One Page Summaries

These summaries are intended to provide an overview of commonly encountered emergencies in oncologic critical care and may be helpful as a "just in time resource" when caring for patients presenting with these issues. However, they are not meant to replace expert consultation.

This resource also remains a work in progress and content will be added on an ongoing basis. Join our mailing list to receive updates when new educational materials are available. 

Emergencies in Hematologic Oncology:

Acute Promyelocytic Leukemia

Although acute promyelocytic leukemia (APL) is relatively rare, it is a medical emergency that is important for the intensivist to recognize. APL is a variant of acute myeloid leukemia (AML) that is highly curable (80 - 90%) but carries a significant early mortality risk due to bleeding and thrombotic complications. Outcomes can be improved through early recognition, prompt initiation of definitive treatment, and aggressive management of coagulopathy.

Contributors/Editors: Dr. Tracy Murphy

Hyperleukocytosis and Leukostasis

Hyperleukocytosis is commonly defined by a WBC > 100 x 109 /L but complications can occur at lower values. It common in patients with acute myeloid leukemia (AML) and is associated with increased mortality. Leukostasis refers to evidence of tissue hypoperfusion in the presence of a very high WBC. Leukostasis is more common in AML than acute lymphoblastic leukemia (ALL) due to the larger size and poor deformability of the myeloblasts. In patients with hyperleukocytosis respiratory failure and intracranial hemorrhage are the most common causes of death, and it is frequently complicated by disseminated intravascular coagulation (DIC) or tumor lysis syndrome (TLS).

Contributors/Editors: Dr. Tracy Murphy

Tumor Lysis Syndrome

Tumor lysis syndrome (TLS) occurs when the rapid breakdown of tumor cells results in the release of intracellular contents causing electrolyte disturbances and acute renal failure. It can occur spontaneously or after starting treatment. Incidence rates vary, but in-hospital mortality rates may be as high as 20%.

Contributors/Editors: Dr. Lisa Burry and Sarah McKenna

General Oncologic Emergencies

Malignant Pericardial Effusion

Malignant pericardial effusion is common in patients with cancer, and it may be life-threatening when associated with cardiac tamponade. Cancers associated with malignant pericardial effusion include lymphoma, leukemia, breast cancer, lung cancer, melanoma, and sarcoma. Unfortunately, prognosis in these patients is often poor which is an important factor to consider in the overall treatment plan.

Contributors/Editors: Dr. Husam Abdel-Qadir

Malignant Spinal Cord Compression

Malignant spinal cord compression (MSCC) is a common complication of malignancy that can result in permanent neurologic deficits if not rapidly diagnosed. Breast, lung, and prostate cancers are the most frequent causes, but it can be seen in a variety of other cancers including lymphoma, multiple myeloma, thyroid cancer and renal cell carcinoma. It may also be the presenting symptom of a previously undiagnosed cancer for up to 1 in 5 patients with MSCC.

Contributors/Editors: Dr. Raymond Jang

Superior Vena Cava Syndrome

Obstruction of the superior vena cava (SVC) in the setting of cancer leads to decreased venous return to the right heart causing a variety of potentially life-threatening effects. It commonly presents late in the course of the malignancy and prognosis is typically poor. Lung cancer is the most common underlying cause, but it can be seen in any cancer with mediastinal involvement including lung cancer, non-Hodgkin lymphoma, thymoma, germ cell tumors, or any solid tumor with mediastinal metastases. For lung cancer patients, SVC syndrome may be the initial presentation.

Contributors/Editors: Dr. Michael Sklar and Dr. Stephen Lapinsky

Syndrome of Inappropriate Antidiuretic Hormone

Hyponatremia is defined by a serum sodium less than 135mEq/L, and it occurs frequently in hospitalized patients with cancer. The syndrome of inappropriate antidiuretic hormone (SIADH) is the most common cause for hyponatremia in cancer patients. SIADH is most frequently associated with small cell lung cancer but it can occur in a broad range of solid tumors and hematologic malignancies. SIADH is associated with increased mortality and other poor outcomes.

Anterior Mediastinal Mass: Risks of Sedation and Intubation

Sedation or intubation of a patient with an anterior mediastinal mass involves several challenges, including a high risk of respiratory and hemodynamic collapse. As such, sedation and intubation should only be pursued when absolutely necessary. Awake intubation is generally the preferred approach. However, if possible, a plan should always be developed in advance with a multidisciplinary team.

Contributors/Editors: Dr. Lisa Myles and Dr. Maha Al Mandhari

Novel Therapies

Toxicities of CAR T-Cell Therapy: Cytokine Release Syndrome

The introduction of chimeric antigen receptor (CAR) T-cell therapy is changing the treatment landscape for patients with acute lymphoblastic leukemia and non-Hodgkin’s lymphoma with additional studies in solid tumors and other hematologic malignancies underway. Cytokine release syndrome (CRS) is an increasingly recognized complication of chimeric antigen receptor CAR T-cell therapy. When severe, CRS can be life-threatening and up to 50% of patients may require ICU admission.

Contributors/Editors: Dr. Arjun Law

Immune-Related Adverse Events Associated with Immune-Checkpoint Inhibitors

Immune checkpoint inhibitors are monoclonal antibodies which promote the recognition and killing of tumor cells by the immune system. They are being used to treat a variety of malignancies including melanoma, non-small cell lung cancer, diffuse large B-cell lymphoma, hepatocellular carcinoma, and urothelial cancer, among others.  However, immune-related adverse events (irAEs) are a potentially life-threatening complication of these novel therapies that must be promptly recognized and treated.

Contributors/Editors: Dr. Sam Saibil