Cancer Complications And Emergencies Flashcards
What are the most likely cancers to spread to the bones ?
Breast
Prostate
Lung
Kidney
Thyroid
Myeloma
Lymphoma
Which bones are usually effected in metastases ?
Spine
Pelvis
Proximal femurs
What are some complications of bone metastases ?
Bone pain
Hypercalcaemia
Pathological fractures
Spinal cord compression
Which cancer is most likely to cause osteoblastic bone metastases ?
Prostate
Which cancer is most likely to cause osteolytic bone metastases ?
Multiple myeloma
What is the pathophysiology of osteoblastic bone mets ?
Cancer cells activate osteoblasts, increasing deposition of new bone and increasing numbers of irregular bone
This results in dense, sclerotic / hardening of bones
What is the pathophysiology of osteosclerotic bone mets ?
Cancer cells cause excessive breakdown of bone. This results in weak, easily breakable bones
What cancer can result in mixed osteoblastic and osteosclerotic bone mets ?
Breast cancer
What is the clinical presentation of bone metastases ?
Bone pain - worse at night ( vary from dull and aching to sharp and intense )
Why do bone mets cause bone pain ?
Bone destruction
Bone instability
Subsequent fractures
What are some important tests to perform when suspecting bone mets ?
FBC
Serum calcium
Sreum alkaline phosphatase
Bone scan
CT
MRI
PET/ CT
What is the management of bone mets ?
Localised therapy - radiation
Systemic - bisphosphonates and systemic radiation
How do bisphosphonates manage bone pain from bone mets ?
It binds to hydroxyapatite on bone surfaces undergoing rapid resorption.
Internalisation of the bisphosphonate into osteoclasts which disrupts bone resorption.
Promotes osteoclast apoptosis
Which cancers are most likely to cause brain mets ?
Lung
Renal cell carcinoma
Melanoma
Breast
Colorectal
How do brain mets occur ?
Cancer cells must get into the circulation, survive in the circulation and arrest in a capillary bed. Once in the capillary bed of the brain they must extravasate into the brain parenchyma and grow.
What are symptoms from brain mets most likely due to ?
The tumour mass and oedema
What are the most common symptoms from brain mets ?
Headache
Focal weakness
Altered mental state
Seizures
Ataxia
Stroke
Nausea and vomiting
What can a frontal lobe tumour cause ?
Anosmia
What can a temporal or occipital lobe tumour cause ?
Visual field deficits - homonymous hemianopia
What can brainstem and cerebellar tumours cause ?
Ataxia and incoordination
Nystagmus
Upper motor neurone signs
What imaging is used when suspecting brain mets ?
Contrast enhanced MRI
What is the management of brain mets ?
Dexamethasone
VTE prophylaxis
Radiotherapy ( whole brain or focal )
Surgery
What are some factors that effect the management of brain mets ?
Prognosis and performance status
Quality of life
Patient preference
Extent of disease
Type of cancer
Symptoms associated with cancer
What is febrile neutropenia ?
A serious complication of chemotherapy characterised by a reduction of neutrophils below normal cell counts. Due to the blunted immune system there is an impaired ability to fight infections.
What is the management of febrile neutropenia ?
Considered a medical emergency
Empirical abx immediately- piperacillin-tazobactam
What happens when low levels of calcium are detected ?
Low serum calcium stimulate the parathyroid gland to release parathyroid hormone which increases calcium levels in 3 ways : renal tubular, vitamin D activation and mobilisation from bone.
Vitamin D increases calcium absorption from the GI tract and decreases renal excretion.
How does calcitonin work ?
Calcitonin is a hormone released by parafollicular cells in the thyroid gland that is involved in decreasing serum calcium levels by preventing renal absorption and calcium mobilisation from bone.
What is the pathophysiology of Hypercalcaemia of malignancy ?
Humoral Hypercalcaemia mediated by increased parathyroid hormone related peptide
Local osteolytic Hypercalcaemia due to breakdown of bone
Excess ectopic or primary PTH secretion
What are some signs and symptoms of Hypercalcaemia ?
Stones - renal (AKI, nephrolithiasis )
Bones (pain and fractures )
Moans - pyschiatric ( confusion, altered mental state, mood changes )
Groans - abdo ( constipation, pain, nausea and vomiting )
What are some investigations when suspecting Hypercalcaemia ?
Serum calcium
Serum albumin
PTH
PTHrP
Vitamin D levels
What is the management of Hypercalcaemia ?
IV fluids to correct dehydration
Exogenous calcitonin ( fast action )
Bisphosphonates - zolendronic acid ( longer term )
Systemic treatment of malignancy
What are some causes of spinal cord compression due to malignancy ?
Primary spinal tumours
Any metastatic tumours
What are the most common signs and symptoms of spinal cord compression ?
