Acute Oncology FRCR Flashcards
What is an oncological emergency?
An acute medical problem related to cancer or its treatment that may result in serious morbidity or mortality if not treated quickly.
What are the potential causes of oncological emergencies?
They may be secondary to structural/obstructive, metabolic, or treatment-related complications.
What percentage of cancer patients suffer from hypercalcaemia?
Around 20–30% of all cancer patients.
What is the commonest neurological complication of cancer?
Spinal cord compression, occurring in approximately 5–10% of all cancer patients.
What are the types of oncological emergencies?
Metabolic, structural/obstructive, and treatment-related emergencies.
What are examples of metabolic emergencies?
Hypercalcaemia and syndrome of inappropriate antidiuretic hormone (SIADH).
What are examples of structural/obstructive emergencies?
Malignant spinal cord compression (MSCC), superior vena cava obstruction (SVCO), raised intracranial pressure, acute airway obstruction, bleeding, urinary obstruction, cardiac tamponade, pain, and thromboembolic disease.
What are examples of treatment-related emergencies?
Neutropenic fever/sepsis, anaphylaxis related to a chemotherapeutic agent, tumour lysis syndrome, and extravasation of a chemotherapeutic agent.
What is the initial treatment approach for oncological emergencies?
Resuscitation measures to ensure airway, breathing, and circulation are maintained.
What is hypercalcaemia?
A condition where corrected calcium is greater than 2.6 mmol/L.
What is the commonest cause of hypercalcaemia in inpatients?
Hypercalcaemia of malignancy.
What are the symptoms of hypercalcaemia?
Fatigue, anorexia, nausea, vomiting, abdominal pain/constipation, polyuria, polydipsia, and confusion.
What can untreated hypercalcaemia lead to?
Somnolence, coma, and death.
What is the treatment for asymptomatic patients with corrected calcium less than 3.0 mmol/L?
Rehydration, mobility, and regular monitoring.
What is the treatment for symptomatic patients or those with corrected calcium greater than or equal to 3.0 mmol/L?
Fluid replacement, bisphosphonates, and monitoring of renal function.
What is SIADH?
Syndrome of inappropriate antidiuretic hormone caused by excess levels of ADH, leading to water retention and low serum sodium levels.
What is the commonest cancer associated with SIADH?
Small-cell lung cancer (SCLC).
What are the symptoms of hyponatremia?
Fatigue, lethargy, nausea, anorexia, muscle cramps, depression, and behavioral changes.
What is the treatment for SIADH?
Fluid restriction, demeclocycline, and treatment of the underlying malignancy.
What is malignant spinal cord compression?
Pressure from a tumor or collapsed vertebral body on the spinal cord or cauda equina.
What are the symptoms of malignant spinal cord compression?
Paraparesis, paraplegia, loss of sensation, and bladder or bowel dysfunction.
What is the initial treatment for malignant spinal cord compression?
Dexamethasone, adequate analgesia, and consideration of thromboprophylaxis.
What is the benefit of immediate circumferential decompression of the spinal cord in MSCC?
It has been shown to be superior to radiotherapy alone, with higher percentage of patients retaining the ability to walk after surgery (84% vs 57%)
This conclusion is based on a study by Patchell et al., 2005.
What are the criteria for patient selection for immediate circumferential decompression in MSCC?
Good performance status, predicted survival greater than 3 months, not paraplegic for more than 48 hours
These criteria are essential for determining eligibility for surgery.
What scoring system is used for pre-operative evaluation of metastatic spinal tumour progression?
Tokuhashi scoring criteria
This system helps in making decisions regarding spinal surgery.
What is the total score range and associated prognosis in the Tokuhashi scoring system?
0–8: 85% live <6 months; 9–11: 73% live >6 months, 30% live >1 year; 12–15: 95% live >1 year
This scoring system helps predict survival based on various factors.
What is the most commonly used treatment for MSCC?
Radiotherapy
Patients should receive radiotherapy as soon as possible after arriving at the oncology unit.
What is the typical radiotherapy technique for treating MSCC?
- Patient positioning: prone or supine
- Localisation: target volume includes compression level and one vertebral body above and below
- Plan: typically a single posterior field
- Dose: 20 Gy in 5 fractions or 30 Gy in 10 fractions
Detailed techniques ensure accurate treatment delivery.
What is the SCORAD trial?
A randomised phase III trial comparing single fraction radiotherapy to multi-fraction radiotherapy in patients with metastatic spinal cord compression
Results of this trial are awaited.
What is SVCO and its common associations?
Superior vena cava obstruction, most often associated with carcinoma of the bronchus (75%) and lymphomas (15%)
Other rare causes include thymoma and germ cell cancer.
What are common symptoms of SVCO?
- Neck and face swelling
- Conjunctival suffusion
- Headache
- Nasal congestion
- Dizziness
- Syncope
Symptoms often worsen when bending forward.
What investigations are used for diagnosing SVCO?
- Chest X-ray
- CT scan
- Histological diagnosis via fine-needle aspiration or biopsy
These investigations help in determining the cause and extent of obstruction.
