Metastatic Disease + Emergencies Flashcards
What is most common malignancy to cause spinal cord compression
What are common cancers that spread to bone in adults and in children
Breast Lung Prostate Myeloma Lymphoma Less commonly renal, thyroid, bladder, colon, melanoma
Children
- Ewings sarcoma
- Medullablastoma
- Neuroblastoma
Where in spine is affected / how does malignancy cause spinal cord compression
Usually vertebral body met causing vertebra collapse = common
Extension of extra-dural tumour into vertebral column = rare
20-30% will be at multiple level
What are features
Back pain = most common presentation
- Usually at level of compression
- Cervical / thoracic / night pain = worrying
- Worse coughing / lying flat
- Radiating round
Later signs LL weakness and arms if cervical Sensory loss and numbness Peri-anal numbness Autonomic - bladder/ bowel incontiennce - ALWAYS ASK Upgoing plantar
Remember
Neuro signs depending on level e.g. if posterior will cause dorsal column signs which is rare and loss of proprioception (off balance / +Ve Romberg)
At level of compression = LMN flaccid + radicular pain
Below lesion = UMN spastic and sensory loss
Spinal cord ends at L1/2 so if below this = LMN signs
If complete compression
Loss of all sensory
Bilateral UMN weakness
Bladder and bowel
If anterior
Partial loss of pain and temp
Bilateral UMN
Bladder and bowel
Can get cauda equine if below L1/2 as where spinal cord ends
What is back pain typically
Thoracic = 70% Radicular nerve pain Night pain Usually bilateral Sharp / shooting Worse with cough / sneezing / movement
Where is most likely lesion
Extradural vertebral body
If above L1
LMN at level and UMN signs below as nothing can get through
Sensory loss below lesions
If below L1
LMN signs as in cauda equine and no spinal cord
Perianal numbness
What are reflexes
Increase below lesion and absent at level
When do you consider
Any patient with Hx cancer and back pain
Or red flags
Do whole spine MRI
How do you manage cord compression
Best red - flat until spine stability assess with MRI
High dose oral dexamethasone + PPI cover
Pain relief
Urgent MRI whole spine 24 hours
Urgent spinal surgical referral / oncological / RT assessment
Consider proplhyatic VTE if reduced mobility
What is role of spinal surgery
Decompression and stabilisation with laminectomy
= gold standard
When is spinal surgery possible
Fit Acute onset paraplegia Low metastatic disease Isolated compression Good sensory and motor prior No Hx of cancer Fracture dislocation Radioresistant tumour
Often not possible due to frailty, bone destruction, multiple sites
What else can be given
Chemo if highly sensitive e.g. germ cell or lymphoma
What is supportive Rx of cord comrpession
Lie flat Catheter if retention Monitor bowel Physio BM monitoring DVT prophylaxis
How do you investigate
MRI whole spine = gold standard as 20-30% will have compression at multiple levels
Isotope bone
FBC, U+E, LFT, Ca, PSA, LDH
Myeloma screen
What is most common cause of SVC obstruction / SMS
Tumour pressing on vena cava or structures in mediastinum = 80%
Lung cancer = most common
- SCLC
- NSCLC
Non-Hodgkin’s Lymphoma
Could be the first presentation of cancer
What are other causes
Rarer malignant Neuroblastoma in children Kapsoi sarcoma Metastatic breast Germ cell
Non-malignant Aortic aneurysm Mediastinal fibrosis - TB / post RT Retrosternal goitre SVC thrombosis - polycythaemia, catheter, shunt,
What are features
Often develops over many weeks Dyspneoa = most common Orthopnoea Tachypnoea Swelling of face, neck, arm - worse morning and lying flat Headache - worse in morn due to cerebral oedema - Papilloedema = very late sign Pemperton sign - Distended neck veins / SOB / facial swelling = worsen when raise arm Stridor if life threatening airway compression Cough Chest pain Facial, neck and upper thoracic plethora Very ill / anxious Engorged neck and chest veins - pulseless Conjuncival and perioedema oedema Visual disturbance / papilloedema Dysphagia due to mediastinal compression Visual disturbance Peripheral cyanosis Pulseless jugular venous distension Increased JVP May have reduced GCS
Symptoms may improve as collateral veins develop
How do you investigate
Dx = usually clinical
If not life threatening then try to obtain diagnosis
