Hematology, Oncology & Immunology · Topic 23 of 28

Common Solid Tumors in Acute Care

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Oncology · breast, colorectal, prostate, pancreas

Common Solid Tumors in Acute Care

Recognize the presentation: rectal bleeding, a left-colon obstruction, jaundice with back pain, a red breast without a mass, or back pain from spinal metastases.

01 · Even with hemorrhoidsRectal bleeding: rule out colorectal cancer

02 · Pancreatic cancerHead tumor: obstructive jaundice in 80–90%

03 · Prostate or breast cancerNew back pain: urgent MRI of the entire spine

Colorectal cancer

Whenever rectal bleeding occurs, rule out colorectal cancer

Rectal bleeding: rule out cancer even with obvious hemorrhoids

Rectal bleeding: rule out cancer even with known diverticular disease

Bleeding with defecation: most common first symptom of rectal cancer

Tenesmus may accompany it

First presentation may be complete obstruction

Perforation: usually walled off with focal pain, rarely diffuse peritonitis

Metastatic signs: hepatomegaly, ascites, supraclavicular nodes

Confirm by colonoscopic biopsy

Stage with CT of the chest, abdomen and pelvis; refer to a specialist

Obtain baseline CEA: too insensitive and nonspecific for screening

See Small & Large Bowel Obstruction.

Right or left colon cancer?

	Right colon	Left colon
Lumen and stool	Large caliber, liquid stool	Smaller lumen, semisolid stool
Bleeding	Usually occult	Stool may be streaked or mixed with blood
Typical first complaint	Fatigue and weakness from severe anemia	Colicky pain or obstruction
Obstruction	Late event	Earlier, may be the initial presentation

Breast cancer

Inflammatory breast cancer often has no palpable mass

Rapid-onset erythema, edema, peau d'orange skin thickening inflammatory cancer

Inflammatory: covers one-third or more of the breast

Inflammatory: often no palpable mass, axillary nodes usually involved

Palpable mass: mammography or other imaging, then biopsy

Test the tumor for estrogen and progesterone receptors and HER2

Fixation, satellite skin nodules, matted axillary nodes: advanced disease

Metastatic: pathologic fracture, abdominal pain, jaundice, dyspnea

Breast cancer also causes hypercalcemia of malignancy

Prostate cancer

Usually silent until advanced

Hematuria, bladder outlet obstruction

Ureteral obstruction: flank pain, renal dysfunction

Bone pain, pathologic fracture, cord compression

Osteoblastic metastases go to the pelvis, ribs and vertebrae

PSA ≥ 4 ng/mL is often considered an indication for biopsy

PSA also rises with infection and prostate enlargement

No PSA cutoff excludes cancer; diagnosis needs needle biopsy

Pancreatic cancer

Nonspecific symptoms, so most disease is advanced at diagnosis

Severe upper abdominal pain radiating to the back, weight loss

Head tumors: obstructive jaundice, often with pruritus, in 80–90%

Order pancreatic-protocol CT or MRI/MRCP

Then EUS with fine-needle aspiration: tissue and resectability

With obstructive jaundice, ERCP may come first, often placing a stent

CA 19-9 monitors known pancreatic cancer

CA 19-9 is not for population screening or establishing the diagnosis

CA 19-9 lacks sensitivity and specificity; some tumors do not produce it

About 80–90% are unresectable at diagnosis

5-year relative survival: about 13% overall, 3% with distant disease

Resectable head tumor: Whipple procedure

Discuss goals of care early

Cancer can activate clotting via tissue factor or a factor X–activating protease

Pancreas primary scores +2 on the Khorana VTE risk score

Paraneoplastic Trousseau syndrome occurs, with a poor prognosis

Merck allows CA 19-9 within screening of selected high-risk patients; average-risk people should not be screened. Survival figures are ACS/SEER for 2015–2021 diagnoses; Merck cites a population study with 5-year survival below 5%. See Hypercoagulable States for anticoagulant choice.

Cancer drugs: what they cause

Tamoxifen raises thromboembolism risk: keep VTE on the differential

Tamoxifen raises endometrial cancer risk

Trastuzumab and pertuzumab can decrease ejection fraction

Androgen deprivation = LHRH agonists or antagonists, or orchiectomy

Androgen deprivation: low libido, erectile dysfunction, hot flushes

Androgen deprivation: osteoporosis, anemia, muscle loss

On androgen deprivation: give calcium and vitamin D

LHRH agonists can temporarily raise PSA

Red flags

New back pain in prostate or breast cancer: possible cord compression MRI entire spine

Possible cord compression with pain or deficits: give dexamethasone consult at once

Breast cancer with new confusion, constipation or polyuria check calcium

Any vaginal bleeding on tamoxifen, including spotting evaluate bleeding

New dyspnea or heart failure symptoms on trastuzumab or pertuzumab order echo

See Malignant Spinal Cord Compression and Hypercalcemia.

Palliating pancreatic cancer

Painopioids

Opioids

Opioids, sometimes a celiac block

Jaundicerelieve obstruction

Biliary stent

Outletgastric obstruction

Duodenal stent or bypass

Prurituscholestyramine

Cholestyramine

Cholestyramine for pruritus

Exocrineinsufficiency

Pancrelipase

Pancrelipase for exocrine insufficiency

Genetics and tumor biology

About 20% of colorectal cancer has an inheritable componentIncludes Lynch syndrome and familial adenomatous polyposis; resected colon cancers are routinely tested for Lynch mutations

Ulcerative and Crohn colitis raise colorectal cancer risk with duration

Breast subtypes: about 70% hormone receptor-positive, HER2-negativeAbout 15% overexpress HER2; 11% are triple-negative, which carries a poorer prognosis

Paget disease of the nipple looks benign: erythema, crusting, scaling, dischargeSignals underlying in situ or invasive carcinoma; 50–60% have a palpable mass at presentation

Pancreatic cancer causes diabetes in up to half of patients

Body and tail tumors can obstruct the splenic veinSplenomegaly, gastric and esophageal varices, GI hemorrhage

Pearl

Hemorrhoids do not explain away rectal bleeding: rule out cancer even when another cause is obvious.

Sources · Merck Manual Professional — Colorectal Cancer · Merck Manual Professional — Pancreatic Cancer · Merck Manual Professional — Breast Cancer · Merck Manual Professional — Spinal Cord Compression · Singer E, Elsayem A et al. Initial management and disposition of metastatic spinal cord compression in the emergency department. Ann Med 2025 · Merck Manual Professional — Hypercalcemia · Merck Manual Professional — Prostate Cancer · MDCalc — Khorana Risk Score for Venous Thromboembolism in Cancer Patients · Wakabayashi M, Kikuchi Y et al. Prognosis of pancreatic cancer with Trousseau syndrome: a systematic review of case reports in Japanese literature. J Egypt Natl Canc Inst 2023 · American Cancer Society. Pancreatic Cancer Survival Rates (SEER, diagnosed 2015–2021) · Merck Manual Professional — Overview of Thrombotic Disorders (Jul 2025) · Follow your institution's protocols.