Acute Oncology Flashcards
Over what time period are patients at risk of neutropenic sepsis following chemotherapy?
This should always be considered in a patient who presents with a fever within one month of chemotherapy.
Neutropenic patients are at high risk of bacterial and fungal infections, most often from enteric gut flora.
Febrile neutropenia is a one off temperature of >38.5 or a sustained temperature >38.
How does neutropenic sepsis present?
Non specific symptoms are common - nausea, diarrhoea, drowsiness, breathlessness.
Signs of systemic illness include fever, tachycardia, hypotension, oliguria and these need urgent admission.
Fever may not always be present, the critical test is the FBC. Patients with a neutrophil count of <1 are managed as febrile neutropenia with immediate IV antibiotics.
How is neutropenic sepsis managed?
Patients who are low risk can be treated out of hospital with oral augmenting and ciprofloxacin if they have no tachycardia, hypotension, hypoxia, or mucositis and an expected short course of myelosuppression.
Resuscitate with intravenous fluids to restore circulatory function; monitor urine output, Glasgow Coma Scale score and central venous pressure
Take cultures of blood, urine, sputum and stool
Consider the need for admission to critical care and consider inotropic support at an early stage
Give empirical antibiotics as per local policy and sensitivities. Commonly used antibiotics should include activity against enteric Gram-negative bacteria and Pseudomonas , e.g. ceftazidime or piperacillin–tazobactam with gentamicin; or meropenem mono therapy. Antibiotics against staphylococci may be needed, e.g. vancomycin especially if indwelling lines are present
Consider imaging, e.g. chest CT, if fever is not responding to broad-spectrum antibiotics, to detect an occult source of fever; consider adding treatment for opportunistic infections:
• Liposomal amphotericin B or voriconazole – Candida and Aspergillus
• High-dose co-trimoxazole – Pneumocystis
• Clarithromycin – Mycoplasma and Legionella
• Anti-tuberculous therapy – Mycobacterium tuberculosis
How does pulmonary embolus present in the cancer patient?
Caused by coagulopathy of cancer and side effect of chemotherapy.
Presents with unexplained breathlessness and episodic exacerbations from multiple small emboli, rather than chest pain.
Think about PE in any cancer patient with breathlessness, hypoxia or chest pain.
CTPA is the investigation of choice.
How should confirmed PE be treated in cancer patients?
Warfarin is ineffective and DOACs are not licensed in reversing coagulopathy of cancer.
LMWH heparin is preferred.
What is superior vena cava obstruction and what cancers are associated with this?
SVCO can arise from any upper mediastinal mass but is most commonly associated with lung cancer and lymphoma.
How does SVCO present?
It presents with difficulty in breathing and/or swallowing, stridor, a swollen oedematous face and arms, venous congestion in the neck and dilated veins in the upper chest and arms.
How is SVCO managed?
Treatment is with immediate steroids, chemotherapy where the tumour is expected to respond and possibly mediastinal radiotherapy. Sometimes vascular stands and anticoagulation are required.
Some tumours like lymphomas, small cell lung cancer, and germ cell tumours are so sensitive to chemotherapy that this is preferred to radiotherapy as the masses are likely to be both large and associated with more disseminated disease elsewhere.
How does spinal cord compression present?
This is a neurosurgical emergency and treatment is needed within 24 hours to save neurological function.
It usually presents with sudden onset of back pain following by weakness affecting the lower limbs and a sensory level. Although watch out for spinal shock where a flaccid paralysis occurs first despite this being an UMN lesion.
Whole spine MRI is the investigation of choice.
How is SCC managed?
High dose steroids and oncological and neurosurgical opinion.
If a patient is not suitable for neurosurgical intervention then radiotherapy may be used.
What is the tumour lysis syndrome?
This occurs if treatment triggers a massive breakdown of tumours cells leading to increased serum levels of urate, potassium and phosphate and secondary hypocalcaemia (due to phosphate binding).
These biochemical changes can give rise to cardiac arrhythmias and seizures.
Urate deposition in the renal tubules can cause renal failure (hyperuricaemic nephropathy).
How is tumour lysis syndrome managed?
Vigorous hydration, often with diuretics, is crucial to maintain high urine outputs. A proportion of patients need dialysis for uricaemia, oliguria or severe electrolyte disturbances.
The xanthine oxidase inhibitor allopurinol should be given before treatment is started in low risk patients. Intravenous rasburicase, a recombinant urate oxidase, is used for prophylaxis in high risk patients.
How is acute hypercalcaemia managed in cancer patients?
This presents with vomiting, confusion, constipation and oliguria.
Treatment is by resuscitation with intravenous fluids first to establish a saline diuresis, and then an intravenous bisphosphonate such as pamidronate or the more potent zolendronic acid.
Treating the cause is crucial.
Denosumab and calcitonin can be used in intractable cases.
How does raised intracranial pressure present?
This presents classically with headache, nausea and vomiting. The headache is worse in the morning and with coughing or straining.
There are often no localising neurological signs and almost never papilloedema until very late in the disease.
For many there is a slower onset of more non specific symptoms such as drowsiness or mental deterioration.
How is raised ICP managed?
Treatment is with high dose steroids and investigation by MRI.
Surgery may be considered if the condition is univocal and/or threatening the fourth ventricle, otherwise whole brain or local stereotactic CyberKnife radiotherapy is required.
