Oncological Emergencies Flashcards
1
Q
What is neutropenic sepsis as described by NICE?
A
A neutrophil count of 0.5 × 10^9 per litre or lower, plus one of the following:
- Temperature ≥ 38°C OR
- Other signs or symptoms consistent with significant sepsis
- Patient undergoing systemic anticancer treatment (SACT)
2
Q
What are some of the causes of neutropenia?
A
Recent chemotherapy
- Malignant bone marrow infiltration
- Extensive radiotherapy
- Bone marrow failure secondary to non-malignant disease (e.g. aplastic anaemia)
- Hypersplenism
- Megaloblastic anaemia
- Drug-induced (e.g. clozapine)
3
Q
What are some of the RFs for neutropenic sepsis?
A
- Patients over the age of 60
- Advanced malignancy
- Previous neutropenic sepsis
- Mucositis
- Poor performance status
- Significant co-morbidities (the risk increases further in the presence of multiple co-morbidities)
- Indwelling central venous catheters
- Corticosteroids (causes immunosuppression)
- Prolonged hospital admission
- Severe or prolonged neutropenia
4
Q
What are some of the clinical signs of neutropenic sepsis?
A
- Hypotension: URGENT ATTENTION – involve outreach and consider escalation above ward care
- Fever
- Reduced urine output
- Altered conscious level or confusion/ impaired MMSE
- Mottled/ashen appearance
5
Q
What investigations should be performed for neutropenic sepsis?
A
Bedside investigations
§Urinalysis: to look for urinary tract infection
§ECG: should be performed in all acutely unwell patients.
§Capillary blood glucose: to exclude hypoglycaemia.
Laboratory investigations
- Baseline blood tests (FBC, U&E, coagulation, CRP, LFTs): white cells may be low or raised and CRP may also be raised. Serum lactate, Group and save,
- Cultures (central and peripheral); urine
- ABG
- Microbiological cultures: wounds, urine, stool, sputum, and line tip (if indwelling line infection suspected).
- Viral respiratory swab: if viral respiratory infection suspected.
Imaging
§Chest X-ray: to look for evidence of pneumonia.
§High-resolution chest CT: if fungal pneumonia is suspected.
§Abdominal ultrasound or CT abdomen: if biliary or abdominal infection suspected.
Other investigations: Bronchoalveolar lavage: if an atypical chest source is suspected, such as Pneumocystis jirovecii.
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6
Q
How is neutropenic sepsis managed?
A
- The sepsis six care bundle should be completed.
- Pharmacological
- 1st line : IV piperacillin with tazobactam (tazocin). Some guidelines may also recommend the administration of gentamicin
- 2nd line (e.g. penicillin allergy) may include IV meropenem (dependent on local guidelines)
- Pharmacological
- Other:
- Additional anti-microbial cover (e.g. teicoplanin) for gram-positive organisms may be required for patients with indwelling central venous catheters.
- Anti-fungal treatment may be considered when the fever persists beyond 4 – 6 days
-
Granulocyte-colony stimulating factor: Recombinant granulocyte-colony stimulating factor (G-CSF) may be used for both prophylaxis and treatment of neutropenia to reduce the risk of neutropenic sepsis.
- Consider in patients who are profoundly septic/neutropenic
- Mechanism: stimulates bone marrow to produce neutrophils and may form part of specific chemotherapy regimens. E.g. filgrastim
7
Q
What are some of the complications of neutropenic sepsis?
A
- Single or multi-organ failure (e.g. renal failure, heart failure and acute respiratory distress syndrome)
- VTE (e.g. PE), DIC, Opportunistic or hospital-acquired infections, Delirium, Psychological complications (e.g. anxiety regarding future infections and chemotherapy treatment)
- Delays in chemotherapy leading to worse cancer outcomes
8
Q
What cancers are most commonly associated with metastatic spinal cord compression?
A
- lung, prostate, breast, myeloma, melanoma.
9
Q
What is the incidence of MSCC?
A
- 3–5% of cancer patients have spinal metastases.
- ~15% of those with advanced cancers develop metastatic spinal cord compression
- 10% of patients with spinal mets develop MSCC
- Incidence may be as high as 19% in breast/prostate/lung cancer
- Breast, prostate and lung account for > 60% of cases
10
Q
How does MSCC arise?
A
- Collapse or compression of a vertebral body due to metastases (common), direct extension of a tumour into vertebral column (rare).
- 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
11
Q
Where (location) does MSCC arise?
A
- 30-50% have > 1 area involved
- Below L2 vertebra =cauda equina compression of peripheral nerves and not spinal cord
12
Q
What are some of the signs and sx of MSCC?
A
- Back pain ~95%. – earliest and most common
- Nocturnal pain and pain with straining.
- Spinal or radicular pain (8/10)
- Red flag: cervical/thoracic pain.
- Other: limb weakness, difficulty walking, sensory loss, bowel/bladder dysfunction
- Sensory loss in the saddle area
- Neurological signs: depend on the level of the lesion.
- Lesions above L1 – usually UMN signs in the legs and a sensory level.
- Lesions below L1 - usually cause LMN signs in the legs and perianal numbness. Tendon reflexes tend to be increased below the level of the lesion and absent at the level of the lesion
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13
Q
What features can be seen of MSCC on clinical examination?
A
- 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)
14
Q
How is MSCC managed?
A
- Admit for bed rest with log rolling – lie pt flat
- Ix: Urgent (within 24h) MRI of whole spine.
- Pharmacological: Dexamethasone 16mg/24h PO + PPI (unless? lymphoma) for prophylatic gastroprotection and blood glucose monitoring.
- Thromboprophylaxis (compression stockings, LMWH: Consider if reduced mobility
- Urgent referral to clinical oncology/cancer MDT
- Radiotherapy is the commonest treatment and should be given within 24 hours of MRI diagnosis.
-
Decompressive surgery (Balloon kyphoplasty) Treatment of choice if fit and good prognosis (>3/12)
-
Prognostic indicators: 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
-
Prognostic indicators: Multiple myeloma, lymphoma, or breast, prostate or renal cancers
- Urinary cathetarisation
- Supportive: Good nursing care; care re pressure areas; Analgesia; Laxatives; Bladder care; Monitor BMs; VTE prophylaxis; Physiotherapy; Occupational therapy
15
Q
In which cancers is metastatic hypercalcaemia most commonly seen?
A
- Most common in SCC (lung, H&N, kidney, cervix).
- Also seen in breast cancer and multiple myeloma
