Oncological Emergencies Flashcards
What can cause a superior vena cava obstruction
Extrinsic
- Tumour compression
Intrinsic
- Tumour induced thrombosis - fast onset
- Foreign body such as line - can also trigger thrombosis
- Tumour within the vessel itself (e.g. Renal)
Which cancers are most associated with superior vena cava compression
Lung cancer is most common
Occurs in 5% of cases
Occurs in 2% of non-Hodgkin’s lymphoma
Most often manifests in patients with a malignant disease process within the thorax
List some benign causes of superior vena cava obstruction
Aneurysm
Goitre
Fibrosis - mediastinal
Infection
Symptoms of superior vena cava obstruction usually appear rapidly - true or false
True
Usually within 6 weeks
List symptoms of superior vena cava obstruction
Swelling of face, neck, one or both arms Distended veins Shortness of breath Cough Headache and CNS symptoms Lethargy Syncope Pemberton's sign - face goes red/congested when both arms raised
If only one arm is swollen in a patient with superior vena cava obstruction what does it suggest
That the obstruction is more distal
List some of the signs of superior vena cava obstruction seen on examination
Early stage - puffy neck, neck veins that don’t collapse
Later stage - distended veins in neck and chest, swelling in face, neck and arms
Advanced - injected conjunctiva and sedation
Benign tumours are more likely to cause superior vena cava obstruction than malignant ones - true or false
False
Malignancy is the cause in 85% of cases
Benign tumours like teratomas or goitres are only the cause in 12%
How do you manage superior vena cava obstruction when caused by a clot
Local thrombolysis with streptokinase/alteplase
Anticoagulation - LMW heparin for 5 days whilst starting warfarin
How do you manage extrinsic causes of superior vena cava obstruction
Chemotherapy - used for responsive tumours like SCLC, lymphoma etc
Radiotherapy - used for some other malignant causes/ to treat underlying cancer
SVC stent - gives rapid relief of symptoms but doesn’t treat cause
Steroids often prescribed but no evidence they help!
How can tumours cause spinal cord compression
Usually due to extravordal compression of spinal cord or cauda equina
1- can invade through the intervertebral foramina (common in retroperitoneal tumours)
2- can invade through the vertebral body (vertebra mets) into the epidural space
3- direct mets into the cord (rare)
4 - tumour induced vascular damage or compression of blood supply can lead to cord infarction
5 - can be due to paraneoplastic syndromes
List the most common malignant tumours to compress the spinal cord
Lung - commonly via the vertebral body
Breast - commonly via the vertebral body
Prostate
Multiple myeloma
Melanoma
Lymphoma - commonly via the intervertebral foramina
Renal cell
List the main symptoms of spinal cord compression
Pain - in spine
- severe, burning pain
- worse on coughing/straining/lying flat
- relieved by sitting
- radicular pain - can spread
Bowel changes - mainly constipation, some incontinence (sphincter disturbed)
Urinary retention
Loss of sexual ability
Weakness - bi or unilateral
Often new difficulty walking or climbing stairs
Sensory changes - loss of proprioception, light touch or pin prick
Numbness and weakness
How quickly do symptoms of spinal cord compression present
Usually over a longer time period
However, some neurological deficits come on rapidly (few hours) - especially in rapidly proliferating cancers
What imaging technique is used to diagnose spinal cord compression
Urgent MRI of full spine
When would you do an LP on someone with suspected spinal cord compression
If you suspect meningeal involvement
List some benign causes of spinal cord compression
Meningioma - benign tumour Haematoma Abscess Slipped disc Osteoporotic fracture of a vertebral body Spondylolithesis Guillain-BArre Plexus lesions Infection - spinal TB
How do you treat malignant spinal cord compression
Steroids - immediate dexa dose as holding measure (even if just suspected)
followed by oral bd
Aims to reduce oedema
Give with PPI or H2 antagonist
Analgesia - pain often severe so needs aggressive treatment
Surgery - resection of isolated mets
Radiotherapy - mainstay of treatment (with or without surgery)
Chemo - used for very sensitive tumours, usually used after RT due to rapid effects
Treat the cancer too!
