ONC Flashcards
list 5 key oncological emergencies
- neutropenic sepsis
- tumour lysis syndrome
- hypercalcaemia
- SVC obstruction
- metastatic spinal cord compression
What are oncological emergencies?
- Complications of known cancer
- Complications of treatment
- Emergency presentations of new cancers
Commonest organisms in febrile neutropenia
Gram +ve organisms commonest today
- Staphylococcus: aureus, coagulase negative
- Enterococcus
- Streptococcus: pyogenes, viridans, pneumoniae
- Corynebacterium pp
Gram –ve organisms commonest in 70s
E.coli, Klebsiella, Pseudomonas, Enterobacter
1st line abx in neutropenic sepsis
IV piperacillin/tazobactam 4.5 g QDS
Plus Amikacin
(in penicillin allergy give Meropenem 1g IV TDS)
2nd line abx in neutropenic sepsis
Meropenem 1g IV TDS
(if no response to 1st line in 48h or if the pt has a penicillin allergy )
Prevention of febrile neutropenia
- Dose reduction of chemotherapy
- Prophylactic GCSF
typically if risk with chemo regime is >20% - Prophylactic antibiotics
-> Not used routinely
-> Increased antibiotic resistance and C diff.
Mx of metastatic spinal cord compression
- Dexamethasone
- Pain control
- Bed rest/log role (spinal precautions).
- Prophylactic anticoagulation
- Contact the MSCC co-ordinator as soon as possible (but definitely within 24hrs).
- Quick management is vital, once neurological function is lost is may not return.
- neurosurg opinion
- +/- radiotherapy, chemotherapy
Prognosis in metastatic spinal cord compression
Many patients have a poor overall prognosis
what is 18-FDG
18-fluoro-deoxyglucose
T4 dermatome
at the level of nipples
S2 Dermatome
S2 dermatome is perineum and back of thigh/calf
1st line med for metastatic spinal cord compression
dexamethasone
(pred is not strong enough)
Causes of SVCO
Cancer responsible for >90%
- NSCLC (50%), SCLC (20%)
- Lymphoma (10%), other 7%
- GCT 3%
- 2-4% patients with lung ca develop SVCO
Non malignant cause e.g. CV catheter thrombosis
signs of SVCO
SOB, stridor
- upper limb and facial oedema
- facial swelling and erythema
neck vein engorgement
dilated superficial veins (e.g. on chest)
- distended neck and chest wall veins as a result of a collateral circulation developing
- arm swelling and distended arm veins
- papilloedema (a late sign)
- stridor (if severe)
- cyanosis (less common).
Mx of SVCO
- Dexamethasone
- +/- anticoagulation (if clot)
- Biopsy (if new presentation)
NB steroids may impact results so discuss with onc first if new presentation
- Stenting
If haemodynamically unstable and/or chemotherapy or radiotherapy not possible. - Chemotherapy
For lymphoma, germ cell and SLCL, response rate up to 80% - Radiotherapy
- Symptomatic improvement within 48hrs, effective in 50-95%, precludes subsequent biopsy.
Do pts with SVCO get cannon A waves?
No
Cannon ‘a’ waves in the JVP are associated with ventricular tachycardia and 3rd degree heart block; they are not seen in SVCO.
What are the commonest causes of SVCO?
- lung cancer
- non-Hodgkin’s lymphoma
Causes of hypercalcaemia of mlaignancy
- 80% tumour production PTHrP
- 20% Osteolytic bone mets
- 1% ectopic PTH secretion, Vit D secreting lymphomas
Mx of hypercalcaemia of malugnaancy
- Rehydration
Normal saline
Sufficient in mild cases (ca <3.0) - Review medication
Stop thiazides and Ca supplements - Bisphosphonates
Response within 2-4 days, Nadir 7-10 days, effective 90% - Investigations
PTH (?), PTHrP (?) - Refractory cases
Repeat bisphosphonates, calcitonin, steroids
With what elevated calcium level will you develop significant sx
> 3.0 mmol/L
severity of hypercalcaemia levels
Mild hypercalcaemia: 2.65–3.00 mmol/L.
Moderate hypercalcaemia: 3.01–3.40 mmol/L.
Severe hypercalcaemia: > 3.40 mmol/L.
adjusted calcium concentration
Abnormalities seen in TLS
↑ PO4
↑K
↓Ca2+
↑Urate
Acidosis
Resulting in AKI/potential for cardiac arrhythmias/seizures
What is TLS?
Tumor lysis syndrome
= group of metabolic abnormalities that can occur as a complication during the treatment of cancer, where large amounts of tumour cells are killed off (lysed) at the same time by the treatment, releasing their contents into the bloodstream.
Mx of TLS
- FLUIDS!
- ↑ PO4 - Phosphate binder, furosemide, mannitol
- ↑K - Insulin/glucose, Ca gluconate
-↓Ca2+ - Correct phosphate
- ↑Urate - Allopurinol or rasburicase
- Early discussion regarding dialysis/renal replacement therapy
Prevention of TLS
- Important in all intermediate/ high risk patients (e.g. high tumour burden with rapid response to treatment)
- Prophylactic treatment – e.g. allopurinol/rasburicase (test for 6GPD deficiency)
- Hydration
- Monitor electrolytes
How does alluporinol prevent TLS?
xanthine oxidase inhibitor
less uric acid produced
Which chemotherapy agent is associated with hypomagnesaemia?
cisplatin
What cancer is CA 15-3 a marker for?
breast cancers
(cancer antigen 15-3)
Which chemotherapy agent is associated with pulmonary fibrosis?
Bleomycin may cause pulmonary fibrosis
Which chemotherapy agent is known for causing cardiomyopathy?
doxorubicin
What is the commonest cause of SVCO?
small cell lung cancer
Which chemotherapy drug causes peripheral neuropathy?
vincristine
Which chemotherapy agent causes haemorrhagic cystitis?
Cyclophosphamide
Which opioids in severe renal impairment?
fentanyl or buprenorphine
What is the first line medication for confusion and agitation in palliative care?
oral haloperidol
