Oncological Emergencies

Question 1

What is this a presentation of?

High temperature, raised neutrophils, 6 weeks of chemotherapy, unwell.

Answer 1

Neutropenic sepsis

Question 2

How is suspected neutropenic sepsis investigated?

Answer 2

Cultures, MSU, swabs from lines, chest x-ray, respiratory viral PCR, atypical pneumonia (legionella, pneumococcal).

Question 3

What is the management of neutropenic sepsis?

Answer 3

1. Cultures before tazocin, sepsis 6.

2. If without fever - granulocyte colony stimulating factor (filgrastim)

Question 4

What is the cause of spinal cord compression in cancer metastases?

Answer 4

Collapse of vertebral body due to metastases.

Question 5

What is this a presentation of?

Back pain, limb weakness, difficulty walking, sensory loss, bladder/bowel dysfunction, previous cancer.

Answer 5

Spinal cord compression due to metastases

Question 6

What is the management of spinal cord compression in metastases?

Answer 6

1. Admit and urgent MRI whole spine
2. Dexamethasone, prophylaxis PPI cover, BM monitoring
3. VTE prophylaxis if needed (stocking and LMWH)
4. Refer to oncology MDT and radiotherapy commonly

Question 7

What is SVC syndrome and what causes it?

Answer 7

1. Reduced venous return from the head, neck, and upper limbs.
2. Lung cancer, lymphoma, breast cancer, thymoma.

Question 8

What is this a presentation of?

Dyspnoea, orthopnoea, stridor, plethora, oedema of faces and arm, headache, engorged neck vein, raised JVP.

Answer 8

SVC syndrome

Question 9

What is Pemberton’s sign and what causes it?

Answer 9

1. Raise hands above head and get facial plethora

2. SVC syndrome

Question 10

What is the management for SVC syndrome?

Answer 10

1. Sit up, sats and ABG, give oxygen if hypoxic.
2. Dexamethasone and radiotherapy if life threatening
3. CT is investigation of choice
4. Balloon venoplasty and SVC stenting for rapid relief of symptoms.

Question 11

What is the most common metabolic abnormality in cancer?

Answer 11

Malignant hypercalcaemia

Question 12

What are the causes of malignant hypercalcaemia?

Answer 12

1. Parathyroid Hormone-Related Peptide

2. Local osteolysis

Question 13

What is this a presentation of?
Weight loss, anorexia, nausea, polydipsia, polyuria, constipation, abdominal pain, weakness, confusion, cancer diagnosis.

Answer 13

Malignant hypercalcaemia

Question 14

What is the management of malignant hypercalcaemia?

Answer 14

1. Aggressive rehydration
2. Bisphosphonates if eGFR >35 (4mg IV zoledronic acid over 30 minutes)
3. If poor GFR, SC denosumab

Question 15

What is this a presentation of?
Headache worse in morning/on coughing/bending over, focal neurology, photophobia, ataxia, seizure, nausea, vomiting, papilloedema.

Answer 15

Brain metastases

Question 16

What is the management of brain metastases?

Answer 16

1. Urgent CT/MRI
2. Dexamethasone
3. Discuss with neurosurgery

Question 17

What is this a presentation of?

Hyperkalaemia, hyperuricaemia, hyperphosphataemia, hypocalcaemia, cancer.

Answer 17

Tumour lysis syndrome

Question 18

What is there a risk of in tumour lysis syndrome?

Answer 18

Arrhythmias and AKI

Question 19

What is the management for tumour lysis syndrome?

Answer 19

1. Acute hyperhydration to dilute and excrete uric acid
2. 10ml 10% calcium gluconate (cardiac stabilisation)
3. 10U actrapid in 50ml 50% dextrose
4. Check glucose every hour, monitor K+, pH, HCO3
5. If acidotic give IV NaHCO3
6. Prophylaxis allopurinol (xanthine oxidase inhibitor) to inhibit uric acid production.

Question 20

What causes hyperviscosity syndrome?

Answer 20

Increased serum protein (high Ig in myeloma/Waldenstrom’s macroglobulinaemia) or hyperleukocytosis (leukaemia)

Question 21

What is this a presentation of?

Mucosal bleeding, blurred vision, neurological disturbance.

Answer 21

Hyperviscosity syndrome

Question 22

What is the management for hyperviscosity syndrome?

Answer 22

Urgent plasmapheresis/leukopheresis