Cancer Care - Oncological Emergencies

Question 1

Metastatic Spinal Cord Compression (MSCC)

Spinal Metastases
Pathophysiology of MSCC
Clinical Features
Medical Management
General Management

Answer 1

1. ) Spinal Metastases - back pain
   - may present with spinal metastases before MSCC
   - sx: unrelenting lumbar back pain, any thoracic or cervical back pain, worse with sneezing, coughing or straining, nocturnal, spinal tenderness
   - a whole spine MRI should be done within 1 week
   - suspect MSCC if there are any neurological features
   - Mx: analgesia, bisphosphonates, radiotherapy
2. ) Pathophysiology - often occurs from extradural compression due to metastases in the vertebral body
   - affects up to 5% of cancer patients, more common in patients with lung, breast and prostate cancer
   - 2/3 of cases occur in the thoracic spine whilst the rest is often lumbosacral
   - other causes: trauma, infection, disc prolapse, epidural haematoma
3. ) Clinical Features
   - deep and localised back pain: earliest symptom
   - lower limb weakness and stabbing radicular sensory disturbance at the level of the lesion
   - L1 and above: UMN sx in the legs and a sensory level
   - below L1: LMN sx in the legs, signs of CES
   - hyperreflexia above the level of the lesion
   - hypo/areflexia below the level of the lesion

4.) Medical Management - oncological emergency
- requires an urgent whole MRI spine within 24hrs
- high-dose PO dexamethasone 16mg BD w/ PPI cover,
to help reduce pressure and swelling around the SC
- tx depends on type of cancer, area of the spine affected, and the patient’s general fitness
- radiotherapy: most common
- surgical decompression: should occur w/in 48hrs

5. ) General Management
   - advised to lie flat and not move your spine: will be examined by physio to assess movement, may be given a collar/brace to help support the neck of spine
   - complications: may have permanent paralysis, pain, difficulty moving, bladder changes, bowel changes
   - help and support at home is available and would be organised before leaving the hospital
   - prognosis: life expectancy is reduced (months)

Question 2

Neutropenic Sepsis

Pathophysiology
Assessment
Investigations
Management

Answer 2

1. ) Pathophysiology - temp >38.5°C (or 2x 38°C) in a patient with a neutrophil count of less than 0.5
   - temp is often the only indication of a severe infection
   - mainly in patients receiving cytotoxic chemotherapy
   - risk factors: neutropenia expected to last > 7 days, clinically unstable, high-intensity chemo, underlying malignancy, significant co-morbidities
2. ) Assessment
   - history: chemo and drug hx, localised sx (e.g. SOB, RLQ pain), PMH inc recent infections and abx used, latent infections, sick contacts, blood transfusions
   - examination: A-E assessment, systems-based examinations, ENT, fundoscopy, DO NOT perform DRE until antibiotics are given)
3. ) Investigations - sepsis 6
   - bloods: cultures (2 sets), FBC, CRP, LFTs, U+Es, ABG
   - monitor urine output
   - identify source of infection: CXR, sputum/urine/stool sample where indicated, swabs from indwelling lines, serology and PCR for viruses
4. ) Management
   - URGENT Abx (don’t wait for WCC): IV Tazocin 4.5g TDS (IV meropenem if allergic)
   - can stop antibiotics once the patient has been apyrexial for 48 hours and is no longer neutropenic
   - add meropenem +/- vancomycin if still febrile and unwell after 48hrs
   - consider antifungal therapy if not responding after 4-6 days (fungal chest infections not seen on CXR and may need HR-CT)
   - consider prophylactic recombinant G-CSF e.g. filgrastim in patients at high risk of neutropenia, can be symptomatic in patient’s in early stages of their chemotherapy cycle
   - consider prophylactic abx in those on high dose chemo (levofloxacin, acyclovir, posaconazole, Co-trimoxazole)
   - can offer prophylactic fluoroquinolones (ciprofloxacin, levofloxacin etc.

