Study guide
8.2 Oncologic Emergencies
ABIM Internal Medicine Exam
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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy
0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan
2 Chapter 1: Cardiovascular Disease (14% of Exam)
1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection
3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)
2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia
4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)
3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV
5 Chapter 4: Infectious Disease (9% of Exam)
4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections
6 Chapter 5: Pulmonary Disease (9% of Exam)
5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule
7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)
6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease
8 Chapter 7: Hematology (6% of Exam)
7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation
9 Chapter 8: Medical Oncology (6% of Exam)
8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care
10 Chapter 9: Nephrology & Urology (6% of Exam)
9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria
11 Chapter 10: Neurology (4% of Exam)
10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders
12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)
11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health
13 Chapter 12: Dermatology (3% of Exam)
12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease
14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)
13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications
15 Chapter 14: Geriatric Syndromes (3% of Exam)
14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings
16 Chapter 15: Allergy & Immunology (2% of Exam)
15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders
17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology
16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design
18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)
17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity
19 Chapter 18: Perioperative Medicine & Medical Consultation
18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications
20 Chapter 19: Ophthalmology (1% of Exam)
19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease
21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)
20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders
8.2 Oncologic Emergencies
Key Takeaways Explain This Topic AI
Superior vena cava syndrome, fever and neutropenia, brain tumors, spinal cord tumors and compression, cardiac tamponade from neoplastic pericarditis, tumor lysis syndrome and hypercalcemia are the enumerated oncologic emergencies.
Suspected malignant spinal cord compression requires immediate corticosteroids and urgent magnetic resonance imaging of the entire spine.
Neurologic function at the time of treatment is the strongest predictor of ambulatory outcome after cord compression, so delay is what causes permanent paralysis.
Tumor lysis syndrome prophylaxis uses aggressive hydration with allopurinol, reserving rasburicase for high-risk disease and established hyperuricemia.
Rasburicase is contraindicated in glucose-6-phosphate dehydrogenase deficiency because it generates hydrogen peroxide and precipitates severe hemolysis.
Last updated: October 2026
- 1. Oncologic Emergencies
- 1. Febrile Neutropenia
Definitions:
Fever: A single oral temperature ≥ 38.3°C (101.0°F) OR a sustained temperature ≥ 38.0°C (100.4°F) over ≥ 1 hour .
Neutropenia: Absolute Neutrophil Count ( ANC ) < 500 cells/mcL , or an ANC expected to fall < 500 cells/mcL over the subsequent 48 hours ( ANC = WBC × [ % Neutrophils + % Bands ] / 100 \text{ANC} = \text{WBC} \times [\%\text{Neutrophils} + \%\text{Bands}] / 100 ANC = WBC × [ % Neutrophils + % Bands ] /100 ).
Risk Stratification: Calculate the MASCC (Multinational Association for Supportive Care in Cancer) Risk Index Score :
Score ≥ 21 indicates low risk (candidates for outpatient oral therapy with Ciprofloxacin + Amoxicillin-Clavulanate if clinically stable and reliable).
Score < 21 indicates high risk (mandates inpatient admission and IV broad-spectrum antibiotics).
EMERGENCY MANAGEMENT PROTOCOL (Door-to-Antibiotic Time ≤ 60 Minutes):
Obtain 2 sets of blood cultures immediately (1 set from a peripheral vein and 1 set from every lumen of any central venous catheter).
Promptly initiate empiric broad-spectrum IV antipseudomonal monotherapy within 1 hour :
First-line Monotherapy Agents: Cefepime (2 g IV q8h), Piperacillin-Tazobactam (4.5 g IV q6h), or Meropenem (1 g IV q8h).
Specific Indications to Add IV Vancomycin: Hemodynamic instability / septic shock, suspected catheter-related infection, clinical evidence of pneumonia, severe skin/soft-tissue infection, or known MRSA colonization. (Do not start vancomycin routinely for uninformative fever alone).
2. Tumor Lysis Syndrome (TLS)
Pathophysiology: Massive, rapid destruction of malignant cells following chemotherapy (or spontaneously in Burkitt lymphoma, ALL, AML), releasing intracellular ions and nucleic acids into the circulation.
Cairo-Bishop Diagnostic Criteria (Laboratory TLS): ≥ 2 of the following electrolyte abnormalities within 3 days before or up to 7 days after starting cytotoxic therapy:
Hyperuricemia: Serum Uric Acid ≥ 8.0 mg/dL (or 25% increase from baseline).
Hyperkalemia: Serum Potassium ≥ 6.0 mEq/L (or 25% increase) → risk of fatal cardiac arrest and arrhythmias.
Hyperphosphatemia: Serum Phosphorus ≥ 4.5 mg/dL (or 25% increase) → binds calcium to form calcium phosphate crystals, precipitating in renal tubules.
Hypocalcemia: Corrected Serum Calcium ≤ 7.0 mg/dL or ionized Ca < 1.12 mmol/L (or 25% decrease) → tetany, seizures, QT prolongation.
Clinical TLS: Laboratory TLS plus at least 1 clinical complication: Acute kidney injury (creatinine ≥ 1.5x baseline), cardiac arrhythmia, seizure, or sudden death.
Prevention & Management:
Aggressive IV Hydration: Isotonic crystalloid at 2–3 L/m 2 /day \text{L/m}^2\text{/day} L/m 2 /day (target urine output > 100 mL/hr). Do NOT alkalinize urine with sodium bicarbonate (alkaluria worsens calcium phosphate precipitation in renal parenchyma).