Up to 60% do not have Dx of malignancy
CXR
- Mass
- Mediastinal LN
- Other signs of lung cancer e.g. pleural effusion
CT chest with thorax
- Define anatomy of obstruction and level
- Can do opportunistic biopsy
Superior vena cava venogram
Bronchoscopy if lung suspected (most likely)
How do you Rx
Sit patient up O2 sats and ABG Give O2 if needed High dose dexamethasone + PPI If life threatening airway compromise e.g. stridor insert stent under radiological guidance
Rx cause with chemo / RT
Balloon venoplasty or stunting for recurrent benign
Thrombolysis and anti-coagulation if due to thrombosis
What is most common life threatening disorder associated with malignancy
How do you work out
Hyperclacaemia
Bad prognostic indicator
Free Ca = measures Ca + (40-albumin x0.02) OR
For every 10g albumin is <40 add 0.2 to calcium
What causes
Bone mets increasing osteolytic activity
- Breast
- MM
- Prostate
- Also lymphoma / SCC
Or production of PTH / TNF / Il by tumour
- SCC of the lung
- T cell lymhpoma
Or tumour specific
- e.g. in myeloma reduced Ca excretion due to AKI by Bence Jones
Other causes of high calcium much less common and are only considered once malignancy / PTH ruled out
What are the features of hypercalcaemia
Dehydration - reduced sensitivity to ADH
Polyuria
Renal stones in chronic
AKI in acute
Bone pain
Osteoporosis in chronic
Weakness
Abdo pain - renal / pancreatitis Constipation N+V Anorexia Weight loss Peptic ulcer due to increased gastric secretion
Fatigue / lethargy Depression - chronic Psychosis Altered mental status / confusion Cognitive impairment Seizure Coma
In severe>3.5
HTN due to vasoconstriction - check Ca in HTN
Prolonged QT
Cardiac arrhythmia
What can hypercalcaemia be mistaken for
Terminal feature of cancer
How do you manage
Monitor Ca, phosphate and check PTH
Treat malignancy + liase with oncology
Supportive
- Avoid drugs that increase - thiazide / vit D
- Avoid sedatives as confuse patient
- Remove Ca from any parenteral
- Encouraging mobilisation
IV access
Rehydration with 4-6l of 0.9% saline = most important to improve flow through kidney
- Monitor U+E closely as Mg and K may fall - may need to add
IV biphosphonate if renal function normal but risk of hypoCa if on denosumab
Loop diuretic to increase excretion (only if overloaded as high complication)
Prophylactic VTE
What is rare management
What do you do if severe >3.5, coma, arrhythmia
Calcitnonin - IM or SC
- Increases excretion and bone resorption
- Very rarely used, works better for other causes
Octeroide
- Somatostatin analogue which reduced PTH
- Very rare
Steroids
Consider ITU with cardiac monitoring
Consider haemofiltration if severe renal failure and can’t use rehydration and biphosphonates
What does chemo result in
Neutropenia
Often day 7-14 days but can be 6 weeks
What causes increase risk
<1 x10 ^9 but extreme = -0.5 Long duration Catheter / central line Mucosal inflammation High dose chemo Stem cell transplant
What do you advise patients to do
Monitor for signs of infection
Seek medical help if temp >38.5 or <36
Two readings >38
What is febrile neutropenia and how do they present
Patient febrile - may have low temp Neutrophils <1 No harm-dynamic compromise Rigors Drowsy
What is neutropenic sepsis
Evidence of sepsis - hypo / tachy / prolonged CRT / reduced UO
Metabolic acidosis
Neutrophil <1
With or without fever
What are common causes
85% from gut / biliary / urine tract Gram -ve E.coli Klebsiella S.pneumonia Enterococci Staph Fungal in prolonged haem - candida / aspergillus
How do you take Hx and exam
Systematic - chest / GI / UTI / CNS / headache / skin / ENT Recent intervention Vital signs Full exam Try to determine source of infection
How do you investigate
FBC - risk of neutropenia / thrombocytopenia from chemo U+E - need for gentamicin LFT - sepsis / chemo affecting CRP - for response ABG - Lactate / acidosis Bone bloods if risk of hypercalcaemia Coag screen if DIC suspected due to sepsis Blood culture MSSU ECG
Depending on suspected infection CXR if resp Stool culture if diarrhoea Throat swab Sputum culture Skin swab LP CT if fungal suspected
How do you manage
ABCDE Keep patient in a side room LIase with oncology - may need dose adjustment - may consider G-CSF As emergency - SEPSIS 6 - Take cultures, measure lactate and UO - IV access - Fluid resus if dehydrated / tachycardia / low BP - O2 if indicated Broad spec Ax as per guidelines Cathterise and monitor UO and vital signs Inotropes / platelet transfusion etc SENIOR HELP May need ICU
