgery consult for decompression SVC syndrome: - Facial swelling, dyspnea, upper-extremity swelling - Consult pulmonology / interventional radiology for possible stenting - Consider anticoagulation Leukostasis: - Usually myeloid leukemias; “big & sticky” cells; WBC often > 100 000 (can be lower) - Symptoms: CNS changes, headache, dizziness, shortness of breath - Asymptomatic: hydroxyurea - Symptomatic: hydroxyurea + leukapheresis Hyperviscosity syndrome: - Seen in MM and Waldenström macroglobulinemia (incidence up to 30 %) - Symptoms: CNS changes, headache, dizziness, shortness of breath - Treatment: plasmapheresis Hypercalcemia of malignancy: - Calcium > 14 mg/dL → treat - Calcium > 12 mg/dL with symptoms → treat - Calcium > 10 mg/dL without symptoms → no immediate treatment 1. Aggressive IV fluids (200–300 mL/h) 2. Calcitonin (rapid onset; tachyphylaxis after ~48 h) 3. IV bisphosphonates (onset ~48 h, duration 3–4 weeks) 4. Adjuncts: loop diuretics, denosumab, steroids, dialysis Cytokine-release syndrome (CRS) / ICANS: - Occurs after CAR-T, bispecifics, or HSCT - CRS: fever, rash, hypoxia, hypotension (hours-to-days post-infusion) - ICANS: altered level of consciousness, seizures, speech changes (CAR-T day 3–10; 2–4 days after CRS) - Treatment: corticosteroids ± tocilizumab; call oncology early Differentiation syndrome: - Seen with AML (~20 %) and APL (~25 %) during therapy - Symptoms: fever, weight gain, hypotension, renal failure, pulmonary opacities, SOB, pleural effusions - Treatment: continue differentiating agent, add steroids, supportive care #Oncologic #Emergencies #Oncology #HemeOnc #Diagnosis
