Acute Oncology Emergencies

Question 1

What causes spinal cord compression?

Answer 1

-OA
-Herniation of discs
-RA
-Spinal injury
-Deformity
-Infection, abscess
-Tumour

Question 2

Prevalence of malignant spinal cord compression

Answer 2

-5% died from cancer have some degree of spinal cord compression
-90% of those with spinal cord compression tumours arise in vertebrae, 80% of which involve vertebral body (anterior affected first)
=Can invade epidural space so press thecal sac, then arteries and veins, cell death from ischaemia. Extradural compression.
=Lung, breast, prostate, myeloma, lymphoma metastasis
=Sarcoma, neuroblastoma in thoracic spine in children

Question 3

Symptoms of malignant spinal cord compression

Answer 3

-Back pain (7 weeks before other symptoms, localised, gradually increasing, worse on straining and lying down, disturbs sleep, nocturnal, associated with tenderness, thoracic or cervical back pain)
-Weakness (UMN pattern: increase muscle tone vs LMN). Focal.
=Lesions above L1 usually result in upper motor neuron signs in the legs and a sensory level. Lesions below L1 usually cause lower motor neuron signs in the legs and perianal numbness. Tendon reflexes tend to be increased below the level of the lesion and absent at the level of the lesion
-Sensory loss and numbness
-Urinary retention and constipation
-Loss of anal tone
-Gait disturbance

Question 4

Diagnosis of malignant spinal cord compression

Answer 4

-MRI whole spine within 24 hours of presentation

Question 5

Management of malignant spinal cord compression

Answer 5

-Metastasis: palliative
-Pre-surgical neurological status= prognosis (early treatment better)
-Initial measures: lie flat, neutral spine alignment (log roll movement)
-Venous compression devices (if above 6th thoracic vertebrae, neurogenic chock can occur= loss of tone in blood vessels and dilation= drop in BP)

-Medical: high dose steroids (dexamethasone 16mg oral), analgesia

-Surgery (laminectomy decompression, already lost neurological function, stabilising spine required for pain management) and radiotherapy (sensitive tumours lie SC lung cancer, not causing spinal instability)

Question 6

Definition and pathophysiology of superior vena cava obstruction (SVCO)

Answer 6

-Blockage of SVC blood flow (A-road)= thrombus/ invasion/ external compression
-Formation of collateral vessels (B-roads)
-Signs and symptoms of SVCO when collaterals not compensating
-RAPID onset if aggressive pathology vs INSIDIOUS if collaterals formed

Question 7

Causes of SVCO

Answer 7

-Non-small cell lung cancer (NSCLC) (50%)
-Small cell lung cancer (SCLC)(25%)
-Non-Hodgkin’s lymphoma (10%)
-Other: germ cell tumours, metastatic breast cancer, metastatic seminoma, Kaposi’s sarcoma
-(Benign causes: SVC thrombosis, post-radiotherapy/mediastinal fibrosis, retrosternal thyroid, aortic aneurysm, goitre)

Usually lung

Question 8

Clinical presentation of SVCO

Answer 8

-Breathlessness
-Facial/neck/arm swelling (conjunctival and periorbital oedema)
-Face/upper chest erythema
-Distended veins on neck/chest wall
-Oedema -> Stridor, dysphagia, hoarseness
-Cerebral oedema -> headaches (often worse in mornings), visual disturbance
-Pulseless jugular venous distention

Question 9

Clinical signs of SVCO

Answer 9

-Swollen neck
-Dilated anterior chest wall collateral veins (blood flowing downwards)
-Pemberton’s sign

Question 10

Investigation of SVCO

Answer 10

-Hx & Ex
-CXR: widened mediastinum/mass
-CT-chest
+/- full staging CT CAP
-Bloods: clotting, tumour markers (AFP, LDH, HCG) if new diagnosis