Back pain - radiating
Reduced power, difficulty walking
Hyperreflexia - UMN lesion
Bladder and bowel dysfunction
What are some differentials for back pain in cancer patients ?
MSK disease - muscle spasm, spinal stenosis
Spinal epidural abscess
Metastatic disease
Radiation myelopathy
What imaging is used when back pain is present in cancer patients ?
MRI
CT
What is the management of spinal cord compression in cancer patients ?
Dexamethasone 16mg + PPI
Analgesia
Surgery
Radiation therapy
What is superior vena cava syndrome ?
The impediment of blood flow through the SVC caused by thrombosis, invasion or compression by pathology involving nearby anatomical structures.
It is a medical emergency
Wht are the causes of impediment of blood flow in the superior vena cava ?
Thrombosis in the SVC
Invasion
Extrinsic pressure exerted by pathology involving nearby anatomical structures
When do clinical features of SVC syndrome present ?
The degree of obstruction is no longer adequately compensated for by the formation of venous collaterals
What are some benign causes of SVC obstruction ?
Thrombosis
Aortic aneurysm
Retrosternal thyroid
What are some malignant causes of superior vena cava obstruction ?
Non-small cell lung cancer
Small cell lung cancer
Non-Hodgkin’s lymphoma
What are the major features of SVC obstruction ?
Dyspnoea
Distension ( oedema of face with erythema )
Dilated chest wall veins
What is the management for SVC obstruction ?
Dexamethasone 16mg + PPI
Stent
Radiotherapy
Chemotherapy ( SCLC, lymphoma and teratoma \
Anti coagulation if thrombus
How does malignancy increase the risk of developing VTE ?
Venous stasis secondary to prolonged periods of immobility
Tumours can compress the vasculature impairing venous return
Hypercoagulability is increased by cancer cells
What is virchow’s triad ?
Venous stasis
Endothelial dysfunction
Hypercoagulable state
What are some patient related risk factors for a VTE ?
History of previous VTE
Thrombophilia
Obesity
Age over 50
Comorbidity
What are some treatment related risk factors for a VTE ?
Surgery
Having chemotherapy
Having hormonal therapy
EPO stimulating agents
Hospitalisation
What investigation should be performed when you are suspecting a DVT ?
Doppler USS
What should be performed when suspecting a PE ?
D dimer
CTPA
VQ scan
What is the management of VTE ?
Prophylaxis - aspirin, Dalteparin
Mainstay treatment - low molecular weight heparin
What are oncological emergencies ?
Group of conditions that occur as a direct or indirect result of cancer or its treatment that are potentially life threatening
What are some signs and symptoms of neutropenic sepsis ?
Fever
Tachycardia
HYPOTENSION
Raised RR
Drowsy
Confusion
What increases the risk of infection in cancer patients ?
Prolonged neutropenia
Severe neutropenia
Significant co-morbidities
Aggressive cancer
Central lines
Mucosal disruption
Hospitalisation
If suspecting neutropenic sepsis what investigations should be performed ?
FBC
U&E’s
LFTs
Lactate / ABG
CRP
Cultures / swabs - blood, urine, sputum, wound
CXR
What is the management of neutropenic sepsis ?
Don’t wait for FBC
Empirical IV broad spectrum abx within an hour
Fluid resus
O2
Consider catheter
Consider G-CSF
What is the smog common site for a spinal cord compression due to mets ?
Thoracic
If there are signs of spinal cord compression due to malignancy what should be ordered and how quickly ?
MRI of the spine within 24 hours
Why is surgery used in the management of spinal cord compression due to malignancy ?
Relieves compression
Removes tumour
Stabilises spine
Preserves greater degree of mobility
Why is radiotherapy given in spinal cord compression due to malignancy ?
Relieves compression of the spine and nerve roots by causing cell death in rapidly dividing tissue
Relieves pain
Stabilises neurological deficit
What is the normal range of corrected calcium ?
2.2-2.51 mmol/L
What cancers is Hypercalcaemia common in ?
Breast
SCC
Renal
Myeloma
Lymphoma
How quickly do bisphosphonates take to work ?
Up to 4 days
What is tumour lysis syndrome ?
A metabolism emergency that presents as severe electrolyte abnormalities.
Massive tumour cell lysis —- release of large amounts of K+, phosphate and uric acid into circulation
What electrolyte imbalances can occur from tumour lysis syndrome ?
Hyperuricaemia
Hyperkalaemia
Hyperphosphataemia
Hypocalcaemia
What is the most common cancers to cause tumour lysis syndrome ?
Haematological cancers - lymphomas and leukaemia
Myeloma
How does tumour lysis syndrome present ?
3-7 days after chemo
N + V
Diarrhoea
Anorexia
Lethargy
Haematuria
Fluid overload
Cardiac arrhythmias
Muscle cramps, tetany and seizures
How can tumour lysis syndrome be prevented ?
Focus on hydration
Allopurinol
Rasburicase
Dialysis