Question 3

Superior Vena Cava Obstruction

Pathophysiology
Clinical Features
Management

Answer 3

1. ) Pathophysiology - compression of the SVC
   - most common cause is lung cancer
   - other malignancies: lymphoma, thymoma, metastatic seminoma, Kaposi’s sarcoma, breast cancer
   - other: SVC thrombosis, aortic aneurysm, goitre, mediastinal fibrosis (chronic, can be asymptomatic for years)
2. ) Clinical Features
   - sx can develop quickly over a few days to weeks
   - dyspnoea: swelling around the trachea
   - facial plethora: swelling and redness of the face, can also affect the neck, arms, hands, eyes (periorbital)
   - headaches: worse in mornings or leaning forwards
   - visual disturbance, dizziness
   - dilated/engorged veins (neck and upper chest)
   - pulseless jugular venous distension
   - Pemberton’s sign: raising hands over the head for >1min precipitates facial plethora and cyanosis
3. ) Management - oncological emergency if SOB
   - sit the patient up, oxygen, analgesia, sedatives
   - short-term high dose (8mg) PO dexamethasone (reduces tumour oedema and laryngeal oedema)
   - imaging: CXR, ultrasound or CT
   - diuretics may be given w/ corticosteroids
   - emergency treatment (treat resp distress/cerebral oedema): steroids, diuretics, endovascular stenting
   - conservative tx: radiotherapy, chemo, surgery
   - average life expectancy is 6 months

Question 4

Tumour Lysis Syndrome (TLS)

What is it?
Pathophysiology
Clinical Features
Management

Answer 4

1. ) What is it? - severe electrolyte disturbances from the breakdown of tumour cells due to treatment
   - most common w/ chemotherapy but can also occur w/ steroid treatment, hormonal therapy, radiation etc
   - ↑prevalence in high-grade lymphoma and leukaemia and cancers that respond very well to treatment
   - prophylactic medication can be given to prevent the potentially deadly effects of tumour cell lysis
2. ) Pathophysiology - breakdown of tumour cells leads to the release of their intracellular contents:
   - hyperkalaemia: release of K+ from cells
   - hyperuricemia: release of purine from DNA in cells
   - hyperphosphataemia: release of PO4- from cells
   - hypocalcemia: Ca2+ binds to increased PO4-
3. ) Clinical Features
   - occurs within 72hrs (3d) of treatment up to 7 days
   - sx: lethargy, N+V, diarrhoea, anorexia, muscle cramps, syncope, pruritus, joint pains, paraesthesia and tetany, cardiac arrhythmias, seizures
   - AKI: due to formation of urate crystals in renal tubules
   - lab results: K+ >6mM, uric acid >0.475mM, phosphate > 1.125mM, calcium < 1.75mM
4. ) Management
   - high risk: IV allopurinol OR IV rasburicase 48hrs before treatment to reduce effects of hyperuricemia
   - allopurinol: xanthine oxidase inhibitor
   - rasburicase: recombinant urate oxidase which metabolises uric acid to allantoin
   - aggressive IV hydration (3L/24hrs)
   - lower risk: PO allopurinol during chemo cycles
   - acute Mx: consider dialysis

Question 5

Hypercalcaemia

Pathophysiology
Clinical Features
Management of Mild Hypercalcaemia
Management of Mod/Severe Hypercalcaemia

Answer 5

1. ) Pathophysiology
   - malignancy is the most common cause in patients in hospital, this may be due to a number of processes:
   - bone metastases, myeloma, PTHrP in NSCLC (SCC),
   - primary hyperparathyroidism is the most common cause in non-hospitalised patients
   - other potential causes of hypercalcemia include:
   - dehydration, thyrotoxicosis, vitamin D intoxication
   - acromegaly, Addison’s disease
   drugs: thiazides, calcium-containing antacids
   - granulomatous: sarcoidosis, TB, lymphoma
2. ) Clinical Features
   - mild: asymptomatic, polyuria, polydipsia, mild cognitive impairment, dyspepsia
   - moderate: dehydration, fatigue, weakness, nausea, constipation
   - severe: abdominal pain, vomiting, pancreatitis, cardiac dysrhythmias, coma
   - moans: constipation, N+V, ↓appetite, pancreatitis
   - groans: confusion, delirium, poor conc, depression
   - bones: pain, weakness, fractures, osteoporosis
   - stones: kidney stones, AKI (nephrocalcinosis)
   - other: secondary HTN, short QT interval on ECG, corneal calcification
3. ) Management of Mild Hypercalcaemia - Ca2+ <3mM and asymptomatic/mild symptoms (e.g. constipation)
   - it does not require immediate treatment, but advise regular hydration to prevent stones, and to avoid:
   - dehydration, prolonged bed rest/inactivity
   - high calcium diet, calcium/vitD supplements
   - dx: thiazide diuretics, lithium
4. ) Management of Mod/Severe Hypercalcaemia
   - asymptomatic patients with chronic moderate ↑Ca2+ (3-3.5mM) may not require immediate treatment ^^^
   - acute rise to >3.5mM requires aggressive treatment:
   - 1.) aggressive IV hydration: 0.9% NaCl ≈ 3L/24hrs, consider loop diuretics in renal failure or HF
   - 2.) IM/SC calcitonin: along with fluids, should lower serum Ca2+ within 12-48 hours
   - 3.) IV zoledronic acid 4mg/15mins: long term control as it takes 2-4 days to become effective for 2-4 weeks
   - renal impairment: consider slower infusion of bisphosphonates or consider denosumab instead
   - 4.) Refractory Hypercalcaemia: if it returns after treating, has very poor prognosis
   - prognosis of malignant hypercalcaemia is up to 1 yr

