Oncological Emergencies

Question 1

Neutropenic sepsis diagnosis:

Answer 1

A person with neutropenia of 0.5 x 10^9 or lower (or risk factors of neutropenia) with a known infection and temperature >38 degrees, although a person can present with hypothermia.

Question 2

Neutropenic sepsis causes:

Answer 2

Commonly, 7-10 days post chemotherapy- bone marrow suppression therefore low neutrophil count.
May also occur with haemopoietic stem cell transplant, immunosuppressive drugs, i.e. azathioprine, methotrexate, sulfasalazine, BM failure, etc.

Question 3

Netropenic sepsis RF:

Answer 3

Neutropenia, especially prolongued.
Chemotherapy
Corticosteroids
Extremes of age
Previous surgery
Advanced malignancy

Question 4

Neutropenic sepsis management:

Answer 4

In GP need to contact 999 straight away.
In secondary care- start sepsis 6 within the first hr.
Important to start anti-pseudomonal abx therapy in neutropenic sepsis therefore consider piperacillin/tazobactam as first line abx.
Advice the pt about neutropenic sepsis and reducing infection risk post chemotherapy.

Question 5

Neutropenic sepsis complications:

Answer 5

Death
Organ failure (commonly AKI)
Delayed treatment
Anxiety 
Opportunistic infections

Question 6

Metastatic Spinal Cord Compression (MSCC) diagnosis:

Answer 6

History and examination.
Most present with back pain initially, (if known cancer should take very seriously).
Secondly get motor weakness, followed by sensory weakness (at diagnosis).
May have autonomic deficits also.
Diagnose with full spine MRI (can have several points of impingement).

Question 7

MSCC causes:

Answer 7

All cancers can cause this, especially breast, prostate and lung.
Either due to; a mets to the vertebrae or due to a paravertebral tumour causing compression.
The cord injury is due to direct compression or occlusion of the vasculature of the cord, secondary to a tumour.

Question 8

MSCC Management:

Answer 8

Treatment should be started when MSCC is suspected, preferably after imaging.
If delay in imaging then start on dexamethasone- IV 10-16mg, followed by 4mg every 4-6hrs.
Radiation therapy is the mainstay treatment.
Can also consider decompressive surgical procedure.

Question 9

TLS causes:

Answer 9

Massive cell death, i.e. in response to chemotherapy. Cell death therefore hyperK+, increase LDH, dead cells release phosphate therefore hyperPO which causes hypoCa2. Also, breakdown of nucleic acids will lead to hyperuricaemia; can deposit in the kidney giving AKI, this combined with hypovolaemia can lead to acute tubular necrosis.

Question 10

Tumour Lysis Syndrome diagnosis:

Answer 10

Symptoms if present include; seizures, reduce urine output, arrhythmias, sudden death etc.
HyperK+
Hyperuricaemia
HypoCa"+
HyperPO
Increased LDH

Question 11

Hypercalcaemia Management:

Answer 11

Initial treatment is IV saline, since pts usually hypovolaemic.
Follow with bisphosphonates; take 2-3 days for the full affect.
May need calcitonin as a ‘rescue’, i.e. for quick reduction in Ca2+, although stay cautious of tachyphylaxis.
Glucocorticoids are useful when the cause is overproduction of calcitriol.

Question 12

TLS RF:

Answer 12

High tumour burden
Treatment sensitive tumour
High tumour grade with rapid cell turnover
Pre-existing renal condition
Specific cancers inc- Burkitt’s Lymphoma, ALL, Lymphoblastic NHL.

Question 13

TLS management:

Answer 13

Hypovolaemia- Fluids
Hyperuricaemia- Give allopurinol as prophylaxis (esp if high risk), give rasburicase to break down already formed uric acid.
HyperPO- Reduce phosphate intake, phosphate binders.
HyperK+- Insulin + dextrose mix, Ca gluconate, dialysis.
HypoCa2+- Ca gluconate.

Question 14

TLS management:

Answer 14

Hypovolaemia- Fluids
Hyperuricaemia- Give allopurinol as prophylaxis (esp if high risk), give rasburicase to break down already formed uric acid.
HyperPO- Reduce phosphate intake, phosphate binders, if severe then haemodialysis.
HyperK+- Insulin + dextrose mix, Ca gluconate, dialysis.
HypoCa2+- Ca gluconate only treat if symptomatic.

Question 15

Superior Vena Cava Syndrome (SVCS) diagnosis:

Answer 15

Can be acute or more insidious; symptoms inc dyspnoea, orthopnoea, cough, headache, sensation of fullness in the H+N.
Physical exam will show face/neck/arm swelling, and dilated chest vessels.
Investigate with CT Chest + IV contrast.

Question 16

Superior Vena Cava Syndrome (SVCS) diagnosis:

Answer 16

Can be acute or more insidious; symptoms inc dyspnoea, orthopnoea, cough, headache, sensation of fullness in the H+N.
Physical exam will show face/neck/arm swelling, and dilated chest vessels.
Investigate with CT Chest + IV contrast.

Question 17

SVCS management:

Answer 17

Very symptomatic- endovascular stenting of SVC.
Secondary to lymphoma- glucocorticoid steroids for symptom relief.
Thrombus induced- anticoaggulation.
Radiation therapy useful for all pts but slow symptomatic relief.
Supportive treatment through oxygen, elevating the head, cautious use of diuretics if laryngeal oedema.

Question 18

SVCS management:

Answer 18

Very symptomatic- endovascular stenting of SVC.
Secondary to lymphoma- glucocorticoid steroids for symptom relief.
Thrombus induced- anticoagulation.
Radiation therapy useful for all pts but slow symptomatic relief.
Supportive treatment through oxygen, elevating the head, cautious use of diuretics if laryngeal oedema.