14 - Oncological Emergencies Flashcards
1
Q
What are some oncological emergencies?
A
- Neutropenic sepsis
- Metastatic spinal cord compression
- Hypercalcaemia
- VTE
- SVC
- Tumour lysis syndrome
2
Q
What is the definition of neutropenic sepsis?
A
Fever > 38° or features of sepsis in a patient with an absolute neutrophil count of < 0.5 x 109/L
It is a medical emergency!!!!!!!! Should contact 24h number if any chemo patient unwell
3
Q
What are some causes of neutropenia?
A
- Genetic
- Cytotoxic related (as targets bone marrow)
- Intrinsic disease of bone marrow
- Infections (e.g malaria, HHV 4/5)
- Immune mediated (e.g RA, Crohn’s)
- Folate and Vit B12 deficiency
4
Q
What patients are at high risk of neutropenic sepsis?
A
- Have sustained, significant neutropenia that is expected to last more than 7 days.
- Are clinically unstable
- Have an underlying malignancy and are being treated with high-intensity chemo
- Have significant co-morbidities (e.g DM, COPD)
5
Q
What are the most common causative organisms of neutropenic sepsis?
A
BACTERIA but cultures often negative
-
Gram-negative
- Escherichia coli
- Klebsiella spp
- Pseudomonas aeruginosa
-
Gram-positive bacteria
- Coagulase-negative staphylococci (e.g. S. epidermidis)
- Staphylococcus aureus
- Streptococcus pneumoniae
-
Other
- Clostridium difficile
Viruses and Fungi in high risk patients
6
Q
How may neutropenic sepsis present?
A
Impaired immune system may have a blunted response with subtle signs so high index of suspicion
Patients may present with the signs and symptoms of a specific infection. For example a purulent cough indicating pneumonia or dysuria indicating a UTI
Often however patients simply present with a fever or (often non-specific) signs of systemic infection such as malaise and fatigue
7
Q
What time frame after chemotherapy does neutropenic sepsis tend to occur?
A
7-14 days after
8
Q
If you are about to start chemo for somebody and predict their neutrophil count could fall below 0.5 what should you do?
A
Start prophylactic fluoroquinolone - ciprofloxacin
9
Q
If you suspect neutropenic sepsis (e.g temp of >38 in someone receiving chemo), what should you immediately do?
A
- Take FBC and two sets of blood cultures and other bloods
- Take blood gas for serum lactate
- Antibiotics must be started immediately, do not wait for the WBC (Piperacillin with tazobactam/Tazocin)
- High flow oxygen
- IV fluids should be started, often 500ml of crystalloid over 15 minutes
- Measure urine output with catheter
- want an ECG, CXR
10
Q
What investigations should you do in neutropenic sepsis to try to locate the source of infection?
A
Do systems based exam to guide investigations e.g dysuria do urine sample
- 2 sets of blood cultures including one from CVAD if there is one
- Swabs from any indwelling lines
- FBC, WCC, CRP, U+Es , LFTs, Albumin
- CXR if clinically indicated
- Serology and PCR for viruses e.g. CMV
- Sputum, urine, stool samples, CT scans etc. where clinically indicated
11
Q
How can the level of risk of a patient with suspected neutropenic sepsis be stratified once the initial sepsis 6 has been completed?
A
MASCC Risk Index
(Multinational Association for Supportive Care in Cancer Risk Index)
Looks at patients disease burden, co-morbidities, status at onset of fever and age
A high score is a patient at lower risk of severe infection that may be suitable for outpatient care
12
Q
When can a patient with suspected neutropenic sepsis be treated as an outpatient?
A
13
Q
What are some signs of severe neutropenic sepsis/signs that sepsis has progressed to late stage sepsis?
A
May consider G-CSF treatment - (granulocyte-colony stimulating factor) treatment involves using a medication to stimulate the bone marrow to produce more white blood cells, particularly neutrophils
14
Q
After sepsis 6 and MASCC score has been calculated what other management needs to be done for suspected neutropenic sepsis?
