Cancer complications / emergencies Flashcards
Malignant bowel obstruction - state the following:
- 2 cancers it’s more likely to happen with
- Pathophysiology
- Presentation
- Investigations
- Management
2 cancers it’s more likely to happen with:
- Bowel
- Ovarian
Pathophysiology:
- Mechanical obstruction (partial or complete) of bowel lumen +/- failure of peristalsis
Presentation:
- N&V +/- faeculant
- Abdominal pain
- Abdominal fullness / distension
- Reduced / absent bowel sounds
- Bowels not opened
Investigations:
- Plain abdominal x-ray (identify site of obstruction)
- CT (mechanical vs peristalsis)
- MRI (distinguishing benign vs malignant bowel obstruction in known malignancy)
Management:
- Haloperidol (antiemetic)
- Hyoscine butylbromide aka. Buscopan (reduce peristalsis, secretions and antiemetic)
- Dexamethasone (reduce oedema, secretions and antiemetic)
If peristalsis failure…Metoclopramide (prokinetic) and analgesia
Malignant hypercalcaemia - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
** Oncological emergency **
- Complications which occurs in 20-30% of patients with cancer
- Increased osteoclast activity, more calcium resorption from bone
Presentation:
- N&V
- Renal stones
- Abdominal pain
- Constipation
- Depression
- Altered mental state / confusion
- Polydipsia
- Polyuria
Investigations:
- Bone profile bloods
- ECG (cardiac arrhythmias)
- Consider skeletal survey if multiple myeloma or bone mets suspected
Management:
Stop any calcium supplements, thiazide diuretics or nephrotoxic drugs
If mild / asymptomatic…
- Encourage oral intake / IV fluids
- Recheck corrected calcium after 24 hrs
If moderate/severe or persistent with fluids…
- IV fluids = 3 litres over 24 hours
- After 24 hours of fluids, IV Zoledronic acid (Bisphosphates)
Malignant ascites - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Accumulation of fluid in the peritoneal cavity
- Can be caused by peritoneal deposits or by liver mets leading to functional cirrhosis
Presentation:
- N&V
- Abdominal distension
- Abdomianl pain / discomfort
- SOB
- Early satiety
- Weight loss / progression of cancer signs
- Shifting dullness on percussion
Investigations:
- Ascitic fluid for cytology (cell count, culture, albumin, glucose etc.)
- CT to help identify underlying cause of ascites
- Blood tests (FBC, U&Es, LFTs, coagulation screen)
Management:
- Consider treatment of underlying cause e.g. chemotherapy to debulk ovarian tumour
- Ascitic drainage (paracentesis)
State the 3 main mechanisms by which malignancy can cause hypercalcaemia
- Osteolytic metastases (commonly in breast cancer)
- Tumour secretion of parathyroid hormone-related protein (PTHrP) (common in SSC of lung, head or neck and renal and ovarian cancer)
- Tumour secretion of 1,25-dihydroxyvitamin D (calcitriol) (common in Hodgkin lymphoma)
State the 2 main mechanisms by which malignancy can cause ascites
- Peritoneal deposits from ovarian / urological cancers leading to blockage of lymphatic drainage and increased vascular permeability
- Cancers with extensive liver metastases which may result in functional cirrhosis and portal hypertension
Outline how malignant pleural effusion presents, how it is investigated and managed
Common complication of thoracic and extrathoracic malignancies and is associated with high mortality
Presentation:
- Incidental finding on chest x-ray
- SOB
- Dull chest pain
- Constitutional symptoms e.g. WL
Investigation:
- Chest x-ray / CT / USS
- Thoracentesis and pleural fluid Analysis (generally exudative)
Management:
Overall poor prognosis, median survival = 3-12 months
If asymptomatic, may monitor without intervention
- Therapeutic thoracentesis (<1.5L)
- If recurrent, pleurodesis / indwelling pleural catheter
Malignant spinal cord compression - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
** Oncological emergency **
- Compression of the spinal cord / cauda equina
- Occurs by direct pressure or vertebral collapse
- First cancer presentation in approximately 20% of cancer patients
Presentation:
- New/severe back pain
- Leg weakness
- Bilateral sciatica
- Urinary retention / incontinence
- Faecal incontinence
- Saddle anaesthesia
Investigations:
- Whole spine MRI within 24 hours of arrival
Management:
- Lie flat and bed rest (limit movement)
- High dose steroids (16mg Dexamethasone) and PPI
- Analgesia
- Liaise with orthopaedics/neurosurgeons (consider surgery debulking / radiotherapy)
Malignant raised ICP - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
** Oncological emergency **
- Increased intracranial pressure
- Caused by either space occupying tumour or obstructive hydrocephalus (sometimes other causes e.g. abscess)
Presentation:
- Headache
- N&V
- Double / blurred vision
- Papilloedema
- Hypertension and bradycardia