What Ax in stage 1
As guidelines Piperacillin Tazobactum Gentamicin Consider vanc / metronidazole if penicillin allergy
When to you switch to stage 2
If febrile after 48 hours or deteriorating
What is stage 2
Meropenum unless culture suggest divergent
When do you change to oral
3 days IV Ax and improving
Oral ciprofloaxicin
What can you consider
G-CSF to boost neutrophil
What else do you give
Paracetamol
Anti-emetic
Catheter if hypotensive
How do you monitor response
Vital signs
Urine output
Daily FBC, U+E, CRP
How do you review treatment
Fluid input and output Vital signs Clinical exam U+E Temp, NP, pulse CRP + neutrphil
What may you need to do
Change chemo regimen
Who is at great risk of falling ill suddenly
Leukaemia patients esp AML
What are they at risk of
Infection
Bleeding
Hyperviscosity
What should you do
FBC, U+E, LFT, Ca, glucose, clotting
Consider CT if suspect CNS bleed
Hyperviscosity
If WCC. >100 thrombi may form in heart, brain and lung
When is G-CSF used
High risk of neutopenia Elderly Specific malignancy - NHL / ALL Previous neutropenia Combination chemo and RT
What is the issue with with cancer patients + fever
No neutrophils so typical symptoms of infection may not be present
Treat any acutely unwell child for infection until proven otherwise
What are early symptoms of raised ICP
Early morning headache
Vomiting - worse in morning
Tense fontanelle
Increased OFC
What are late signs of raised ICP
Constant headache Papilloedema Diplopia (VI palsy) Loss of upgaze - Parinaud Neck stiffness Status epilepticus Reduced GCS Cushings - Low HR - High BP - Irregular breathing / low RR
How do you investigate
CT = 1st line
MRI
Only do if safe
What do you do for raised ICP to palliate
Dexamethasone to reduce oedema and increase CSF flo
What are other options
Neurosurgery
- Ventriculostomy
- EVD
- VP shunt
What is tumour lysis
Cancer cells grow rapidly so after chemo / dexamethasone get rapid death and release of intracellular contents into plasma
Increased K, urate, phosphate
Low calcium
AKI - suspect in AKI and chemo regime
Risk of arrhythmia
When does it occur
Shortly after Dx if fast growing tumour or after Rx e.g. chemo
Can occur after RT / dexamethasone but more rare
Common in leukaemia and lymphoma and germ cell
What does it result in
Hyperkalaemia Hyper-phosphate Hyper-Mg Hyper-urate High LDH / AFP Hypo- calcium AKI due to increased CK / deposition of CaPO4 in tubules
What is required for Dx
Lab values +1 of Increased CK Seizure Arrythmia Sudden death As well as biochemical abnormality
How do you prevent and Rx
Prevent
IV fluid
IV allopurinol / urate aoxidase to decrease uric before chemo and a few days after
Monitor electrolytes in fast growing tumour
ECG
FLUIDS = mainstay
Diuresis
NEVER give potassium
Can give Rasburicase to decrease uric acid (enzyme that binds)
Treat hyperkalaemia
Renal replacement therapy
How do you treat hyperkalaemia
Ca Resonium in long term
Salbutamol
Insulin dextrose
RRT
If someone presents with features of hypercaclaemia how do you investigate
Hx - drugs + FH Bloods - Bone profile - Ca, phosphate, PTH - U+E - Myeloma - ALP - Amylase for pancreatitis - Glucose for polyuria etc. ECG Imaging for cause
How does hypercalcaemia cause AKI
Renal tubular damage
Leads to hypokalaemia, dehydration, increased Na excretion which causes renal vasoconstriction and AKI
Where are brain mets most common from
Lung = 50% Breast = 15% Melanoma Unknown primary Others = renal / colon
What is most common type of brain tumour
Brain mets
How can it present
Seizure
Focal neuro - dysphasia, UMN weakness, visual field, ataxia
Confusion
Personality chane
How do you investigate
MRI brain with contrast
What will MRI show
Multiple discrete well demarcated lesion Hypointense on T1 Hyperintense on T2 Marked gadolinium enhancement Considerable vaosgenic oedema
How do you manage
High dose dexamethasone with PPI cover
Symptom control e.g. seizure
Liase with oncology to Dx primary
What should be considered for Rx
Whole brain RT
Consider chemo if chemo-sensitive tumour - SCLC / breast
Consider neurosurgery - biopsy useful if unknown primary