A
Daily measures of fever and baseline bloods until the patient is apyrexial and neutrophil count above 0.5x109
- NEWS every 15 minutes initially
- Discontinue chemotherapy on admission
- Consider Vancomycin for MRSA if CVAD - Central Venous Access Device
- Ask oncology if need to remove CVAD
- Aggressive fluid replacement in dehydration.
- Hourly urine output measurement
- Early critical care if deterioration, severe sepsis (any evidence of organ failure) or suspected invasive fungal infection
15
Q
When can antibiotics in neutropenic sepsis be stopped?
A
When neutrophil count is normal, has been afebrile for 48 hours and blood tests have normalised
Always do daily FBC and U+Es
16
Q
What should be done if neutropenic sepsis fever is unresponsive to antibiotics after 48 hours?
A
- Consider fungal cause and do investigations e.g HRCT
- Discuss with microbiology what to switch to
- Should discuss with micro every 48 hours regardless
17
Q
What does a low MASCC score mean?
A
Higher morbidity and mortality
Mortality of 2 to 21%
18
Q
How can we prevent neutropenic sepsis?
A
- Patient advice
- Lower dose of chemotherapy
- Prophylactic antibiotics
19
Q
What is Malignant Spinal Cord Compression (MSCC)?
A
Dural sac and it’s contents of the cord/cauda equina are compressed by cancer
20
Q
Which cancers have a high chance of spinal metastases and MSCC?
(important card)
A
BLP and Myeloma!
20% of cancer presentations are MSCC
Pancreatic has lowest
21
Q
What are the causes of MSCC?
A
- 80% due to collapse of vertebral body due to metastatic arterial seeding aka spinal mets
- 10% by direct tumour invasion
22
Q
What part of the spine do metastases tend to occur?
A
Usually thoracic
23
Q
How may MSCC present if the cord is compressed?
A
- Severe back pain is first sign before any neurology
- Symmetrical lower limb weakness
- UMN signs e.g Babinski reflex, hypereflexia
-
Paraesthesia with sensory level
cauda equina
Perianal numbness and painless retention of urine
Urinary incontinence
Bilateral sciatica
Erectile dysfunction
Saddle anasthesia
24
Q
How may MSCC present if the cauda equina (below L2) is being compressed?
A
- LMN signs
- Usually unilateral
- Saddle anaesthesia
- Reduced anal tone
- Painless urinary retention (and overflow incontinence)
- Back pain
- Impotence
- Absent ankle jerk
25
What is the back pain in MSCC like?
* First symptom
* Unresponsive to analgesia
* Band-like
* Radicular - pain that radiates along the path of a nerve, typically due to irritation or inflammation of a nerve root at its connection to the spinal column. It can cause pain, numbness, and tingling in the area supplied by the affected nerve.
* Exacerbated by coughing, sneezing, straining, neck flexion
26
How is suspected MSCC investigated?
**Urgent whole spine MRI** if symptoms within 24 hours of presentation
27
How is MSCC managed?
**Surgical Emergency**
**_General_**
* **Adequate analgesia**
* **VTE prophylaxis:** LMWH and TED stockings
* **Catheter**
**_Definitive_**
* **High dose dexamethasone with PPI**
* **Surgical decompression** and reconstruction within 24h of diagnosis
* **OR External Beam or Stereotactic radiotherapy**
28
What patients would be eligible for surgery in a case of MSCC? (only have 48h from neurological signs to paraplegia)
* Fit and prognosis \>3/12
* Good motor function at presentation
* Good performance status
* Limited co-morbidity
* Single level spinal disease
29
When would you use radiotherapy for MSCC and what are the two different options for this?
* **External beam radiotherapy**
* **Stereotactic body radiotherapy**: higher doses of radiotherapy to be targeted more directly at the tumour while minimising exposure to adjacent tissue 10-15% risk of vertebral collapse with this type of radiotherapy
30
What is some supportive care that needs to be done in the management of MSCC?
31
What is the prognosis with MSCC?
**No recover of mobility:** 1-3/12
**Walking**: 5-8/12
Loss of sphincter function is poor prognostic sign
32
How is high dose dexamethasone given?
