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Oncology > Oncological Emergencies > Flashcards

Oncological Emergencies Flashcards

1
Q

What can cause a superior vena cava obstruction

A

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)
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2
Q

Which cancers are most associated with superior vena cava compression

A

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

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3
Q

List some benign causes of superior vena cava obstruction

A

Aneurysm
Goitre
Fibrosis - mediastinal
Infection

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4
Q

Symptoms of superior vena cava obstruction usually appear rapidly - true or false

A

True

Usually within 6 weeks

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5
Q

List symptoms of superior vena cava obstruction

A 
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
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6
Q

If only one arm is swollen in a patient with superior vena cava obstruction what does it suggest

A

That the obstruction is more distal

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7
Q

List some of the signs of superior vena cava obstruction seen on examination

A

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

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8
Q

Benign tumours are more likely to cause superior vena cava obstruction than malignant ones - true or false

A

False
Malignancy is the cause in 85% of cases
Benign tumours like teratomas or goitres are only the cause in 12%

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9
Q

How do you manage superior vena cava obstruction when caused by a clot

A

Local thrombolysis with streptokinase/alteplase

Anticoagulation - LMW heparin for 5 days whilst starting warfarin

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10
Q

How do you manage extrinsic causes of superior vena cava obstruction

A

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!

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11
Q

How can tumours cause spinal cord compression

A

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

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12
Q

List the most common malignant tumours to compress the spinal cord

A

Lung - commonly via the vertebral body
Breast - commonly via the vertebral body
Prostate
Multiple myeloma

Melanoma
Lymphoma - commonly via the intervertebral foramina
Renal cell

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13
Q

List the main symptoms of spinal cord compression

A

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

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14
Q

How quickly do symptoms of spinal cord compression present

A

Usually over a longer time period

However, some neurological deficits come on rapidly (few hours) - especially in rapidly proliferating cancers

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15
Q

What imaging technique is used to diagnose spinal cord compression

A

Urgent MRI of full spine

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16
Q

When would you do an LP on someone with suspected spinal cord compression

A

If you suspect meningeal involvement

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17
Q

List some benign causes of spinal cord compression

A 
Meningioma - benign tumour 
Haematoma 
Abscess 
Slipped disc 
Osteoporotic fracture of a vertebral body 
Spondylolithesis 
Guillain-BArre 
Plexus lesions 
Infection - spinal TB
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18
Q

How do you treat malignant spinal cord compression

A

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!

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19
Q

What is the definition of neutropenic sepsis

A

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

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20
Q

Neutropenia is most common immediately after chemo - true or false

A

False

It is most common 10-14 days post chemotherapy (but can occur within 7 days for taxanes)

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21
Q

How does neutropenic sepsis present

A

Symptoms may be minimal - low threshold for diagnosis

OR chills, fevers, rigors, sore throat, aches

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22
Q

How do you treat neutropenic sepsis

A

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

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23
Q

How does chemo cause neutropenic sepsis

A

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

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24
Q

List sources of infection in neutropenic sepsis

A

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

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25
Q

How long should it take for bacterial infection to respond to antibiotics in neutropenic sepsis

A

2-7 days

If patient has fevers past this point then consider fungal infection or maybe viral

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26
Q

Which surgical technique is used for malignant cord compression

A

Anterior laminectomy – allows better removal of tumour and re-construction of vertebral body

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27
Q

When is radiotherapy used alone for treatment of cord compression

A

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
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28
Q

How is radiotherapy given for malignant cord compression

A

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

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29
Q

Radiotherapy for cord compression has an immediate benefit - true or false

A

False
No immediate effect

Some neurological improvement over following weeks; improved pain control; or halting of further deterioration

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30
Q

What is radicular pain

A

Band like burning pain sometimes with hypersensitivity

Seen in cord compression

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31
Q

Which patients get surgery for malignant cord compression

A

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

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32
Q

Chemotherapy is used to treat malignant cord compression in which cases

A

In theory can be used for the very sensitive tumours:

  • Lymphoma.
  • Teratoma.
  • SCLC (maybe)

Not usually used alone

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33
Q

What are the initial investigations for SVC obstruction

A

CXR – is there a mass?
Venogram – is there a clot?
CT Chest

34
Q

What can cause malignant hypercalcaemia

A

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.

35
Q

How do cancer patients with hypercalcaemia present

A 
Nauseated, anorexic
Weight loss
Thirsty - dehydration
Pass lots urine (polydypsia and polyuria).
Constipated
Abdominal pain 
Depression
Confused.
Poor concentration, drowsy, lethargy 
Bone pain
36
Q

How do you investigate hypercalcaemia

A

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

37
Q

How do you treat malignant hypercalcaemia

A

Rehydration first - need several litres of normal saline (careful if risk of heart failure)

Bisphosphonates - usually zoledronic acid

Systemic management of malignancy

38
Q

Why must you make sure a hypercalcaemic patient is hydrated before treating with bisphosphonates

A

Can cause renal failure so must make sure properly rehydrated first.

39
Q

What is pericardial tamponade

A

Pericardial effusion develops and compresses ventricle

This reduces cardiac output and collapses the right atrium increasing venous back pressure.

40
Q

What can cause a pericardial effusion

A

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.

41
Q

How does malignant pericardial tamponade present

A 
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

42
Q

How do you investigate a malignant pericardial tamponade

A

CXR - enlargement of cardiac silhouette (globular)
ECG - reduced complex size (low QRS voltage)
Echocardiogram – rim of pericardial fluid.
Cytology of pericardial fluid

43
Q

How do you treat a malignant pericardial tamponade

A

Pericardiocentesis – drain pericardium.