Question 11

Management of SVCO

Answer 11

• Dependent on: performance status, extent of disease, symptom acuity and severity, ?New cancer diagnosis vs known cancer
  -Initial: sit patient up, supplemental O2 if required, consider steroids (if known Ca:8mg Dexamethasone BD + PPI)
  -New cancer diagnosis: biopsy, hold off steroids if stable pending biopsy
  -Treatment options: endovascular stent (gold standard, emergency if severe symptoms, immediate relief of symptoms), chemo (in SCLC, lymphoma, germ cell, quick response), radio (if stenting not possible, for palliation of symptoms +/- local treatment of primary malignancy), +/- anticoagulation

Question 12

Background of brain metastasis

Answer 12

-In 10-30% of cancer patients
-Most common intracranial tumour in adults

-Site correlates with blood supply:
=80% in cerebral hemispheres
=15% in cerebellum
=5% in brainstem

-Common primary sites
=Lung
=Renal
=Melanoma
=Breast
=Colorectal

Question 13

Presentation of brain metastasis

Answer 13

-Initial cancer presentation or later in disease course

-Asymptomatic OR
-Headache
-N&V
-Seizures
-Cognitive/behavioural change
-Focal neurological deficit
=Diplopia, CN deficit, hemiparesis

-Headache red flags:
=Worse when bending over/ sneezing coughing/ in the morning

Question 14

Investigation of brain metastasis

Answer 14

-CT head (with contrast)
-MRI head

+/- if no cancer history
-CT-CAP
-Consider biopsy

Question 15

Management of brain metastasis

Answer 15

-Steroids: if symptomatic dexamethasone 4-8mg per day initially (higher dose if mass effect/ severe Sx)
-Anticonvulsants if seizures (levetiracetam) Consider neurosurgical discussion
-Consider patient: performance status, prognosis, QoL, patient preference, extent of disease
-Treatment options: best supportive care, WBRT, stereotactic radiosurgery, surgery, systemic therapy

Question 16

Treatment options in brain metastasis

Answer 16

-Surgery
=Large single metastasis
=Superficial lesions
=Lots of associated oedema
=Obstructive hydrocephalus

-Systemic therapy
=Dependent on primary malignancy
=Or if asymptomatic from brain mets

-Radiotherapy
=Stereotactic radiosurgery (SRS): if deep small lesions not amenable to surgery, and primary disease stable so relatively good prognosis
=Whole brain radiotherapy (WBRT): if multiple brain mets & prognosis 3-12 months

-Best supportive care
=Steroids
=Palliative care team

Question 17

Risks of brain mets

Answer 17

-Obstructive hydrocephalus
-Intratumoural bleed
-Seizures
-Raised ICP = herniation

Question 18

Adverse risk factors

Answer 18

-Increased age
-Poor PS
-Multiple lesions
-Large metastases

Question 19

Prognosis of brain mets

Answer 19

-Without treatment, median survival for all tumour types is<3 months
-With treatment, prognosis dependent on tumour type, patient factors, and treatment– average prognosis with WBRT is 3-12 months
-Honest discussions and consider QoL & patient wishes

Question 20

What is febrile neutropenia?

Answer 20

-Temperature <36 C or >38 ͦC
-Neutrophil count <1x109/L

Question 21

What is neutropenic sepsis?

Answer 21

-Temperature <36 C or >38 ͦC
-Neutrophil count <1x109/L
-With features of sepsis
=High RR
=Tachycardia
=Hypotension
=Oliguria

Question 22

What is neutropenic septic shock?

Answer 22

-Temperature <36 C or >38 ͦC
-Neutrophil count <1x109/L
-Hypotension unresponsive to adequate fluid resuscitation
-Life threatening. Commonly occurs 7-14 days after chemo
=Coagulase negative Gram positive bacteria moist common Staph epidermis)

Question 23

Risk factors for neutropenic sepsis?