* PO if possible
* High dose is 16mg (which is 8 2mg tablets); often have 8mg at breakfast (8:00am) then 8mg at lunchtime (12:00pm)
* Want to give in morning as can cause sleep disturbance
33
What is malignant hypercalcaemia and what cancers does this tend to occur in?
Calcium \>2.6
**Causes:** breast, multiple myeloma, lymphoma and lung (e.g. squamous cell carcinoma)
Most common cause of hypercalcaemia
Usually poor prognostic sign
34
How is calcium distributed in the body?
35
What is the pathophysiology of malignant hypercalcaemia?
**_Osteolytic metastasis_**
Most common in breast cancer, 20% of cases of malignant hypercalcaemia. Deposition of tumour cells within bone leads to local production of inflammatory cytokines and other mediators stimulating osteoclasts
**_PTH-related protein (PTHrP) secretion_** (most common cause)
Cause PTH receptors to be activated so absorption of calcium from gut and bone
**_Increased 1,25-dihydroxyvitamin D production_**
Increased expression of activated vitamin D so more gut absorption of calcium. Common in Hodgkin's lymphoma
36
How may hypercalcaemia present?
**'Stones, bones, thrones, abdominal groans and psychiatric moans’**. (Renal stones, bone pain, polyuria, abdominal pain/constipation and psychiatric features)
**_Mild_**
* **Often asymptomatic**
* **Polyuria and polydipsia**
* **Mild cognitive impairment**
* **Dyspepsia**
**_Moderate_**
* **All mild features**
* **Constipation**
* **Weakness**
* **Fatigue**
* **Dehydration**
* **Nausea**
**_Severe_**
* **All mild and moderate features**
* **Abdominal pain**
* **Vomiting**
* **Cardiac dysrhythmias**
* **Pancreatitis**
* **Coma**
37
What are the four most common symptoms of malignant hypercalcaemia?
* Nausea and vomiting
* Constipation
* Thirst and polyuria
* Confusion
38
What are some other causes of hypercalcaemia apart from malignancy?
Primary Hyperparathyroidism
39
If somebody has hypercalcaemia and no cancer diagnosis what investigations need to be done to rule out/in a cancer diagnosis?
* **PTH levels** (will be suppressed if malignancy)
* **Breast examination**
* **Myeloma screen** (immunoglobulins, protein electrophoresis, urinary light chains)
* **CT screen** for cancer
40
What patients with malignant hypercalcaemia need admission?
**\>3mmol/L or symptomatic**
Anything else can be managed as outpatient with 3-4L fluid a day
41
How is malignant hypercalcaemia managed?
**_1st Step_**
**IV hydration:** *3-4L 0.9% saline* for 24 hours to correct any dehydration
**_2nd Step_**
**Bisphosphonates:** *IV Pamidronate or Zoledronic Acid*, inhibit osteoclast activity. Can cause renal failure so need adequate hydration first. Can take up to 4 days for effect but lasts weeks
**_Others_**
**Calcitonin:** promoting urinary calcium excretion and inhibits bone resorption. Its action begins after a few hours
**Denosumab:** monoclonal antibody used in osteoporosis
42
What monitoring should you do for patients after an episode of malignant hypercalcaemia?
* 2 to 3 weekly blood tests as high chance of recurrence
* May need regular bisphosphonate infusions
43
What is the prognosis once a cancer patient has had an episode of hypercalcaemia?
Poor prognostic indicator, less than 3 months
44
What are some complications of hypercalcaemia of malignancy?
* Bisphosphonate induced flu-like syndrome
* AKI
* Coma
* Acute pancreatitis
*Other side effects of bisphosphonates: acute osteonecrosis of jaw, hypocalcaemia if given to pts with critical vit D deficiency*
45
Patients with cancer are at an increased risk of VTE, are they given prophylaxis for this?
due to the inflammatory nature of the disease itself, as well as the cancer treatments, which can damage blood vessels and activate the clotting system
No as risk of bleeding still seen to outweigh risk of clot
Give if they have a clot for at least 6 months
46
What is the Well's score for a DVT?
47
What is the Well's score for a PE?
48
How is a VTE managed in cancer patients?
