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onco emergencies Flashcards

1
Q

tumour lysis syndrome

A

rapid lysis of tumour cells releases intracellular components

results in 
 Hyperuricemia
 Hyperkalemia
 Hyperphosphatemia
 AKI (uric acid and/or calcium phosphate crystals in the renal
tubules)
 Hypocalcemia
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2
Q

RFs tumor types

patient specific RFs

for tumor lysis syndrome

A 
o Large tumour burden
o Extensive marrow involvement
o ALL
o Burkitt lymphoma
o High chemosensitivity
o High proliferation rate
pt specific RFS
o Renal impairment 
 Pretreatment hyperuricaemia
 Hypovolemia/ Pretreatment diuretic use
 Pretreatment LDH high
 Urinary tract obstruction from tumor
o Pre-existing metabolic abnormalities are associated with TLS
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3
Q

Sx and signs of tumour lysis

A 
present 3-7 days post chemo
Symptoms
o	Nausea
o	Diarrhoea
o	Anorexia
o	Lethargy
o	Seizures
o	Altered mental status
o	Muscle cramps
Signs
o	Fluid overload
o	Haematuria
o	Tetany & paraesthesia
o	Weakness
o	Bronchospasm
o	Arrhythmias 
 Peaked T waves, QTc derangement
 Primary presentation of malignancy
 ‘Spontaneous tumor lysis’
o	AKI
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4
Q

Ix for TLS

A 
Urea and electrolytes
	Metabolic abnormalities: Hyperkalaemia, Hyperphosphatemia, Hyperuricaemia, Hypocalcaemia
o	Urine dip followed by MC&S
o	Full blood count
o	Serum lactate
o	Basic metabolic panel
o	Phosphorus
o	High Lactate dehydrogenase
o	ECG
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5
Q

define neutropenic sepsis

responsible pathogens

A

 Patient undergoing systemic anticancer treatment (SACT)
 Temp >38
 Neutrophil count < 0.5 x 10 9 per litre or lower
- reaches its lowest level 5 to 10 days after the last dose of chemotherapy

gram +ve cocci; indwelling plastic catheters promote colonisation
- staph aureus, staph epidermidis, enterococcus and streptococcus

fungal candida

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6
Q

Sx of neutropenic sepsis

signs

A 
Fever
 Symptoms related to a specific system
 cough, shortness of breath
 Drowsy
 Confused
signs
- Febrile
 Tachycardic and hypotensive
 Drowsy
 Impaired MMSE
 Signs of infection?
Don’t forget:
 Hickmann/Picc Line
 Skin wounds/ soft tissue
 Mouth
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7
Q

Ix of neutropenic sepsis

A 
Blood tests:
 FBC (with differential)
 U&Es/Renal profile
 LFTs (including albumin)
 Lactate
 CRP

Cultures:

  • Blood – central and peripheral
  • Urine

Swabs:
 Lines
 Wounds

ABG

imaging
CXR
AXR
CT/MRI

DDx
malig related fever
chemo related fever
PE

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8
Q

Mx of neutropenic sepsis

A
  • empirical IV ABx within one hour
  • > TAZOCIN
  • fluid resuscitation
  • consider catheterisation
  • if risk is low switch to oral ABx
  • GCSF on profoundly septic/neutropenic
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9
Q

pathophysiology of malignant spinal cord compression

A

 Usually caused by the collapse or compression of a vertebral
body that contains metastatic disease (arterial seeding)
 10% by direct tumour (paraspinal mass) extension into the
vertebral column
 Compression of cord initially causes oedema, venous congestion
and demyelination which are reversible
 Prolonged compression  vascular injury, cord necrosis and
permanent damage

BLT and kosher pickle

Ix
MRI whole spine

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10
Q

signs and Sx of malignant spinal cord compression

A 
back pain first and prolonged 
spinal or radicular pain
- exarcerbated by straight leg raising, coughing, sneezing or straining
- limb weakness
- sensory level
- bladder and anal sphincter dysfunction
diminishing performance status
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11
Q

examination of MSCC

A
  • Acute onset; flaccid paralysis
     Progressing over time
  • Spasticity (increased tone, clonus and hyperreflexia in limbs below
    level of MSCC
     Plantar reflexes up going (not cauda equina)
     Sensory loss with well defined dermatonal level
     Palpable bladder (urinary retention)

Ix full spinal MRI

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12
Q

if a pt comes with MSCC

A

Local pathway for rapid diagnosis, treatment,
rehabilitation and on-going care
 Educate high risk patients
 Pain suggestive of spinal mets; MRI within 1 week
 Signs MSCC; MRI within 24 hours
 Admit
 Bed rest with log-rolling
 Dexamethasone 16mg + PPI (unless ?lymphoma)
 Adequate analgesia
 Treatment within 24 hours of diagnosis

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13
Q

Mx of MSCC

A

Steroids improve functional outcome stat dex 16mg then 8mg BD til the imaging
 > 48hr no motor function; best supportive care, 1# RT for pain
 SURGERY - relieves compression, removes tumour, stabilises spine
- Continence preserved
- Reduced pain
- Greater degree of mobility
preserved
 Treatment of choice if fit and good prognosis (>3/12)

balloon kyphoplasty

 Good nursing care; care re pressure areas
 Analgesia
 Laxatives
 Bladder care
 Monitor BMs
 VTE prophylaxis
 Physiotherapy
 Occupational therapy
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14
Q

prognostic indicators of MSCC

A 
Multiple myeloma, lymphoma, or breast, prostate or renal cancers
 Good motor function at presentation
 Good performance status
 Limited comorbidity
 Single-level spinal disease
 Absence of visceral metastasis
 Long interval from primary diagnosis
 Also for biopsy or stabilisation
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15
Q