Answer 23

-Immunocompromised
=Recent chemotherapy
=High dose steroids(haem)
=Solid organ transplant
=Stem cell transplant

Question 24

Medications that may cause neutropenia

Answer 24

-Chemotherapy
-Clozapine
-Hydroxychloroquine
-Methotrexate
-Sulfasalazine
-Carbimazole
-Quinine
-Infliximab
-Rituximab

Question 25

Management of neutropenic sepsis

Answer 25

-Priority
=If pyrexial and immunocompromised assume counts are low.
=Start IV antibiotics within 1hour (do not wait for blood results) Sepsis 6

1. Observations (NEWS score) within 15 minutes
2. Cannulate and take bloods, FBC UE, CRP, lactate, LFT, albumin, coag, blood cultures (peripheral and lines)
3. Start IV antibiotics (IV fluids 500ml STAT if septic, or lactate >2.5. Piperacillin with Tazobactam)
4. Investigate for a source: CXR, MSU, Stool, viral throat swab, skin swab
5. Monitor UO (consider catheter), monitor BM, withhold ACEi, ARBs, NSAIDs, diuretics, metformin as per Sick Day rules. If NEWS rising or >4 escalate to senior medic F2 or above

if patients are still febrile and unwell after 48 hours an alternative antibiotic such as meropenem is often prescribed +/- vancomycin
if patients are not responding after 4-6 days the Christie guidelines suggest ordering investigations for fungal infections (e.g. HRCT), rather than just starting therapy antifungal therapy blindly

Question 26

Antibiotic choice for neutropenic sepsis

Answer 26

-1st dose IV while awaiting bloods
-Always consider allergies
-Local guidelines/micro guide

-Standard risk: IV piperacillin - tazobactam 4.5g IV QDS/ penicillin allergy IV ceftazidime + IV gentamicin + metronidazole
-High risk: IV piperacillin- tazobactam 4.5g IV QDS + IV gentamicin/ penicillin allergy IV vanco + IV aztreonam + IV gentamicin + metronidazole

Question 27

What is the MASCC risk index score?

Answer 27

-Febrile neutropenia with symptoms
-Hypotension
-COPD
-Previous fungal infection
-Dehydration
-Inpatient fever
-Age >60 years

Score <21: high risk inpatient management (lower value= more severe)
Score >21: low risk, consider outpatient management (oral antibiotics, worsening advice)

Question 28

What is malignant hypercalcaemia?

Answer 28

Corrected calcium >2.6
-Corrected calcium = measured calcium +((40 - serum albumin) X 0.02)

Question 29

Risk factors for malignant hypercalcaemia

Answer 29

-Bone metastases
-Myeloma (increased osteoclastic bone resorption caused by local cytokines)
-Lung cancer (PTHrP from squamous cell)
-Breast cancer
-Renal cancer
-20% do not have bone metastases

Question 30

Symptoms of malignant hypercalcaemia

Answer 30

Bones, stones, groans, psychic moans

-Confusion
-Constipation
-Abdominal pain
-Nausea & vomiting
-Muscle weakness
-Polyuria
-Polydipsia
-Corneal calcification
-Shortened QT interval on ECG
-Hypertension

Question 31

Investigation of hypercalcaemia

Answer 31

-Parathyroid hormone levels

Question 32

Treatment of malignant hypercalcaemia

Answer 32

1. Correct dehydration: 3L of 0.% NaCl over 24 hours. Caution: dependent on patients cardiac status
2. Recheck bloods and renal function
3. After adequate hydration and eGFR >30. IV zoledronate 4mg in 100ml 0.9% NaCl over 15 minutes. If eGFR <30 consider use of pamidronate. Take 2-3 days to work with maximal effect at 7 days. Consider calcitonin
4. Review medication that could raise calcium or affect renal function: adcal, ACE inhibitors, diuretics
5. Continue to monitor calcium and renal function. Risk of deterioration in renal function, hypocalcaemia. 7 days for full bisphosphonates effect.