# Oncological Emergencies > Spinal cord compression, hypercalcaemia of malignancy and neutropenic sepsis recognition, with first-line management, for NEET-PG Medicine exam preparation. - Canonical URL: https://prepelephant.com/topics/neet-pg/medicine/oncological-emergencies - Exam / course: NEET-PG · Subject: Medicine - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-08 - Last updated: 2026-10-08 - Reference basis: Harrison's Principles of Internal Medicine; DeVita's Principles and Practice of Oncology; ESMO Clinical Practice Guidelines - How to cite: "Oncological Emergencies", PrepElephant, https://prepelephant.com/topics/neet-pg/medicine/oncological-emergencies ## Direct answer Oncological emergencies are acute complications of cancer or its treatment that threaten life within hours to days and must be recognised before the tumour itself is treated. The three that dominate examinations are spinal cord compression, hypercalcaemia of malignancy and neutropenic sepsis. Each has a clinical trigger that demands immediate action: back pain with new limb weakness or a sensory level, a corrected calcium above the normal range with polyuria and confusion, or fever with an absolute neutrophil count below 0.5 × 10^9/L. ## What you must remember - **Cord compression sources:** Vertebral metastases from breast, prostate, lung, renal cancers, myeloma or lymphoma; bone pain precedes neurology, and a new sensory level, urinary retention or altered gait signals an emergency. - **Investigation:** MRI of the whole spine is the test of choice, because skip lesions are common and plain radiographs miss epidural disease. - **Steroids and radiotherapy:** High-dose dexamethasone is started on clinical suspicion before imaging, except where a lymphoma biopsy is pending, since steroids can obscure histology; radiotherapy suits radiosensitive tumours, and surgery suits instability. - **Corrected calcium:** Measured calcium adjusted for albumin; PTHrP from squamous and renal tumours is the classic humoral cause, while myeloma and bone metastases cause osteolysis. - **Hypercalcaemia treatment:** Isotonic saline first to restore volume, then a bisphosphonate such as zoledronic acid or denosumab; calcitonin acts quickly but briefly. - **Neutropenic fever definition:** A single temperature of 38.3 °C or above, or 38.0 °C sustained for an hour, with an absolute neutrophil count below 0.5 × 10^9/L. - **Empirical antibiotics:** A broad-spectrum antipseudomonal beta-lactam within one hour of recognition, without waiting for cultures or neutrophil recovery; vancomycin is added only for specified indications under local protocol. ## Worked scenario: back pain in a woman with breast cancer A 52-year-old woman with treated breast cancer presents with three weeks of thoracic back pain that worsens lying flat, followed by heaviness in both legs. The first step is recognising that this is an emergency rather than a bone pain problem. 1. **Examine the cord:** Check power, sensation and reflexes, look for a sensory level, and ask about urinary hesitation. 2. **Start steroids and image:** Dexamethasone is started at once if cord compression is suspected, and MRI of the whole spine is requested as an emergency. 3. **Choose the treatment:** A radiosensitive lesion without instability is treated with radiotherapy, while a collapsed vertebra compressing the cord may need surgical decompression first. 4. **Record baseline function:** The ability to walk before treatment is the strongest predictor of outcome, so function is recorded at presentation, not after the first dose of radiotherapy. The MRI result decides between these two routes, which is why the imaging is requested as an emergency. ## Where the exam tests the timing Four traps recur on this topic. - **Trap:** waiting for confirmation before acting. — **Correct:** a bone scan or plain film is a slower test, while the question wants MRI and steroids. - **Trap:** treating stable neutropenia as neutropenic fever. — **Correct:** an absolute neutrophil count of 0.4 × 10^9/L with a temperature of 37.2 °C is a risk to watch, not an emergency. - **Trap:** giving diuretics before volume repletion in hypercalcaemia. — **Correct:** isotonic saline restores volume first, because diuretics before repletion worsen dehydration. Viva questions often ask why steroids are withheld before a lymphoma biopsy, and the answer is histological, not clinical. ## Frequently asked questions ### Which investigation confirms metastatic spinal cord compression? MRI of the whole spine is the investigation of choice for suspected metastatic spinal cord compression, because it shows the epidural level and the extent of disease. Plain radiographs and bone scans are used for background staging but do not exclude epidural compression quickly enough. The imaging should be performed as an emergency once the clinical suspicion is raised. ### What is the first-line treatment for hypercalcaemia of malignancy? Isotonic saline is the first-line treatment for hypercalcaemia of malignancy, restoring volume and promoting calcium excretion. Intravenous bisphosphonates such as zoledronic acid or denosumab are then added to reduce bone resorption. Calcitonin gives a rapid but short-lived effect and is used as a bridge. ### How is febrile neutropenia defined in adults? Febrile neutropenia in adults is a single oral temperature of 38.3 °C or above, or 38.0 °C sustained for one hour, with an absolute neutrophil count below 0.5 × 10^9/L. The definition triggers immediate empirical antibiotics, and the neutrophil count is checked rather than assumed. Local protocols define the exact thresholds used. ### Why is dexamethasone given before MRI in suspected cord compression? Dexamethasone reduces oedema around the compressed cord and may preserve neurological function, so it is started on clinical suspicion without waiting for imaging. The exception is suspected lymphoma, where steroids can obscure histology and the biopsy should come first. Radiotherapy or surgery follows once the level is defined. ### Which empirical antibiotic is used first in neutropenic sepsis? An antipseudomonal beta-lactam such as piperacillin-tazobactam or cefepime is the usual first-line empirical antibiotic in neutropenic sepsis, given within one hour. Vancomycin or other agents are added only when specific indications apply, such as haemodynamic instability or a line infection. Local protocols determine the final regimen.