Radiotherapy for MSCC

A
  • Majority (extensive disease and poor physiological
    reserve)
     Delivered within 24 hour of confirmation
     Relieves compression of the spine and nerve roots by causing cell death in the rapidly dividing tumour tissue
     Relieves pain
     Stabilises neurological deficit
     Life expectancy often measured in months
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16
Q

what is SVCO

A
  • Obstruction of blood flow through the SVC
     Compression or occlusion of SVC
causes
SCLC/lymphoma 
lymphoma
post RT fibrosis
TB
17
Q

symptoms and signs of SVCO

A 
Sx
- Breathlessness (50%)
 Swelling of face and neck (40%)
 Trunk and arm swelling 
 Headache - worse in the mornings
- visual disturbance -  Hallucinations
- pulseless jugular venous distension
 A sensation of choking
 A feeling of head fullness
 Lethargy
 Chest pain
 Cough
 Dysphagia
 Cognitive dysfunction

 Seizures

Signs
Thoracic vein distension
(65%)
 Neck vein distension (55%)
 Facial oedema (55%)
 Increased RR (40%)
 Plethora 15%
 Cyanosis 15%
 Arm oedema 10%
 Advanced stages
 Laryngeal stridor
 Drowsy
 Coma and death
18
Q

Ix of SVCO

Mx

A 
URGENT CXR - mass - mediastinum or mass lesion in the lung
CT with contrast
Extensive collateralization
Intraluminal thrombus of
SVC
Evidence of extrinsic
compression

Mx
initial -> sit pt up -> OXYGEN & stat dose of dexamethasone steroids

acute stent - if not radio or chemo sensitive
chemotherapy - used for SCLC lymphoma and teratoma

radiotherapy

19
Q

hypercalcaemia

A
  • Most common in SCC (lung, H&N, kidney, cervix)
     Also seen in breast cancer and multiple myeloma
    Tumour secretion parathyroid hormone-related peptide (PTHrP)
    (80%)  increased bone resorption and renal reabsorption
prognosis 
 Most patients who develop hypercalcaemia have
disseminated disease
 Many die in < 3/12
 52 days for solid organ malignancy
 362 days for haematological malignancy
20
Q

features of hypercalcaemia

Ix

Mx

A

nausea and vomiting, anorexia
thirst
polydipsia, polyuria, lethargy, renal failure, acute pancreatitis
bone pain, abdominal pain, constipation, confusion and weakness.
ECG - short QT interval

Ix
ionised calcium

Mx
rehydration
 Rehydration first: at least 24 hours of normal saline
 Bisphosphonates:
e.g. 60-90mg pamidronate IV or IV zolendronic acid 4mg SYMPTOMATIC SEVERE
Can cause renal failure so must make sure properly
rehydrated first
Takes up to a week to work
 (Denosumab 120mg SC for refractory hypercalcaemia)
 Systemic treatment of malignancy

21
Q

Mx of tumour lysis

A

o Hydration
 Dextrose containing IV fluids at twice the maintenance rate. Keep urine-specific gravity <1.010 and urine output >100 mL/m2/hr.
o Hyperkalaemia- check ECG
 IV calcium gluconate, insulin/dextrose infusion and nebulised salbutamol. Cardiac monitoring advised on this
o Hyperphosphatemia
 Dietary restriction. Phosphate binders may be used. In severe cases, patients may require hemofiltration
o Hyperuricaemia
 Allopurinol inhibits xanthine oxidase to prevent formation of uric acid and should only be given PO.
 Rasburicase (synthetic uricase) concerts uric acid to more soluble allantoin. Use in high risk especially if uric acid >7.5 mg/dl. Don’t use if know G6PD as may result in methemoglobinemia
o Monitor potassium, calcium, phosphorus, uric acid and urinalysis closely
o Prophylaxis
 May take the form of oral hydration, IV hydration, allopurinol and rasburicase
o Haemofiltration
 Intractable fluid overload
 Refractory hyperkalaemia
 Hyperphosphataemia-induced symptomatic hypocalcaemia
 High calcium-phosphate product

22
Q

what is leukostasis

A

high white cell count, respiratory failure, intracranial haemorrhage and early death

occurs in pts with AML and ALL

high fever and papilloedema? retinal vein bulging, retinal haemorrhage and focal neurological deficits
thrombocytopenia

23
Q

Mx of leukostasis

A

Rapid cytoreduction is the initial treatment, ideally with induction chemotherapy, which can dramatically reduce the white cell count within 24 hours.

prophylaxis with allopurinol or raburicase high risk of tumour lysis syndrome

24
Q

SIADH

A

tumor cellls may secrete ADH esp small cell lung cancer

pt present with hyponatraemia

asymptomatic may cause
Depression and lethargy.
Irritability and other behavioural changes.
Muscle cramps.
Seizures.
Depressed consciousness leading to coma.
Neurological signs (such as impaired deep tendon reflexes and pseudobulbar palsy).

25
Q

cancers that can spread to the bones

A 
breast
prostate
lung
thyroid
melanoma
myeloma
renal

cancer (10 decks)

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