*\*Signs & symptoms would be same. Investigations also same (although don't do d-dimer in cancer pt as it would be raised anyway)*
**_VTE (excluding massive PE)_**
If the patient has active cancer
* DOAC (e.g. apixaban or rivaroxaban), unless this is contraindicated
* Continue for 3-6 months
**_Massive PE_**
* Thrombolysis using alteplase (give UFH prior to thrombolysis and stop within 24hrs of thrombolysis)
49
What blood work should be done for a suspected VTE?
* Baseline FBC
* U+Es
* LFTs
* PT and APTT
Do not do d-dimer as will be raised anyway
50
What is the first and second biggest mortality for oncological emergencies?
* Neutropenic sepsis
* VTE
51
What is SVCO and the aetiology of this?
Obstruction to the flow of blood through the superior vena cava secondary to a cancer
Usually **lung cancer (NSCLC or SCLC)** or **NHL**
Extrinsic compression, metastasis or thrombus
52
What are signs and symptoms of SVCO?
Usually **dyspnoea, facial swelling, head fullness and cough**
**Symptoms**
* Dyspnoea
* Facial swelling
* Head ‘fullness’
* Symptoms exacerbated by bending forwards / lying down
* Cough
* Dysphagia
* Blurred vision
**Signs**
* Facial swelling
* Distended neck and chest wall veins
* Upper limb oedema
* Pemberton's sign
* Facial plethora
* Cyanosis
* Cognitive dysfunction
* Coma
53
How does SVCO lead to death?
**Airway compromise** or **Cerebral Oedema**
Stridor from laryngeal oedema
54
What is Pemberton's sign?
Ask patient to elevate both arms above the head for 1-2 minutes
Positive if it causes congestion, cyanosis or respiratory distress
This occurs due to increased venous return from the upper extremities exacerbating any obstruction
55
What investigations are done to diagnose SVCO?
**Initial:** CXR as can exclude other causes of breathlessness e.g pneumonia. Findings include mediastinal widening and (malignant) pleural effusion.
**Diagnostic:** CT with contrast. Will show collateral vessels
**Others:** Duplex US, histology via bronchoscopy
56
If SVCO is presenting as an emergency with stridor or cerebral oedema, how is it managed?
* Sit upright/elevate head
* Oxygen
* **Dexamethasone 16mg with PPI**
* Stenting
57
How is SVCO managed generally if it is not an emergency?
**_Conservative_**
* Elevation of head and neck
* Oxygen
**_Medical_**
* **Radiotherapy** is first line therapy in patients with NSCLC and lymphomas
* **Chemotherapy** in chemosensitive tumours such as SCLC and NHL
* **Anticoagulation or thrombolysis** if due to intravascular thrombosis
**Surgical therapy**
* **Endovenous stent** placed percutaneously with access via the internal jugular, basilic or femoral veins under local anaesthetic
58
What are some complications of an endovascular stent used to manage SVCO?
* Infection
* PE
* Stent migration
* Perforation of SVC
59
What is the prognosis following SVCO?
**Average life expectancy of 6 months**
Negative prognostic indicator in terms of cancer survival. This reflects the extent of tumour or lymphadenopathy necessary to develop obstruction of the superior vena cava
60
What is tumour lysis syndrome and the electrolyte abnormalities that occur in this?
**Metabolic disturbances arising from the breakdown of malignant cells** following the initiation of treatment for malignancy
More common in haematological malignancies (lymphoma and leukaemia)
61
What are some of the complications of tumour lysis syndrome?
* **AKI** from uric acid and/or calcium phosphate crystals
* **Seizures**
* **Arrhythmia**
* **Sudden death**
62
What factors increase the risk of TLS?
* **Haematological malignancy**
* **High proliferation rate**
* **Chemosensitivity**
* **Large tumour burden**
* **Pre-existing metabolic abnormalities e.g** hyperuricaemia and hyperphosphataemi
* **Renal impairment**
63
Why do we need to risk stratify all cancer patients receiving cytotoxic therapy?
Assess the need for prophylactic treatment and the monitoring after initiating therapy.
