Oncological emergencies Flashcards
what are oncological emergencies?
Group of conditions, that occur as a direct or indirect result of cancer or it’s treatment that are potentially life threatening
name some oncological emergencies
neutropenic sepsis
metastatic spinal cord compression
hypercalcaemia of malignancy
superior vena cava obstruction
tumour lysis syndrome
venous thromboembolism
what is the definition of neutropenic sepsis?
- Patient undergoing systemic anticancer treatment (SACT)
- Temp >38
- Neutrophil count < 0.5 x 10 9 per litre
suspect in all chemo patients who become unwell as some chemo pt cannot mount a fever
neutropenic sepsis is a life threatening complication of chemotherapy. how many days after chemo does it typically present?
7-10 days post chemo
what are some signs and symptoms of neutropenic sepsis?
- Fever
- Tachycardia >90
- HYPOTENSION < 90 systolic= URGENT
- RR > 20
- Symptoms related to a specific system e.g. cough, SOB, line, mucositis
- Drowsy
- Confused
what are some things that increase infection risk
- prolonged neutropenia >7 days
- severe neutropenia
- significant comorbidities - COPD, DM, renal/hepatic impairment
- aggressive cancer
- central lines
- mucosal disruption
- hospital inpatient
what are some causes of neutropenia?
genetic - congenital neutropenia, chediak-Higashi syndrome
acquired - malignancy, infection, drugs, autoimmune
what microbes are most frequently isolated in neutropenic sepsis?
Staph aureus, staph epidermidis, enterococcus and streptococcus
source identified in only 20-30% of pt and blood cultures are often negative
what investigations can be done from neutropenic sepsis?
observations
bloods - VBG/ABG, FBE, CRP, U&Es, LFTs, bone profile, clotting, fungal assays, blood borne virus screen
cultures - anything that you suspect may be causing infection - blood, line, sputum, urine, stool, viral PCR, wound swabs
imaging - CXR, LP, ECHO
how is neutropenic sepsis managed?
sepsis 6 & senior input asap
IVabx - need to be given within 1 hour of presentation, give immediately
IVF
O2
blood cultures
urine output
lactate
what antibiotics are given in neutropenic sepsis?
empirical treatment with piperacillin/tazobactam - tazocin
meropenem in pen allergic - renal function
usually need 5/7 broad spec, may switch to oral after 48 hours if low risk
what antibiotics can be added if a patient has central venous access in neutropenic sepsis?
vancomycin
what is the Multinational Association for Supportive Care in Cancer (MASCC) Risk Index?
way of risk stratifying patients with neutropenic sepsis
- Low risk (≥ 21) - consider oral abx, out pt care
- High risk (< 21) - IV abx, in pt mx
what is metastatic spinal cord compression and what causes it?
when dural sac and its contents are compressed at the level of the cord or cauda equina
80-85% caused by collapse of vertebral body that contains metastatic disease
10% by direct tumour extension into the epidural space
how does MSCC progress?
initially causes oedema, venous congestion and demyelination = REVERSIBLE
prolonged compression = vascular injury, cord necrosis, permanent damage
which cancers is MSCC most common in?
breast, prostate, lung = 60% of cases
also in lymphoma, myeloma, renal & thyroid
what is the most common location for MSCC
Thoracic
30-50% have > 1 area involved
(below L2 = cauda equina)
how does MSCC present?
pain - poorly responsive to analgesia, radiating round chest or down legs, worse after lying down
motor symptoms - reduced power, difficulty standing, walking, climbing stairs, often symmetrical
sensory loss
sphincter dysfunction - urinary hesitancy, frequency, urinary retention with overflow, faecal incontinence
what is seen on examination of MSCC?
what is the imaging of choice for MSCC?