What is the definition of neutropenic sepsis
Fever in patient with neutropenia
Fever (>38°C) for ≥2h when neutrophil count < 0.5 x 10^9/L
Or other clinical signs of infection
Neutropenia is most common immediately after chemo - true or false
False
It is most common 10-14 days post chemotherapy (but can occur within 7 days for taxanes)
How does neutropenic sepsis present
Symptoms may be minimal - low threshold for diagnosis
OR chills, fevers, rigors, sore throat, aches
How do you treat neutropenic sepsis
Septic screen and sepsis 6 to start - emergency
Treatment with tazocin and gentamicin
Consider penicillin allergy and renal function
Can tailor antibiotics once the cultures come back
How does chemo cause neutropenic sepsis
Suppression of the bone marrow = leads to decreased white cell (inc. neutrophils) production and therefore increased infection risk
Cells in the GI tract mucosa are affected by chemo as they are rapidly dividing - this can allow some gut flora to cross into the blood (due to comprimised mucosal layer) and cause an infection
List sources of infection in neutropenic sepsis
In most cases the cause is not found - positive blood culture is the only sign
Lungs, GI tract, urinary tract are common sites
Central venous access devices such as PIC lines are another potential source
How long should it take for bacterial infection to respond to antibiotics in neutropenic sepsis
2-7 days
If patient has fevers past this point then consider fungal infection or maybe viral
Which surgical technique is used for malignant cord compression
Anterior laminectomy – allows better removal of tumour and re-construction of vertebral body
When is radiotherapy used alone for treatment of cord compression
Majority of cases
- In patients unfit for surgery
- Those with multi-level disease
- With disease elsewhere that may or may not be controlled
- In those with some residual neurological function
How is radiotherapy given for malignant cord compression
20Gy in 5 # over 1 week
May use higher dose if post op or if only site of metastasis
Direct field, single posterior
Prescribed to the depth of the cord
Radiotherapy for cord compression has an immediate benefit - true or false
False
No immediate effect
Some neurological improvement over following weeks; improved pain control; or halting of further deterioration
What is radicular pain
Band like burning pain sometimes with hypersensitivity
Seen in cord compression
Which patients get surgery for malignant cord compression
If fit for surgery
If only one vertebral level/region involved
No widespread mets
Radio-resistant primary e.g. renal, sarcoma.
Previous RT to site.
Unknown primary - take tissue sample
Chemotherapy is used to treat malignant cord compression in which cases
In theory can be used for the very sensitive tumours:
- Lymphoma.
- Teratoma.
- SCLC (maybe)
Not usually used alone
What are the initial investigations for SVC obstruction
CXR – is there a mass?
Venogram – is there a clot?
CT Chest
What can cause malignant hypercalcaemia
Humoural - often mediated by PTH related protein (paraneoplastic seen in lung cancer)
Local bone destruction/invasion - especially in lung, breast and myeloma
Tumour production of vitamin D analogues (calcitriol) -especially lymphomas.
How do cancer patients with hypercalcaemia present
Nauseated, anorexic Weight loss Thirsty - dehydration Pass lots urine (polydypsia and polyuria). Constipated Abdominal pain Depression Confused. Poor concentration, drowsy, lethargy Bone pain
How do you investigate hypercalcaemia
Calcium level - symptoms usually start over 2.6
Albumin to correct calcium
Urea and electrolytes – looking for dehydration.
Phosphate - low in hyperparathyroidism
If no known malignancy – myeloma screen
How do you treat malignant hypercalcaemia
Rehydration first - need several litres of normal saline (careful if risk of heart failure)
Bisphosphonates - usually zoledronic acid
Systemic management of malignancy
Why must you make sure a hypercalcaemic patient is hydrated before treating with bisphosphonates
Can cause renal failure so must make sure properly rehydrated first.
What is pericardial tamponade
Pericardial effusion develops and compresses ventricle
This reduces cardiac output and collapses the right atrium increasing venous back pressure.
What can cause a pericardial effusion
Malignant.
Trauma – injury, post-op, iatrogenic e.g. pacing line.
Infection – TB, viral.
Post MI.
Connective tissue disease e.g. SLE, Rheumatoid.
Drugs e.g. hydralazine, isoniazid.
Uraemia.
How does malignant pericardial tamponade present
Primarily shortness of breath. Cough Fatigue. Palpitations. Symptoms of pericarditis (chest pain improved by sitting forward). Symptoms of advanced cancer.
Jugular venous distension.
Pulsus paradoxus -venous return drops when intra-thoracic pressure raised (breathing in)
Soft heart sounds or pericardial rub.
Poor cardiac output – tachycardia with low BP and poor peripheral perfusion
How do you investigate a malignant pericardial tamponade
CXR - enlargement of cardiac silhouette (globular)
ECG - reduced complex size (low QRS voltage)
Echocardiogram – rim of pericardial fluid.
Cytology of pericardial fluid
How do you treat a malignant pericardial tamponade
Pericardiocentesis – drain pericardium.
Pericardial window – operation to allow pericardial fluid to drain into pleural cavity.
Systemic management of malignancy.