Question 6

Diagnosis of a DVT

Clinical Features
Wells Criteria x10
Differential Diagnosis

Answer 6

1. ) Clinical Features
   - unilateral localised pain when weight bearing
   - calf swelling or swelling of entire leg
   - tender, oedema, redness, warmth, vein distension
2. ) Wells Criteria - assessment for suspected DVT
   - whole leg swelling, swelling (>3cm), pitting oedema,
   - collateral superficial veins, localised tenderness along distribution of deep venous system
   - active cancer, previous DVT, recently bedridden or major surgery, recent immobilisation of lower limbs
   - alternative diagnosis as likely (score -2)
3. ) Differential Diagnoses
   - cellulitis, ruptured Baker’s cyst, compartment syn…
   - right sided HF, lymphoedema, venous insufficiency

Question 7

Suspected DVT: Diagnosis and Initial Management

Suspected DVT Likely
Suspected DVT Unlikely
Ultrasound Scan Positive
Ultrasound Scan Negative

Answer 7

1. ) Suspected DVT Likely - wells score 2 and above
   - proximal leg vein ultrasound scan within 4 hours, OR:
   - scan within 24hrs + D-dimer test + interim anticoagulation
2. ) Suspected DVT Unlikely - D-dimer test
   - interim anticoagulation if results will take > 4hrs
   - if D-dimer positive, treat like suspected DVT likely
   - if negative, stop anticoagulation
3. ) Ultrasound Scan Positive - diagnostic
   - diagnose DVT and offer/continue treatment
4. ) Ultrasound Scan Negative - depends on D-dimers
   - if positive D-dimers, stop anticoagulation and repeat scan 6-8 days later
   - if negative D-dimers or second USS, stop anticoagulation and think about other diagnoses

Question 8

Suspected PE: Diagnosis and Initial Management

PE Wells Score
Suspected PE Likely
Suspected PE Unlikely
CTPA Positive
CTPA Negative

Answer 8

1. ) PE Wells Score
   - 3: clinical features of DVT, most likely diagnosis
   - 1.5: HR >100, previous DVT/PE, immobilisation for >3days or surgery in previous 4 weeks
   - 1: haemoptysis, malignancy in last 6 months
2. ) Suspected PE Likely - wells score of 5 and above
   - immediate CTPA (anticoagulation while awaiting)
3. ) Suspected PE Unlikely - D-dimer test
   - interim anticoagulation if results will take > 4hrs
   - if D-dimer positive, treat like suspected PE likely
   - if D-dimer negative, stop anticoagulation
4. ) CTPA Positive - diagnostic
   - diagnose PE and offer/continue treatment
5. ) CTPA Negative
   - if DVT is suspected, consider proximal leg vein USS
   - if DVT not suspected, stop any anticoagulation

Question 9

Anticoagulation

General Information
Normal Usage of Anticoagulants
Active Cancer

Answer 9

1. ) General Information
   - perform bloods but start anticoagulation before results are available: FBC, U+Es, LFTs, clotting
   - anticoagulation is for at least 3 months (up to 6 months in active cancer) and then reviewed
   - in a PE with haemodynamic instability (sysBP <90), treat w/ UFH infusion and consider thrombolytic therapy with IV alteplase
   - contraindicated if platelet count is <50
2. ) Normal Usage of Anticoagulants
   - 1°: apixaban OR rivaroxaban
   - 2°: dabigatran/edoxaban (bridging therapy w/ LMWH)
   - 3°: warfarin (w/ LMWH as bridging therapy for 5 days)
   - severe renal impairment (eGFR <15m/min): DOACs are contraindicated so LMWH or UFH or warfarin (with bridging therapy w/ LMWH or UFH) are used
3. ) Active Cancer - this is defined as any cancer that has been diagnosed in the past 6 months OR receiving antimitotic treatment OR recurrent/metastatic/inoperable
   - can use any DOAC and LMWH can be used on its own:
   - 1°: consider a DOAC
   - 2°: LMWH
   - 3°: warfarin (with LMWH as bridging therapy for 5 days)