Acute oncology

Question 1

Cause of MSCC

Answer 1

Metastatic invasion of the vertebral bodies or paraspinal within the spinal cord. 2/3rds occur within the thoracic vertebrae. Breast, bronchus and prostate more commonly.

Question 2

Symptoms of MSCC

Answer 2

Localised tenderness
Back pain: may be worse on movement/coughing
Motor weakness: this loss maybe rapid or slow
Subjective sensory disturbance: ‘pins and needles’ ‘loss of sensation.’
Bladder/bowel dysfunction (often presents late) e.g. urinary retention.

Question 3

Signs of MSCC

Answer 3

• Weakness, paraparesis, paraplegia
• Changes in sensation below the level of compression
• Reflexes increased
• Clonus
• Painless bladder distension.

Question 4

How to investigate? In what time peroid?

Answer 4

Urgent whole spine MRI (24 hours)

Question 5

How to manage?

Answer 5

Dexamethasone 16mg (+PPI cover)
Surgical/radio/chemo or a combination

Question 6

Causes of superior vena cava obstruction.

Answer 6

Extrinsic compression, thrombosis, invasion of the SVC wall. Most commonly lung cancer or lymphoma.

Question 7

Symptoms of SVCO

Answer 7

Breathlessness (worse lying down)
Headache (a feeling of fullness)
Facial, arm and neck swelling
Cough
hoarse voice

Question 8

Signs of SVCO

Answer 8

Facial oedema
Prominent neck veins (neck, trunk, arms)
Cyanosis

Question 9

Investigations and treatment

Answer 9

CXR
Contrast CT thorax

Dexamethasone 16mg daily
Vascular stenting
Radio/chemo depending on primary tumour

Question 10

Causes of hypercalcaemia

Answer 10

1: Hyperparathyroidism
2: Cancer: release bone reabsorption factors and increase renal tubular calcium reabsorption.

Question 11

Symptoms/Signs of hypercalcaemia

Answer 11

General: dehydrated, weakness, fatigue
CNS: confusion, seizure, proximal neuropathy, hyporeflexia and coma
Gastro: Weight loss, nausea, vomiting, abdo pain, constipation, ileus, dyspepsia.
Gent: polyuria
Cardiac: Bradycardia, short QT, arrhythmia, arrest

Question 12

Investigations and treatment of hypercalcaemia

Answer 12

Serum calcium

1. Rehydration: normal saline 1L 4 hourly for 24 hours, then 6 hourly for 48-72 hours.
2. IV bisphosphonate eg pamidronate
   (consider furosemide if there is risk of fluid overload.)

• Forcefall diuresis promotes calcium excretion.

IF arrhythmia or seizure: calcitonin and corticosteroids

Question 13

Definition of neutropenic sepsis.

Answer 13

Absolute neutrophil count (ANC) less than 1 X109/L with fever of 38.5 or >38 for >1 hour.

Question 14

Questions to ask patient in neutropenic sepsis

Answer 14

Are they having chemo? When were they last treated? 
Previous had problems
Localised symptoms:
- change in bowel (diarrhoea) 
- Increased frequency of urinating 
- productive cough
- Skin changes
- Canular or pickman/hickman line: when was it change
- Any recent surgery
- Any trauma 
- Mouth ulcers

Question 15

Investigations in neutropenic sepsis

Answer 15

Blood cultures: from lines and cannula
Bloods: FBC, U&Es, LFTs
Looking for source of infection:
Urinanalysis, stool sample, sputum sample, swabs from any infected skin lesions,CXR

Question 16

Treatment for neutropenic sepsis. Common and extreme.

Answer 16

Start empirical antibiotics ASAP: Tazosin

If has severe gastro symptoms consider adding mentronidazole.

If fever persists, ring micro may need antifungals/antivirals/other antibiotics.

If severe hypotension: ring ICU as needs inotropes (adrenaline/noradrenaline)

Question 17

What is MASCC score?

Answer 17

Assesses risk of complications during febrile neutropenic episode. Looks at cancer/infection/co-morbdities/BP/COPD/age