- Seizures
- Reduced conscious level
Investigations:
- Urgent MRI brain / CT head
Management:
- Sit upright
- High dose steroids (16mg Dexamethasone) and PPI
- Consider IV Mannitol
- Analgesia
- Antiemetics e.g. Prochlorperazine, Haloperidol
- Consider definitive therapy e.g. surgery / radiotherapy
Outline how palliative malignant raised ICP is managed (not for surgery / radiotherapy)
- Dexamethasone long-term
- Analgesia (may need very high doses)
- Antiemetics e.g. Prochlorperazine, Haloperidol
- Consider sedation e.g. Benzodiazepines
Malignant-related seizures - state the following:
- Pathophysiology
- Management (acute seizure)
Pathophysiology:
- Seizures are common for patients with brain tumours (up to 65%)
- Temporary surge of abnormal electrical activity, can present in many ways depending on area of brain affected
Management:
- Make area safe (put something under head, remove glasses etc.)
- Anticonvulsants (class depend on the type of seizure), but either IV Lorazepam or buccal Midazolam
- If unresolving, additional IV Lorazepam
Malignant superior vena cava obstruction - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
** Oncological emergency **
- Nearly always caused by malignancy
Presentation:
- Facial / neck / arm swelling
- Thoracic and neck veins distention
- Non-pulsatile JVP
- Central/peripheral cyanosis
- Dyspnoea
- Tachypnoea
- Cough
- Stridor (laryngeal oedema) and hoarse voice
- Chest pain
- Headaches and/or confusion
Investigations:
- FBC, clotting, U&Es
- CTPA (tumour extent, site of occlusion, any thrombus)
Management:
- Sit upright
- Oxygen
- High dose steroids (oedema) and PPI
- Analgesia as required
- Anticoagulation if thrombotic cause found
- Liaise with oncology for resolving underlying cause (stent / chemotherapy / radiotherapy)
Neutropenic sepsis - state the following:
- Pathophysiology
- When is most likely to occur after chemotherapy
- Presentation
- Investigations
- Management
Pathophysiology
** Oncological emergency **
- Potentially life-threatening complication of neutropenia
- Patients will a low neutrophil count are more susceptible to infections and sepsis
- Suspect in patients who have known neutropenic or chemotherapy within the last 6 weeks
When is most likely to occur after chemotherapy:
- 7-10 days post-chemotherapy
Presentation:
May appear well
- Fever or low temperature
- Shivering and sweating
- Feeling confused
- Sore throat / cough
- Rashes and swelling
- Diarrhoea
- UTI symptoms
- Flu-like symptoms
- Meningitis symptoms
Investigations:
- Bloods (urgent FBC, U&E, LFTs, CRP, glucose, lactate)
- Blood cultures (peripheral and central line)
- MRSA screen
If symptomatic = looking for source of infection…
- MSSU/CSU if symptomatic
- Stool culture if diarrhoea
- Wound swabs if breaks in skin
- Sputum if available
- Chest x-ray if clinically indicated
Management:
- IV Tazocin 4.5g stat dose (Meropenem second line) within 1 HOUR
- IV fluids
- Oxygen as required
- Measure fluid balance
Outline the criteria for when to suspect neutropenic sepsis
In a patient with a neutrophil count of < 0.5 x 109/L or undergoing recent chemotherapy…
Temperature:
>38°C
OR temperature >37.5°C on 2 occasions 30 minutes apart
OR temperature <36°C
State some risk factors for neutropenic sepsis (in addition to recent chemo)
- Duration of neutropenia
- Indwelling vascular line / devices
- Comorbidities
- Elderly
- Other cancer therapies/treatments
- Malnutrition
Tumour lysis syndrome - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
** Oncological emergency **
- When tumour cells break down, they release large amounts of cell contents into the bloodstream
- Tumour lysis syndrome occurs when this overload of cell content is more than the body can cope with
- Leads to metabolic disturbances of hyperkalaemia, hyperuricemia, hyperphosphatemia and hypocalcaemia
- Can occur spontaneously or in response to therapy
Presentation:
= Metabolic disturbances (increased K+, increased uric acid, increased phosphorus, decreased calcium)
- Urinary problems (renal damage) dysuria or oliguria
- Gout/joint swelling
- Symptoms of hypocalcaemia e.g. abdominal pain, weakness, N&V, muscle cramps, seizures
- Cardiac arrhythmias (hyperkalaemia)
Investigations:
- Baseline bloods (identify metabolic disturbance)
- ECG to check for cardiac abnormalities
Management:
Risk based approach
- Ongoing monitoring - 6 hourly until stable
- Give IV fluids and strict input / output monitoring
- Allopurinol or Rasburicase
Most patients = Allopurinol (xanthine oxidase inhibitor)
Medium-high risk patients e.g. high-grade lymphoma and leukaemia = Rasburicase (urate oxidase inhibitor)
State the 4 main metabolic disturbances seen in tumour lysis syndrome
Hyperkalaemia (K)
Hyperuricaemia (uric acid)
Hyperphosphataemia (phosphate)
.
