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Oncological emergencies

The cancer emergencies a junior doctor must recognise on the first night: what to do in the first hour.

Written and clinically reviewed by , consultant minimally invasive and bariatric surgeon, Al-Makassed Hospital, Jerusalem, and Assistant Professor of Surgery, Al-Quds University. Last updated .

Level 3 · Treatment principles

Key points

  • Neutropenic sepsis: IV antibiotics within one hour, without waiting for the blood count.
  • Back pain in a cancer patient: think cord compression; MRI the whole spine.
  • Tumour lysis: potassium, phosphate and urate rise; calcium falls.
  • Cancer causes surgical emergencies too: obstruction, perforation, bleeding, jaundice.

Neutropenic sepsis

A temperature over 38 °C or any sign of sepsis in a patient on chemotherapy, with a neutrophil count of 0.5 × 109/L or less. Give IV broad-spectrum antibiotics (for example piperacillin–tazobactam) within one hour of arrival, after cultures, and do not wait for the count. It is the commonest cause of death from chemotherapy.

Malignant spinal cord compression

Back pain, especially thoracic, worse lying down or at night, with or without leg weakness, numbness or bladder and bowel symptoms. Urgent MRI of the whole spine (within 24 hours, immediately if there are neurological signs), high-dose dexamethasone, then radiotherapy or surgery. The function the patient walks in with is usually the function they keep.

Superior vena cava obstruction

Swelling of the face and arms, distended neck and chest veins, breathlessness; usually lung cancer or lymphoma. Sit up, oxygen, steroids in some cases, then stenting and treatment of the cause.

Hypercalcaemia of malignancy

From PTH-related peptide or bone metastases. Thirst, polyuria, confusion, constipation. IV 0.9% saline, then a bisphosphonate. See the hypercalcaemic crisis page.

Tumour lysis syndrome

Rapid cell death releases potassium, phosphate and uric acid (all rise) and calcium falls, causing kidney injury and arrhythmias. Typically after treatment of high-grade lymphoma or leukaemia. Prevent with hydration and allopurinol or rasburicase.

The surgical emergencies of cancer

  • Malignant bowel obstruction: from the primary or peritoneal disease; stent, stoma, resection or palliative care.
  • Perforation: of the tumour or, during treatment, from steroids, bevacizumab or immune colitis.
  • Bleeding: endoscopic or radiological control first.
  • Obstructive jaundice and cholangitis: drainage by ERCP or percutaneously.
  • Pathological fracture and raised intracranial pressure from metastases.
From the book Coming soonThis page follows our surgical oncology book, which is being written now. Once it is published, the matching chapter will be linked here.

Frequently asked questions

What are the main oncological emergencies?

Neutropenic sepsis, malignant spinal cord compression, superior vena cava obstruction, hypercalcaemia of malignancy, tumour lysis syndrome, and surgical emergencies such as obstruction, perforation and bleeding.

How quickly should antibiotics be given in neutropenic sepsis?

Within one hour of arrival, after blood cultures, without waiting for the neutrophil count.

What are the blood findings in tumour lysis syndrome?

High potassium, high phosphate and high uric acid, with low calcium, often with acute kidney injury.

How is malignant spinal cord compression investigated?

With urgent MRI of the whole spine, and high-dose dexamethasone while radiotherapy or surgery is arranged.

Further reading

  1. NICE NG151. Neutropenic sepsis: prevention and management in people with cancer. 2012 (updated).
  2. NICE NG234. Spinal metastases and metastatic spinal cord compression. 2023.
  3. Cairo MS, Bishop M. Tumour lysis syndrome: new therapeutic strategies and classification. Br J Haematol 2004;127:3–11.
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