Cancer Screening

Question 1

What percentage of patients are ambulatory when they are first seen with spinal cord compression?

Answer 1

Approximately 90%

Question 2

What are the symptoms of spinal cord compression?

Answer 2

More than 90% of patients complain of back pain. Patients with a history of cancer must be advised that back pain should be promptly evaluated by their physician.

Other symptoms of neurologic compromise include numbness, paresthesias, muscular weakness, and urinary and fecal incontinence.

Question 3

What is the character of spinal cord compression pain?

Answer 3

Pain is localized to the spine and exacerbated by movement, recumbency, cough, sneezing, or strain.

The pain can be radicular in nature (sharp and electric shocklike, radiating in the distribution of a spinal nerve root).

Question 4

What is the duration of pain in most patients with spinal cord compression?

Answer 4

Most have pain for weeks before the onset of neurologic symptoms; however, neurologic compromise is usually more rapid, typically occurring in hours to days.

Question 5

What are the physical findings in patients with spinal cord compression?

Answer 5

• Tenderness to percussion at the involved spine.
• Neck flexion or straight leg-raise precipitates pain at the level of the problem.
• Neurologic findings are decreased sensation and motor strength, positive Babinski sign, and hyperreflexia.

Question 6

What is the radiographic study of choice to rule out spinal cord compression?

Answer 6

MRI of the cervical, thoracic, and lumbar spine

Question 7

How does metastatic cancer cause loss of neurologic function in the spinal cord?

Answer 7

The tumor restricts the vascular supply to the spinal cord with resultant spinal cord infarction.

Question 8

What is the treatment of acute spinal cord compression?

Answer 8

• High-dose dexamethasone, followed by radiation therapy or surgical decompression.
• Occasionally, chemotherapy can be used alone or in combination with radiotherapy.

Question 9

What are the malignant causes of increased intracranial pressure?

Answer 9

Carcinomatous meningitis, intracranial metastases, and primary intracranial tumors

Question 10

What are the symptoms and signs of intracranial metastatic disease?

Answer 10

Headache, nausea and vomiting, altered mental status, seizures, visual loss, focal neurologic deficits, papilledema, and coma

Question 11

How are intracranial metastases diagnosed?

Answer 11

CT scan or MRI of the head

Question 12

What is the treatment for acutely symptomatic intracranial metastases?

Answer 12

• High-dose steroids
• Anticonvulsants Mannitol
• Hyperventilation (if the patient is intubated)
• Surgery (for isolated masses) versus radiation therapy (for multiple lesions)

Question 13

What are the symptoms of carcinomatous meningitis?

Answer 13

Headache, nausea and vomiting, radicular pain, altered mental status, diplopia, and blurred vision

Question 14

What are the physical signs of carcinomatous meningitis?

Answer 14

• Cranial nerve palsies
• nuchal rigidity
• other focal neurologic deficits
• papilledema

Question 15

How is the diagnosis of carcinomatous meningitis made?

Answer 15

Lumbar puncture for cytology.

Because of the lack of sensitivity, even multiple negative results do not rule out carcinomatous meningitis.

Question 16

What is the treatment for carcinomatous meningitis?

Answer 16

Whole brain radiation therapy.

Intrathecal chemotherapy is occasionally successful for a short time, depending on the underlying tumor type.

Question 17

What is SVC syndrome?

Answer 17

The clinical expression of the obstruction of blood return through the SVC

Question 18

What are the common signs of SVC syndrome?

Answer 18

Visible collaterals of the superficial thoracic vein, neck vein distention, facial edema, and tachypnea.

Occasionally, facial plethora, cyanosis, upper extremity edema, Horner syndrome, and vocal cord paralysis

Question 19

What is the most common radiographic finding in the SVC syndrome?

Answer 19

A right mediastinal mass

Question 20

Is SVC syndrome usually acutely life-threatening?

Answer 20

Not usually

Question 21

What is the treatment for SVC syndrome?

Answer 21

First, a biopsy sample of the mass is obtained for a definitive diagnosis because there are nonmalignant causes.

In malignant cases, both chemotherapy and radiation may be used depending on the type of cancer.

Question 22

What is the treatment for hypercalcemia?

Answer 22

• Aggressive hydration.
• Diuretics after aggressive IV hydration can enhance calciuresis.
• Bisphosphonates are effective and are commonly used after rehydration.

Question 23

What are some causes of hyperuricemia?

Answer 23

High-purine diet, tumor lysis syndrome, decreased uric acid excretion

Question 24

What are some of the consequences of hyperuricemia?

Answer 24

Renal insufficiency (urine becomes supersaturated with urate and crystals of uric acid), uric acid arthropathy, and gout

Question 25

What is the management of hyperuricemia?

Answer 25

• Prophylactic measures need to be undertaken before cytotoxic chemotherapy.
• Medications that lead to an elevated serum uric acid or that acidify urine are discontinued.
• Allopurinol is started, IV hydration is begun to maintain the urine output of 150–200 cc/h, and urine is alkalinized with sodium bicarbonate to a pH of 7–7.5.

Question 26

Which malignancies are the most common cause of the tumor lysis syndrome?

Answer 26

Large bulky tumors (>10 cm) that are responsive to chemotherapy (e.g., ALL, AML, high-grade lymphomas such as Burkitt lymphoma, Hodgkin disease, and SCLC)

Question 27

What are the electrolyte and metabolic abnormalities that occur with tumor lysis syndrome?

Answer 27

• Hypocalcemia
• hyperuricemia
• hyperkalemia
• hyperphosphatemia
• metabolic acidosis

Question 28

What causes renal failure in patients with tumor lysis syndrome?

Answer 28

Precipitation of urate crystals in the tubules

Question 29

How is tumor lysis syndrome treated?

Answer 29

• Hydration and alkalinization of the urine (the urinary pH is
  maintained at 7–7.5).
• Dialysis may be required.

Question 30

What prophylactic therapy should be used in patients with a large tumor burden who are at risk for tumor lysis syndrome?

Answer 30

• Allopurinol.

- The dose often needs to be adjusted for renal insufficiency in this setting.

Question 31

At what WBC count is the patient at significant risk for infection?

Answer 31

An absolute neutrophil count that is <1,000/mm^3 places the patient at the risk for infection. Patients with absolute neutrophil counts <500/mm^3 are at the greatest risk.

Question 32

What is the management of patients with significant neutropenia, fever, and no obvious source of infection?

Answer 32

• Panculture and broad-spectrum antibiotics (e.g., a penicillinase-resistant beta-lactam or third-generation cephalosporin + an aminoglycoside).
• The choice of antibiotic depends on the flora and sensitivities at the hospital (consider additional coverage for gram-positive organisms for severe mucositis).

Question 33

What is the management for patients with significant neutropenia, no obvious source, and fever for 2–5 days despite antibiotics?

Answer 33

If fevers persist after 2–5 days, then antifungal agents should be considered.

Question 34

What other treatment options are considered for patients with neutropenic fever?

Answer 34

Granulocyte colony-stimulating factor