Hypocalcaemia (can be caused by hyperphosphataemia)
What 2 drugs can be used in the management of tumour lysis syndrome and how they work
- Allopurinol
Xanthine oxidase inhibitor = stops uric acid production - Rasburicase
Urate oxidase inhibitor = stops uric acid being processed further
Given to medium-high risk patients e.g. high-grade lymphoma and leukaemia
State some complications of tumour lysis syndrome if left untreated
Complications related to metabolic disturbances:
- Renal damage / AKI (hyperuricaemia)
- Cardiac arrhythmias (hyperkalaemia)
- Seizures (hypocalcaemia)
- Death
State characteristics of some cancers which increases the likelihood of tumour lysis syndrome
- Large cancer mass
- Highly proliferative cancer
- Very responsive to treatment
- High-grade B-cell lymphoid malignancies (e.g. Burkitt’s lymphoma
- Acute leukaemias e.g. AML and ALL
State what parameters are required for tumour lysis syndrome to be classed both laboratory or clinically (Cairo-Bishop definition)
Laboratory parameters needed:
- 2 or more of the following metabolic abnormalities: hyperuricaemia, hyperphosphataemia, hyperkalaemia, or hypocalcaemia
Clinical parameters needed:
- Laboratory confirmation above
- 1 or more of the following clinical manifestations: AKI, cardiac arrhythmia, seizure, or sudden death
Immune related colitis - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Common immune related adverse event (associated with immune checkpoint inhibitors) from immunotherapy
- Typically occurs 1-2 months after the 2nd/3rd dose of treatment
Presentation:
Mild = < 4 stools / day over baseline
Moderate = 4-6 stools / day over baseline + abdominal pain + mucus in stool
Severe = > 7 stools / day over baseline + abdominal pain + dehydration + fever + blood in stool + limiting ADL
Investigations:
- Baseline bloods (FBC, U&E, LFTs, TFTs, cortisol & CRP)
- Stool microscopy and culture (C. diff)
- Faecal calprotectin
- Abdominal x-ray if mod-severe
Management:
- Fluid balance
- Encourage fluids / IV fluids
- Prednisolone if moderate (Methylprednisolone if severe)
- Consider omitting next dose of immunotherapy
- Consider Infliximab if severe
Mucositis (complication of chemotherapy) - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Inflammation or mucosa, anywhere from mouth to anus
- Occurs from chemotherapy or radiotherapy killing rapidly dividing cells, which include the mucous lining
- Common in radiotherapy for head and neck cancers
- Can be serious, stop the patient from eating and drinking and lead to weight loss, risk of local and systemic infection
- Can stop subsequent radiotherapy session (poor cancer outcomes)
Presentation:
- Painful or sore mouth / gums / tongue
- Inflammation
- Difficulty swallowing / eating & drinking talking
- Xerostomia, mild burning, or pain when eating food
- Soft, whitish patches or pus in the mouth or on the tongue
- Diarrhoea
Investigations:
- Urgent FBC, U&Es, LFT, CRP, Lactate
- Blood Cultures
- Stool sample if diarrhoea (check for infective cause)
- Fungal culture if candida suspected
Management:
- Encourage oral hygiene
- Oral analgesics e.g. Paracetamol or Ibuprofen
- Local anaesthetic spray e.g. Difflam
- Mouthwashes e.g. Chlorhexidine
- Loperamide if not infectious on stool sample
- Dietician input: ensure food charts, weights
- Analgesia / syringe drivers if severe