Allopurinol (300 mg daily PO/IV): Competitive xanthine oxidase inhibitor; prevents new uric acid synthesis (does not degrade existing uric acid); indicated for low/intermediate risk TLS.
Rasburicase (0.2 mg/kg IV or fixed 3–6 mg single dose): Recombinant urate oxidase enzyme; rapidly catabolizes existing insoluble uric acid into soluble Allantoin , decreasing uric acid levels within 4 hours. Indicated for high-risk TLS or established severe hyperuricemia.
CRITICAL CONTRAINDICATION FOR RASBURICASE: Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency . Rasburicase catabolism of uric acid generates hydrogen peroxide ( H 2 O 2 H_2O_2 H 2 O 2 ). In G6PD-deficient erythrocytes (lacking NADPH), hydrogen peroxide triggers catastrophic severe hemolytic anemia and methemoglobinemia .
3. Malignant Spinal Cord Compression (MSCC)
Etiology: Epidural metastatic disease from solid tumors (prostate, breast, lung, renal cell carcinoma) or multiple myeloma.
Clinical Presentation: Progressive back pain (present in > 95% of cases) that worsens when recumbent / supine (due to distention of epidural venous plexus) and with Valsalva maneuvers (coughing, straining). Followed by motor weakness, sensory deficit with a clear dermatomal level, and late autonomic dysfunction (urinary retention, overflow incontinence, loss of anal sphincter tone).
EMERGENCY MANAGEMENT PROTOCOL:
Immediate IV Dexamethasone: Administer a 10 to 16 mg IV bolus immediately , followed by 4 to 16 mg daily divided q6h. Do not delay steroid administration for imaging ; early corticosteroids reduce vasogenic spinal cord edema and prevent permanent paralysis.
Urgent Whole-Spine MRI: Perform sagittal T1/T2 with axial MRI of the entire spine within 12–24 hours (multiple non-contiguous epidural metastases occur in > 30% of patients).
Multidisciplinary Triage: Urgent neurosurgery and radiation oncology consultation. Direct surgical decompressive resection followed by postoperative radiation therapy is superior to radiation alone for patients with spinal instability, bony compression, radioresistant tumors, or progressive neurologic deficits with life expectancy > 3 months (Patchell trial).
4. Hypercalcemia of Malignancy
Mechanisms:
Humoral Hypercalcemia of Malignancy (~80%): Tumor secretion of Parathyroid Hormone-related Protein (PTHrP) ; associated with squamous cell carcinomas (lung, head/neck, esophagus), renal, and bladder cancer. Labs: Elevated PTHrP, suppressed intact PTH, normal 1,25-dihydroxyvitamin D.
Osteolytic Bone Metastases (~20%): Extensive bone metastases with local osteoclast activation (breast cancer, multiple myeloma). Labs: Normal PTHrP, suppressed PTH.
1,25-Dihydroxyvitamin D (Calcitriol) Overproduction (<1%): Extrarenal 1-alpha-hydroxylase expression in lymphomas. Labs: Elevated 1,25-(OH)2-D, suppressed PTH.
Phased Management Protocol:
Phase 1 (Immediate Volume Expansion): Aggressive IV 0.9% Normal Saline (200–300 mL/hr, 2–4 L in first 24–48 hours) to restore intravascular volume, enhance GFR, and promote urinary calcium excretion. (Add loop diuretics like furosemide only after euvolemia is restored and only if fluid overload occurs).
Phase 2 (Rapid Acute Reduction): Subcutaneous/IM Calcitonin (4 to 8 units/kg q12h); rapidly inhibits osteoclast resorption and enhances renal excretion within 2–4 hours. Tachyphylaxis develops within 48 hours due to calcitonin receptor downregulation.
Phase 3 (Sustained Osteoclast Inhibition): IV Zoledronic Acid (4 mg over 15 min) or IV Pamidronate (60–90 mg over 2–4 hours) ; onset of action in 48–72 hours, nadir at 4–7 days. Dose reduce for baseline renal insufficiency.
Refractory Disease or Severe Renal Failure (CrCl < 30 mL/min): Subcutaneous Denosumab (120 mg) (monoclonal antibody targeting RANKL) effectively suppresses osteoclasts without renal clearance.
5. Superior Vena Cava (SVC) Syndrome
Etiology: Extrinsic compression or intravascular thrombosis of the SVC, caused by intrathoracic malignancies (~75%: small cell lung cancer, NSCLC, mediastinal lymphoma) or indwelling central venous catheters/pacemaker leads.
Clinical Presentation: Dyspnea, facial fullness, facial and neck edema, periorbital swelling, distended collateral veins over the upper chest wall, and conjunctival injection. Pemberton Sign: Elevation of both arms above the head for 1 minute induces severe facial plethora, cyanosis, and inspiratory stridor due to thoracic inlet narrowing.
Diagnostic Evaluation: Contrast-enhanced CT of the chest with IV contrast defines the level of obstruction, tumor extent, and presence of intraluminal thrombus.
Management: Elevate head of bed, supplemental oxygen. Urgent Endovascular SVC Stenting provides rapid and complete symptomatic relief within 24–48 hours. Followed by definitive histology-directed systemic chemotherapy (for SCLC or lymphoma) or palliative radiotherapy (for NSCLC).