Why are PEs common in malignancy
Malignancy is a pro-thrombotic state
How does PE present
Acute deterioration in SOB Tachypnoea Tachycardia Cough Haemoptysis Low pa CO2 - blowing it off Pleuritic chest pain Unilaterla leg swelling
How do you manage a PE
Support patient – O2, IV fluids, resuscitation if necessary
Anticoagulation
For most cancer patients this is LMWH for 6 months
Also treatment dose fragmin
Consider Rivoroxaban if recurrent DVTs / PE
List some metabolic oncological emergencies
Hypercalcaemia - most common
Tumour lysis syndrome
SIADH
List some neurological oncological emergencies
Spinal cord compression
Brain mets leading to raised ICP
List some cardiovascular oncological emergencies
Malignant pericardial effusion
SVC obstruction
List some haematological oncological emergencies
Hyperviscosity due to dysproteinaemia
Hyperleukocytosis
DIC
List some infectious oncological emergencies
Neutropenic fever and sepsis
What is a paraneoplastic syndrome
A consequence of cancer that is not due to the local presence of cancer cells
Mediated by hormones or cytokines excreted by tumour cells or by an immune response against the tumour
Which cancers most commonly cause a paraneiplastic syndrome
Lung
Breast
Ovaries
Lymphoma
Which cancers most commonly cause malignant hypercalcaemia
Myeloma Squamous Cell Lung Cancer Renal Cancer Breast Cancer Prostate Cancer (NB: Very rarely) Squamous Cell Head and Neck Cancer Leukemia
How can hypercalcaemia affect an ECG
Bradycardia Short QT interval Prolonged PR interval Wide T wave Atrial or ventricular arrythmias
Which cancer is associated with SIADH
Small cell lung cancer
How do you treat SIADH
Treatment of cancer
Fluid restriction (1 – 1.5 L daily)
Demeclocycline
How can brain mets present
New onsetheadaches Cognitive, personality, and behavioral changes Nausea andvomiting Memory loss Increased intracranial pressure Paraesthesias Vision disorder Bells palsy Ataxia Seizures
Which cancers often cause a malignant pericardial effusion
Lung cancer Breast cancer Lymphoma Leukemia Melanoma
List common pathogens which cause neutropenic sepsis
Escherichia coli Pseudomonas aeruginosa Acinetobacter baumannii Klebsiella pneumoniae Coagulase positive/negative staphylococci
What is the definition of an oncological emergency
Broad term
Typically a pathology that will be irreversible and harmful if not treated within minutes- days
When does tumour lysis occur
Any time after the introduction of anti-cancer therapy
What causes tumour lysis syndrome
Chemo or other treatment causes rapid breakdown of tumours/cancer cells
They release their intracellular matierials including K+ etc.
This disturbs the electrolyte balance and upsets the kidneys
Tumour lysis syndrome is associated with which cancers
Lymphomas
Germ cell tumours
Those that respond well to treatment
List risk factors for tumour lysis syndrome
Specific tumour types - AML, ALL, Burkitt’s lymphoma are all high risk
Nephrotoxic drugs
Dehydration
History of renal disease
Those that are high risk can be given prohlyaxis
What prophylaxis is available for tumour lysis syndrome
Low risk - hydration (3L a day) +/- allopurinol
Intermediate risk - hydration (3L a day) and allopurinol
High risk - Hydration for up to 7 days post-chemo and rasburicase IV
How does tumour lysis syndrome present
High K+, phosphate, urate Low calcium Oliguria AKI Nausea and vomiting Cardiac arrhythmia Seizure Confusion
How do you manage tumour lysis syndrome
Urgent treatment of any arrhythmia and hyperkaelamia
Fluid resuscitation
Close monitoring of input/output
Correct electrolyte abnormalities
How do you differentiate between hyperparathyroidism and hypercalcaemia of malignancy
Check PTH level
Will be high in hyperparathyroidism and low in cancer
Also check calcium and phosphate
How does raised ICP present
Headache - chronic/daily - Worse on coughing, leaning forward etc Often associated with nauses Weakness, sensory changes Personality change Seizures
What can cause raised ICP in cancer patients
Brain mets - lung, breast, prostate etc.
Bleeds from the tumour - may have been asymptomatic on its own
How do you treat intracranial mets
Steroids started immediately - reduces oedema and symptoms
Surgery - role in limited disease
With large lesions,, debulking can prolong survival
Radiotherapy
How do you innvestigate SVCO
CXR - may see widened mediastinum or the mass lesion
CT chest - shows location, severity and associated pathology (e.g. mass or thrombus)
Which organisms are the main cause of neutropenic sepsis
Gram negatives
What can trigger opiate toxicity
Over medication
Renal failure
Frailty and intercurrent illness
How does opiate toxicity present
Pinpoint pupils
SLow, shallow breathing
Falling asleep or loss of conscioussness
Blue fingers etc
How can you severe opiate toxicity
Administer naloxone - if in respiratory depression
If mild toxicity just withdraw opiate and monitor
Which cancers can lead to malignant bowel obstruction
Disseminated intraabdominal cancers
e.g. ovarian, peritoneal
Others include, colon, gastric, breast with mets
How does malignant bowel obstruction present
Abdominal pain Distension No bowel sounds present No bowel movement - absolute constipation Vomiting Bloating
How do you diagnose malignant bowel obstruction
AXR - dilated bowel loops and air/fluid level
CT abdo/pelvis to assess the cause
How do you manage malignant bowel obstruction
Usually palliative at this point
Make them NBM
Give IV fluids and electrolytes Decompression and bowel rest - NG tube
Analgesia
Can give subcut steroids to reduce oedema
Prokinetcics to stimulate peristalsis - e.g. metoclopramide
May do debulking, resection etc to relieve symptoms
