Oncological Emergencies and Palliative Care

Oncological emergencies are life-threatening complications of cancer or its treatment requiring immediate recognition and management.

Neutropenic sepsis (febrile neutropenia) is defined as temperature ≥38.3°C (or ≥38.0°C sustained >1 hour) with absolute neutrophil count <0.5 × 10⁹/L (or <1.0 × 10⁹/L with expected rapid fall). This is a medical emergency — mortality without prompt treatment approaches 10–20%. NZ protocol: blood cultures (peripheral + each lumen of central line), urine and chest imaging as indicated, then empiric broad-spectrum antibiotics within 1 hour — most NZ centres use piperacillin-tazobactam 4.5g IV 6-hourly (or meropenem in penicillin allergy or if high-risk for resistant organisms). Risk stratification using the MASCC score (≥21 = low risk, can consider oral antibiotics + early discharge in selected patients). G-CSF (filgrastim) as primary or secondary prophylaxis reduces neutropenic episodes in high-risk chemotherapy regimens.

Tumour lysis syndrome (TLS) results from rapid cancer cell death releasing intracellular contents — uric acid, potassium, phosphate — overwhelming renal excretion. Cairo-Bishop criteria define laboratory TLS: ≥2 of: uric acid ≥476 μmol/L, potassium ≥6.0 mmol/L, phosphate ≥1.45 mmol/L, calcium ≤1.75 mmol/L. Clinical TLS = laboratory TLS + any of: acute kidney injury, cardiac arrhythmia, seizure, death. Highest risk: haematological malignancies with high proliferative rate (Burkitt lymphoma, ALL, DLBCL). Management: aggressive IV hydration, allopurinol (xanthine oxidase inhibitor, reduces uric acid production — use prophylactically pre-chemotherapy), rasburicase (recombinant urate oxidase, rapidly degrades existing uric acid — use in high-risk or established TLS; contraindicated in G6PD deficiency).

Hypercalcaemia of malignancy affects ~10% of cancer patients. Mechanisms: (1) PTHrP (parathyroid hormone-related protein) secretion — most common, occurs in squamous cell cancers, breast, renal cell; (2) osteolytic metastases releasing calcium from bone (breast, myeloma); (3) 1,25-(OH)₂D excess in lymphomas. Symptoms: "bones, groans, psychic moans" — bone pain, constipation/nausea, confusion, polyuria. Management: IV 0.9% NaCl hydration, bisphosphonates (zoledronic acid 4mg IV — inhibits osteoclast activity, takes 48–72h to act), denosumab (RANK-L inhibitor, more effective in bisphosphonate-refractory disease), calcitonin for rapid short-term effect.

Metastatic spinal cord compression (MSCC) presents with back pain (often the first symptom), progressive leg weakness, sensory level, and bowel/bladder dysfunction. It is a surgical emergency — prognosis for ambulation is highly time-dependent. Management: high-dose dexamethasone 16mg IV stat (reduces perilesional oedema), urgent MRI whole spine, neurosurgical ± radiation oncology consultation. RT is the mainstay of treatment for most MSCC; surgical decompression indicated in radioresistant histology or spinal instability.

Superior vena cava (SVC) syndrome results from obstruction of venous return via the SVC — usually by lung cancer or lymphoma. Features: facial plethora and oedema, arm swelling, dilated neck and chest veins, headache, dyspnoea. Management: tumour-specific treatment (RT for NSCLC, chemotherapy for SCLC/lymphoma), systemic steroids, SVC stenting for rapid symptom relief.

Palliative care is the active, total care of patients whose disease is not responsive to curative treatment, addressing physical, psychological, social, and spiritual suffering. In NZ, palliative care is delivered by specialist palliative care teams in hospitals and the community, and by Te Omanga Hospice, Mary Potter Hospice, and regional hospice services. PCOC (Palliative Care Outcomes Collaboration) is the national benchmarking programme for palliative care quality. Pain management uses the WHO analgesic ladder: Step 1 (non-opioids: paracetamol/NSAIDs), Step 2 (weak opioids: codeine/tramadol), Step 3 (strong opioids: morphine, oxycodone, fentanyl patch, methadone). Morphine is the first-line strong opioid in NZ. Breakthrough dosing = 1/6th of the total daily oral morphine dose. Converting oral to subcutaneous morphine infusion (syringe driver): divide oral 24-hour dose by 2. Key symptom management: nausea (haloperidol, metoclopramide, ondansetron), breathlessness (low-dose morphine, fan, positioning), agitation (midazolam, haloperidol SC), secretions ("death rattle" — glycopyrrolate SC).