Cancer Emergencies: TLS, SVC, Hypercalcemia

• TLS: high-risk patients get fluids plus rasburicase (check G6PD!); manage hyperkalemia; refractory K⁺/PO₄/overload triggers dialysis.
• Febrile neutropenia: antipseudomonal coverage within 1 h; reserve vancomycin for specific indications.
• SVC syndrome: head elevation, steroids, stenting/biopsy; don't biopsy blindly through the compression.
• Other crises include hyperleukocytosis (leukostasis → leukapheresis), hypercalcemia of malignancy, and cord compression (steroids + MRI + XRT).

Evaluating and Managing Suspected or Documented Malignancy-Associated Hypercalcemia

• Clinical suspicion of spinal cord compression → perform neurologic examination
• Abnormal neurologic examination?
• Dexamethasone 10 mg PO or IV followed by 4 mg PO or IV q6h → MRI
• Plain x-rays
• Abnormal plain x-rays?
• MRI
• Possibly bone scan
• Abnormal bone scan?
• MRI
• Observe clinically
• Does MRI show spinal cord compression?
• Surgical candidate?
• Operate ± postoperative radiation
• Tumor highly chemotherapy sensitive?
• Start chemotherapy ± radiation
• Radiation therapy
• No spinal cord compression — observe clinically

Preventing and Managing Tumor Lysis Syndrome (TLS) in High-Risk Patients

• TLS risk → check serum uric acid
• Uric acid level?
• Elevated (≥8 mg/dL): give rasburicase · allopurinol · recheck labs q8–12h
• Post-treatment uric acid?
• Uric acid ≥8 mg/dL → give rasburicase again · allopurinol · recheck labs q8–12h
• Uric acid <8 mg/dL → begin therapy
• Normal (<8 mg/dL): intravenous hydration · allopurinol · rasburicase if warranted → begin therapy
• Track BMP, PO₄⁻, Ca²⁺, UA, LDH q8–12h
• Address hyperkalemia (see electrolyte disorders) · keep urine output above 100 mL/hr · persistent hyperkalemia, hyperphosphatemia, hyperuricemia, or acidosis → dialyze

Evaluating and Managing Suspected or Confirmed Superior Vena Cava (SVC) Syndrome

• SVC syndrome
• Intrathoracic mass on CT or MRI?
• Cancer diagnosis known?
• Chemotherapy sensitivity
• Chemosensitivity high?
• Chemotherapy ± XRT ± stent
• XRT ± stent
• Take tissue biopsy
• Central venous catheter?
• Thrombosis evident?
• Start anticoagulation
• Is SVC fibrosis present?
• Dilation ± stent an option
• Seek alternative causes of upper body swelling
• Look for other causes of upper body swelling

Evaluating and Managing Hyperleukocytosis

• Hyperleukocytosis present
• Symptoms or blasts >100,000/mL?
• Hydroxyurea 50–100 mg/kg/day
• Leukapheresis
• Blasts now <50,000/mL?
• Move on to status of specific diagnosis
• Keep up leukapheresis
• No symptoms and blasts <100,000/mL: give hydroxyurea 50–100 mg/kg/day
• Status of specific diagnosis
• Diagnosis confirmed?
• Begin definitive therapy · take TLS-prevention measures (→ Pathway 66.2)
• Pending — once confirmed, begin definitive therapy; take measures to prevent TLS
• All patients: cerebral edema → dexamethasone 10 mg IV, then 4 mg every 6 hours · significant hypoxia → monitor in ICU and consider mechanical ventilatory support · correct any coagulopathy · start hydroxyurea when chemotherapy is not immediately planned, but never as a substitute for definitive therapy