Common tumor emergencies and principles of management Malignant tumor patients, especially the more advanced ones, often have some urgent illnesses that must be treated immediately, which may be life-threatening and are usually called tumor emergencies. There are many kinds of tumor emergencies (see table), and tumor emergencies are actually part of the tumor complications, which are characterized by the urgent need for emergency treatment. There are different causes of tumor emergencies, but they can be broadly classified into three categories: the first category is tumor emergencies of obstructive structure, which are caused by the mass of tumor partially or completely or compressing an organ structure of human body. The second category is metabolic tumor emergencies, which are caused by metabolic imbalance due to the secretion of certain hormonal analogues by the tumor. The third category is treatment-related tumor emergencies, which can be said to be triggered by treatment. Although tumor emergencies can be divided into the above three categories, different tumor emergencies still have different symptoms, different treatments and different prognoses. The following is a brief introduction of several common tumor emergencies. (a) Malignant pericardial effusion or tamponade Malignant pericardial effusion often occurs in patients with lung cancer or breast cancer, or sometimes in patients with lymphoma or leukemia. This emergency occurs when cancer cells metastasize to the pericardium, creating a pericardial effusion and thus causing compression of the heart, which is unable to pump properly. Patients have difficulty breathing, coughing, C and cold extremities, and in some cases, chest pain because of the poor functioning of the heart. In terms of diagnosis, chest X-ray, electrocardiogram, cardiac ultrasound, and chest computed tomography can make a clear diagnosis. In terms of treatment, the most important thing is to extract the pericardial fluid immediately. If necessary, a catheter can be temporarily left in the pericardial cavity, and chemical injection can also be considered to reduce the chance of rehydration. Targeted treatment, such as chemotherapy and radiation therapy, can then be done. (b) Superior vena cava obstruction syndrome This emergency occurs in patients with lung cancer (especially small cell lung cancer) and lymphoma. It occurs because the tumor itself or its metastatic lymph node lesions compress the superior vena cava and even cause thrombosis inside the superior vena cava. When the superior vena cava is partially or completely blocked, patients may experience edema of the face (especially the eyes), neck, and upper extremities, as well as headache, tearing, difficulty breathing, and in more severe cases, severe congestion and edema of the brain, leading to confusion and seizures. In terms of diagnosis, chest X-ray and CT, together with the patient’s symptoms, can make a correct diagnosis. The treatment is based on the treatment of the cancer, including chemotherapy and radiation therapy. Patients should be bedridden, with head elevation and oxygenation to reduce low cardiac output and lower venous pressure. Diuretics and restriction of salt intake can reduce edema. Hormones inhibit the inflammatory response within normal tissues thereby reducing compression. If the patient is in a hypercoagulable state, some anticoagulation and antithrombotic therapy can be given if necessary. Patients should be given fluids through the veins of the lower extremities to avoid aggravating symptoms and causing phlebitis. (c) Spinal cord compression Spinal cord compression is also an occasional tumor emergency that occurs in patients with lung cancer, breast cancer, prostate cancer, etc. It occurs mostly because such tumors metastasize to the spine and grow further into the spine or cause vertebral fractures and compression in the spinal cord. Initial symptoms include back pain, pain along the dermatomes, pain caused by nerve root lesions, or sensory and motor abnormalities. Further, it may cause weakness and paralysis of the lower limbs and incontinence of urine and stool. It is an emergency that must be treated as soon as possible, otherwise it may cause irreversible damage, such as permanent incontinence and paralysis of the lower limbs. In terms of diagnosis, spinal X-ray and magnetic resonance imaging can provide a correct diagnosis. Once spinal cord compression is established, high doses of steroids should be given to the patient, and radiation therapy, surgery, or chemotherapy should be arranged depending on the type of cancer to save the patient from permanent neurological damage as soon as possible. The purpose of treatment is to: (i) restore nerve function; (ii) control local tumor; (iii) maintain spinal stability; and (iv) relieve pain. (iv) Hypercalcemia Hypercalcemia is also one of the tumor emergencies. Many cancers including lung cancer, breast cancer, multiple myeloma, lymphoma, etc. may occur. Patients do not necessarily have to have bone metastases because some cancer cells secrete a substance similar to parathyroid hormone to directly trigger hypercalcemia. Symptoms that may occur in patients include polyuria, thirst, dehydration, weight loss, nausea, vomiting, constipation, general weakness, itchy skin, etc. In more severe cases, irregular heart rate or altered consciousness and coma may even occur. In terms of diagnosis, hypercalcemia can be diagnosed by blood tests in conjunction with clinical symptoms. If it is hypercalcemia, the patient should be given a large amount of fluids as soon as possible and diuretics should be given to excrete calcium from the urine. Also, bisphosphonates can be used to reduce the activity of osteoclasts in the bones, and other drugs such as steroids can be used. Usually the blood calcium is lowered and the patient’s symptoms can be relieved quickly. (E) Tumor disintegration syndrome Some chemical sensitive cancers, such as leukemia and lymphoma, cause the rupture of a large number of tumor cells during chemotherapy, and some ions and other substances in the cancer cells are released, thus causing complications such as high blood potassium, high blood phosphorus, high uric acid, and low blood calcium (in general). and acute renal failure. Therefore, patients at risk of tumor collapse syndrome should be given precautionary measures during chemotherapy, including massive infusions, diuretics, and uric acid-lowering drugs, as well as frequent blood tests during chemotherapy. Treatment should be directed at hyperkalemia, hypophosphatemia, hypocalcemia and hyperuricemia, and if necessary, hemodialysis should be performed. Besides the above five tumor emergencies, other emergencies such as bleeding, respiratory obstruction, massive pleural effusion, intracranial metastasis combined with rise in intracranial pressure or seizure, intestinal obstruction, urinary tract obstruction, etc. are also common tumor emergencies. Clinically, the treatment should be planned according to the specific conditions of each system and based on the aforementioned principles of tumor complications.