Pericardial window – operation to allow pericardial fluid to drain into pleural cavity.

Systemic management of malignancy.

44
Q

Why are PEs common in malignancy

A

Malignancy is a pro-thrombotic state

45
Q

How does PE present

A 
Acute deterioration in SOB
Tachypnoea
Tachycardia
Cough 
Haemoptysis  
Low pa CO2  - blowing it off
Pleuritic chest pain
Unilaterla leg swelling
46
Q

How do you manage a PE

A

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

47
Q

List some metabolic oncological emergencies

A

Hypercalcaemia - most common
Tumour lysis syndrome
SIADH

48
Q

List some neurological oncological emergencies

A

Spinal cord compression

Brain mets leading to raised ICP

49
Q

List some cardiovascular oncological emergencies

A

Malignant pericardial effusion

SVC obstruction

50
Q

List some haematological oncological emergencies

A

Hyperviscosity due to dysproteinaemia
Hyperleukocytosis
DIC

51
Q

List some infectious oncological emergencies

A

Neutropenic fever and sepsis

52
Q

What is a paraneoplastic syndrome

A

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

53
Q

Which cancers most commonly cause a paraneiplastic syndrome

A

Lung
Breast
Ovaries
Lymphoma

54
Q

Which cancers most commonly cause malignant hypercalcaemia

A 
Myeloma
Squamous Cell Lung Cancer
Renal Cancer
Breast Cancer
Prostate Cancer (NB: Very rarely)
Squamous Cell Head and Neck Cancer
Leukemia
55
Q

How can hypercalcaemia affect an ECG

A 
Bradycardia
Short QT interval
Prolonged PR interval
Wide T wave
Atrial or ventricular arrythmias
56
Q

Which cancer is associated with SIADH

A

Small cell lung cancer

57
Q

How do you treat SIADH

A

Treatment of cancer
Fluid restriction (1 – 1.5 L daily)
Demeclocycline

58
Q

How can brain mets present

A 
New onsetheadaches
Cognitive, personality, and behavioral changes
Nausea andvomiting
Memory loss
Increased intracranial pressure
Paraesthesias
Vision disorder
Bells palsy
Ataxia
Seizures
59
Q

Which cancers often cause a malignant pericardial effusion

A 
Lung cancer
Breast cancer
Lymphoma
Leukemia
Melanoma
60
Q

List common pathogens which cause neutropenic sepsis

A 
Escherichia coli
Pseudomonas aeruginosa
Acinetobacter baumannii
Klebsiella pneumoniae
Coagulase positive/negative staphylococci
61
Q

What is the definition of an oncological emergency

A

Broad term

Typically a pathology that will be irreversible and harmful if not treated within minutes- days

62
Q

When does tumour lysis occur

A

Any time after the introduction of anti-cancer therapy

63
Q

What causes tumour lysis syndrome

A

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

64
Q

Tumour lysis syndrome is associated with which cancers

A

Lymphomas
Germ cell tumours

Those that respond well to treatment

65
Q

List risk factors for tumour lysis syndrome

A

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

66
Q

What prophylaxis is available for tumour lysis syndrome

A

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

67
Q

How does tumour lysis syndrome present

A 
High K+, phosphate, urate 
Low calcium 
Oliguria 
AKI 
Nausea and vomiting 
Cardiac arrhythmia 
Seizure 
Confusion
68
Q

How do you manage tumour lysis syndrome

A

Urgent treatment of any arrhythmia and hyperkaelamia
Fluid resuscitation
Close monitoring of input/output
Correct electrolyte abnormalities

69
Q

How do you differentiate between hyperparathyroidism and hypercalcaemia of malignancy

A

Check PTH level
Will be high in hyperparathyroidism and low in cancer

Also check calcium and phosphate

70
Q

How does raised ICP present

A 
Headache - chronic/daily 
- Worse on coughing, leaning forward etc 
Often associated with nauses 
Weakness, sensory changes 
Personality change 
Seizures
71
Q

What can cause raised ICP in cancer patients

A

Brain mets - lung, breast, prostate etc.

Bleeds from the tumour - may have been asymptomatic on its own

72
Q

How do you treat intracranial mets

A

Steroids started immediately - reduces oedema and symptoms

Surgery - role in limited disease
With large lesions,, debulking can prolong survival

Radiotherapy

73
Q

How do you innvestigate SVCO

A

CXR - may see widened mediastinum or the mass lesion

CT chest - shows location, severity and associated pathology (e.g. mass or thrombus)

74
Q

Which organisms are the main cause of neutropenic sepsis

A

Gram negatives

75
Q

What can trigger opiate toxicity

A

Over medication
Renal failure
Frailty and intercurrent illness

76
Q

How does opiate toxicity present

A

Pinpoint pupils
SLow, shallow breathing
Falling asleep or loss of conscioussness
Blue fingers etc

77
Q

How can you severe opiate toxicity

A

Administer naloxone - if in respiratory depression

If mild toxicity just withdraw opiate and monitor

78
Q

Which cancers can lead to malignant bowel obstruction

A

Disseminated intraabdominal cancers
e.g. ovarian, peritoneal

Others include, colon, gastric, breast with mets

79
Q

How does malignant bowel obstruction present

A 
Abdominal pain 
Distension 
No bowel sounds present 
No bowel movement - absolute constipation 
Vomiting 
Bloating
80
Q

How do you diagnose malignant bowel obstruction

A

AXR - dilated bowel loops and air/fluid level

CT abdo/pelvis to assess the cause

81
Q

How do you manage malignant bowel obstruction

A

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

Oncology (7 decks)

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