What is the initial management for SVCO?
- Sit the patient up
- Administer oxygen and steroids
- Consider a superior vena caval stent
Treatment aims to relieve symptoms and allow for diagnosis.
What are the potential causes of raised intracranial pressure (ICP)?
- Intracranial tumours
- Intracranial hemorrhage
- Cerebral edema
- Venous sinus thrombosis
- Intracranial infection in immunosuppressed patients
These factors can contribute to increased ICP in malignancy.
What are the common presentations of raised ICP?
- Headache
- Nausea
- Vomiting
- Visual disturbance
- Seizure
- Ataxia
Clinical findings may include visual field loss and papilloedema.
What is the treatment protocol for raised ICP?
- Assess airway, breathing, circulation
- Administer steroids and mannitol if severe
- Provide analgesia for headache
- Consider neurosurgical opinion for 3 or fewer brain metastases
Treatment is aimed at managing symptoms and underlying causes.
What is acute airway obstruction and its common causes?
Blockage of the main-stem bronchi, trachea, or larynx, commonly caused by lung cancer or head and neck cancer
This condition requires immediate attention.
What are the primary treatments for acute airway obstruction?
- Heliox administration
- High-dose steroids
- Nebulised bronchodilators
- Emergency tracheostomy or intubation if severe
These interventions aim to alleviate the obstruction and improve breathing.
What is the effectiveness of steroids with gastroprotection?
There is no good evidence of its effectiveness.
Steroids are sometimes considered in treatment protocols, but their efficacy in specific contexts remains unproven.
What should be given if there is evidence of bronchospasm?
Nebulised bronchodilators.
Bronchodilators help relax the muscles of the airways, improving airflow.
What may be required if the upper airway is severely compromised?
Emergency tracheostomy or endotracheal intubation.
These procedures are critical for securing the airway in life-threatening situations.
What is the primary goal of specific interventions for airway obstruction?
To diagnose and treat the obstruction.
What is the primary treatment for most patients with lung cancer?
External beam radiotherapy.
This treatment can be combined with chemotherapy for enhanced effectiveness.
What is the Rockall score used for?
Risk assessment for GI haemorrhage.
It helps predict mortality based on clinical variables.
What score indicates a predicted mortality of around 50% according to the Rockall score?
A Rockall score of 6 or more.
What factors are identified as independent variables predicting re-bleeding and death?
- Shock
- Age
- Comorbidity
- Specific endoscopic findings
These factors help in assessing patient risk in acute situations.
What is massive haemoptysis defined as?
Expectoration of more than 100 mL of blood in a single episode during 24–48 hours.
What percentage of upper GI bleeding is related to malignancy?
Approximately 2–5%.
What should be performed to establish diagnosis and identify the site of bleeding?
- Full blood count
- Clotting screen
- Renal and liver profile
- CT scan or endoscopy
- Urine or sputum microscopy and culture
These tests provide crucial information for treatment planning.
What is the initial management step for patients requiring active resuscitation?
Secure airway, breathing, and circulation.
What fluid is commonly used for resuscitation to restore blood pressure?
0.9% NaCl or colloid.
What is the treatment for patients with haemoglobin below 100 g/L?
Blood transfusion.
What is argon plasma coagulation used for?
Endoscopic intervention for bleeding from central airway tumours.
What is the recommended dose of external beam radiotherapy for lung cancer?
20 Gy in 5 fractions.
What are the options for treating haematemesis?
- Drug therapy (e.g., proton pump inhibitors)
- Endoscopic therapy (e.g., direct injection of adrenaline)
- Radiotherapy to the tumour bed
These methods aim to control bleeding and manage symptoms effectively.
What urinary obstruction is commonly associated with urological or gynaecological tumours?
Carcinoma of prostate or cervix.
What imaging technique can show bilateral hydronephrosis?
Renal tract ultrasound.
What treatment is used for bladder outflow obstruction?
Insertion of a urethral or suprapubic catheter.
What should be considered if the obstruction is secondary to ureteric compression?
The patient’s performance status, stage of disease, and chance of response to anti-cancer treatment.
What measures may be required for severe uraemia or hyperkalaemia?
Haemofiltration or dialysis.
What is cardiac tamponade?
Increased intrapericardial pressure from excess pericardial fluid, reducing cardiac filling and impairing blood circulation.
What conditions are most commonly associated with cardiac tamponade?
Malignant pericardial effusion from lung cancer, ovarian cancer, and primary cardiac tumours.
What are common symptoms of cardiac tamponade?
- Breathlessness
- Chest pain
- Orthopnoea
- Weakness
What signs indicate haemodynamic compromise in cardiac tamponade?
- Raised jugulo-venous pressure (JVP)
- Tachycardia
- Hypotension
- Increased pulsus paradoxus
- Oedema
What is the primary diagnostic tool for cardiac tamponade?
Two-dimensional echocardiography.
What are the treatment options for cardiac tamponade?