64
What prophylaxis is given against TLS depending on the risk stratification?
**Low-risk**
Oral hydration
**Intermediate risk**
IV hydration and ***Allopurinol 300 mg daily*** for up to 7 days following the initiation of cytotoxic therapy is typical
**High risk**
IV hydration and one off dose of ***Rasburicase***
DRUGS GIVEN TO PREVENT AKI BY LOWERING URIC ACID
65
When and how may TLS present?
First 3 to 7 days
**_Symptoms_**
* Lethargy
* ***N & V***
* ***Diarrhoea***
* ***Anorexia***
* ***Muscle cramps***
* ***Seizures***
**_Signs_**
* Fluid overload
* ***Haematuria***
* Tetany & paraesthesia (hypocalcaemia)
* Bronchospasm
66
What blood tests should you do to monitor for TLS if a patient is high risk?
**Renal function, electrolytes, and serum urate** every 4-6 hours
*Serum urate levels taken in patients treated with rasburicase should be sent to the lab on ice to prevent falsely low levels*
67
What additional blood tests can you do for TLS?
68
What is the diagnostic criteria for tumour lysis syndrome?
**Cairo-Bishop scoring system**
**_Laboratory diagnosis_**
Pesence of two or more abnormal serum values that occur three days prior to or seven days after beginning treatment
**_Clinical diagnosis_**
Patient who meets the laboratory diagnosis with the presence of one or more of the following features that cannot be attributed to a therapeutic agent:
* **Serum creatinine** (\> 1.5 upper limit normal)
* **Cardiac arrhythmia / sudden death**
* **Seizure**
69
How can the severity of TLS be graded?
Also uses Cairo-Bishop system
Rating from 0-5 based on the laboratory rise in serum creatinine, the presence of cardiac arrhythmias and the development of seizures
70
Why are Allopurinol and Rasburicase used in TLS and how do they work on a cellular level?
Prevent hyperuricaemia and the subsequent precipitation of uric acid within the nephrons
**Allopurinol:** Xanthine oxidase inhibitor, can only be used for prophylaxis
**Rasburicase:** metabolises uric acid to allantoin, can be used for prophylaxis and treatment as works on uric acid in renal tubules
71
How is tumour lysis syndrome managed?
Correct electrolytes and renal impairment
**Hyperphosphataemia:**
* Adequate hydration and dietary restriction
* Phosphate binders may be used
* In severe cases, patients may require haemofiltration
**Hyperkalaemia:**
* IV calcium gluconate, insulin/dextrose infusion and nebulised salbutamol
* Cardiac monitoring for patients with potassium levels \> 6 mmol/L or with a 25% increase compared to their baseline
**Hypocalcaemia:**
* May result in increased calcium phosphate deposits in the kidney so if asymptomatic do not treat
* IV replacement if arrhythmias or symptomatic
**Renal impairment:**
* Fluids rehydration
* Adjustment of drug doses
* Escalation to haemofiltration if needed
72
What are some indications for dialysis in TLS?
* Intractable fluid overload
* Refractory hyperkalemia
* Hyperphosphatemia-induced symptomatic hypocalcemia
* High calcium-phosphate product
73
What are some **potential** oncological emergencies that have not been discussed in this deck?
74
What are some risk factors for VTE in cancer patients?
* Patient related
* Cancer related
* Treatment related
* Biochemical markers
75
It is rare to give prophylaxis for VTE in cancer. What situations would you give prophylaxis in?
76
What score is used to determine whether a patient with neutropenic sepsis can be treated as an outpatient?
MASCC score
77
What is a venting gastronomy?
Palliative intervention in malignant bowel obstruction that prevents the need for an NG tube
78
What types of cancer tend to get malignant bowel obstruction?
* Bowel
* Gynaeocological
79
What medications are used in malignant bowel obstruction being treated palliatively?
* **Analgesia**
* **Antiemetic:** Haloperidol or Cyclizine
* **Antimuscarinic**: Hyoscine butyl bromide
* **Corticosteroid**
* **Somatostatin analogue:** Octreotide to lower gastric secretions and increase absorption of water from GI lumen
* avoid laxitatives