- Oxygen therapy
- Volume expansion with blood, plasma, or isotonic sodium chloride solution
- Pericardiocentesis under ultrasound guidance
- Surgical pericardial window if fluid re-accumulates
- Radiotherapy to the pericardium if pericardial window is unsuitable
What increases the risk of thromboembolic disease in cancer patients?
Pro-coagulant activity of tumour cells and treatments such as chemotherapy and surgery.
What anticoagulant should be used for thromboembolic disease if renal function is adequate?
Low molecular weight heparin (LMWH).
How long should LMWH be administered for thromboembolic disease?
At least three to six months.
What may be considered for patients with recurrent VTE when anticoagulation has been optimized?
Placement of a vena cava filter.
What is neutropenic sepsis?
A serious condition that may occur after chemotherapy, characterized by neutropenia with sepsis or severe sepsis.
What are the main risk factors for developing neutropenic sepsis?
- Age greater than 65 years
- Poor performance status
- Previous episodes of febrile neutropenia
- Combined chemotherapy and radiotherapy
- Poor nutrition
- Advanced disease
- Comorbidities
- Open wounds or active infections
What guideline outlines the prevention and management of neutropenic sepsis?
NICE clinical guideline 151.
Why is patient education important in cancer treatment?
It helps patients recognize infective symptoms and how to monitor their temperature.
What temperature indicates that a cancer patient should inform their cancer center immediately?
A temperature of > 37.5°C.
What is the initial treatment for patients suspected of having neutropenic sepsis?
Administer intravenous antibiotics within one hour
Prompt assessment and treatment are crucial for patient outcomes.
What investigations should be conducted for suspected neutropenic sepsis?
Investigations should include:
* FBC
* Urea and electrolytes (U+E)
* Liver function tests (LFT)
* Bone profile
* Coagulation screen
* C-reactive protein (CRP)
* Blood cultures
* Blood sugar
* Lactate
* Mid-stream urine (MSU)
Additional samples may include sputum, stool, and wound swabs.
What are the signs of sepsis?
Signs of sepsis include:
* Temperature < 36°C or > 38°C
* Tachycardia
* Tachypnoea
* Altered mental state
* Hyperglycaemia (in absence of diabetes)
* White cell count (WCC) > 12 or < 4 × 10^9/L
Early recognition of these signs is vital for management.
Define septic shock.
Septic shock is sepsis with hypotension despite adequate fluid resuscitation
It may include perfusion abnormalities like lactic acidosis and oliguria.
What constitutes hypotension in a septic patient?
Hypotension is defined as:
* Systolic blood pressure < 90 mmHg
* Reduction of > 40 mmHg from baseline
This should be assessed in the absence of other causes.
What initial measures should be taken for septic shock?
Immediate measures include:
* Intravenous access with medium- to wide-bore cannula
* Start 1 L 0.9% NaCl or 500 mL colloid over 30 minutes
* Give oxygen if hypoxic
* Investigate serum lactate and other blood tests
These measures are critical for stabilization.
How is the MASCC score used in neutropenic sepsis?
The MASCC score stratifies patients into low or high risk of serious complications based on factors such as:
* Age
* Evidence of dehydration
* Hypotension
* Coexisting chronic obstructive pulmonary disease (COPD)
A higher score indicates lower risk.
What is the recommended antibiotic treatment for high-risk neutropenic patients?
For high-risk patients, start:
* Meropenem 1 g i.v. t.d.s. (if no penicillin allergy)
* Vancomycin 1 g b.d. and gentamicin 6 mg/kg i.v. o.d. (if penicillin allergy)
Follow local protocols for antibiotic administration.
What is the treatment for low-risk neutropenic patients with a neutrophil count > 0.5 × 10^9/L?
Treat with oral antibiotics according to hospital guidelines and consider early discharge
Important for patient safety and resource management.
What is the role of G-CSF in neutropenic sepsis?
G-CSF can be considered in patients with:
* Profound neutropenia (ANC < 0.1 × 10^9/L)
* Prolonged neutropenia (> 10 days)
* Pneumonia
* Hypotension
It is not used routinely but may be beneficial in high-risk cases.
What are the common anti-cancer drugs associated with anaphylaxis?
Common drugs include:
* Paclitaxel
* Carboplatin
* Docetaxel
* L-asparaginase
Anaphylaxis can occur with both immediate and delayed reactions.
What are the symptoms of anaphylaxis?
Symptoms may include:
* Agitation
* Hypotension
* Bronchospasm
* Rash
* Angioedema
* Abdominal pain
Prompt recognition and treatment are essential.
What is Tumour Lysis Syndrome (TLS)?
TLS is caused by sudden tumour necrosis leading to metabolic abnormalities such as:
* Hyperkalaemia
* Hyperuricaemia
* Hyperphosphataemia
* Secondary hypocalcaemia
It is often seen in chemosensitive, bulky tumours.
What is the maximum theoretical score for the MASCC score?
The maximum theoretical score is 26
This score helps in assessing the burden of illness in neutropenic patients.