MRI
how is MSCC managed?
analgesia - WHO ladder
VTE prophylaxis - LMWH, TEDs
catheter to manage bladder dysfunction
Dexamethasone - 16mg acutely (monitor glucose)
Radiotherapy
Surgery
describe some indicators for surgery in MSCC
treatment of choice if fit and good prognosis
good motor function at presentation
good performance status
limited comorbidity
single level spinal disease
absence of visceral mets
long interval from primary diagnosis
biopsy
stabilisation
describe radiotherapy for MSCC
used in the majority of cases - extensive disease and poor physiological reserve
delivered within 24 hour of confirmation
single posterior field, pt usually supine, targets abnormal area plus 1-2 vertebra either side
describe some supportive care measures for MSCC
good nursing care - pressure areas, log rolling if unstable
analgesia
laxatives
bladder care
monitor BMs
VTE prophylaxis
physio
OT
what is malignant hypercalcaemia?
serum calcium >2.6mmol/L secondary to a malignant process
what cancers is malignant hypercalcaemia most common in
breast
scc
renal
myeloma
lymphoma
what are the 2 broad causes of hypercalcaemia in malignancy?
humoural case in around 80% - chemical agents released by tumour that disrupt normal calcium homeostasis (PTH related protein, overproduction of vit D)
bone invasion in around 20% - osteolytic metastases with local release of cytokines - increased bone resorption and calcium release from bone
what are the symptoms of hypercalcaemia?
stone, thrones, bones, abdominal groans and psychiatric moans
(renal stones, bone pain, polyuria, abdominal pain, psychiatric features)
how can malignant causes for hypercalcaemia be distinguished from primary hyperparathyroidism?
malignant hypercalcaemia PTH will be suppressed
how is malignant hypercalcaemia managed?
rehydration - usually at least 24 hours IVF
bisphosphonates - inhibits osteoclastic bone resorption (IV pamidronate or zolendronic acid)
calcitonin - promoting urinary calcium excretion and inhibits bone resorption
nice recommends admission for any pt with serum calcium >3mmol
what is superior vena cava obstruction?
obstruction of blood flow through the SVC
compression or occlusion of the SVC
can be a first time presentation of an underlying cancer diagnosis
what are the commonest causes of SVCO?
extrinsic compression - intrathoracic primary lung cancer or mesothelioma
can also be mediastinal lymph nodes, metastatic or lymphoma
what are some signs and symptoms of SVCO?
- Swelling of face, neck and upper limbs
- Distended neck and chest veins
- Shortness of breath and cyanosis
- Stridor
- Hoarse voice
- Lethargy
- Headache and confusion
- Conjunctival swelling and blurred vision
- Can → to laryngeal oedema, airway obstruction, cerebral oedema and death
what is pembertons sign?
when elevating both arms above head for 1-2 minutes causes congestion, cyanosis or respiratory distress = increased venous return from upper extremities exacerbating obstruction
= positive
how is SVCO managed?
sit upright/elevate head
oxygen
dexamethasone
pain relief
CXR and CT
long term management of SVCO
endovascular stenting - percutaneoulsy inserted
thrombolysis - if venogram confirms presence of clot, usually combined with stent insertion
radiotherapy -
chemotherapy
what is tumour lysis syndrome?
metabolic emergency that presents as severe electrolyte abnormalities
caused by rapid breakdown of large numbers of cancer cells and subsequent release of large amounts of intracellular content into the bloodstream - overwhelming normal homeostatic mechanisms
how is tumour lysis syndrome defined/classified?
classified as laboratory TLS - defined as presence of 2 or more of the following metabolic abnormalities:
- hyperuricaemia
- hyperphosphataemia
- hyperkalaemia
- hypocalcaemia
or clinical TLS - defined as laboratory TLS with 1 or more of the following clinical manifestations:
- AKI
- cardiac arrhythmia
- seizure
- sudden death
what cancers is TLS most commonly associated with?
Most commonly associated with highly proliferative, bulky, chemosensitive haematological malignancies, particularly high-grade B-cell lymphoid malignancies
however - seen in more other malignancies due to advances in cancer Tx
what are 2 modifiable risk factors predisposing to TLS?
high serum creatinine ≥ 1.5 x upper limit of normal
dehydration
what are some risk factors for tumour lysis syndrome?
- High volume/bulky disease
- Pre-treatment LDH high
- High circulating WCC
- Pre-existing renal dysfunction/ nephropathy
- Pre-treatment hyperuricaemia
- Hypovolemia
- Pretreatment diuretic use
- Urinary tract obstruction from tumour
how does TLS present?
- Normally day 3-7 post chemotherapy
- Nausea and vomiting
- Diarrhoea
- Anorexia
- Lethargy
- Haematuria → oliguria → anuric
- Fluid overload
- Cardiac arrhythmia/arrest (peaked T waves, QTc derangement)
- Muscle cramps/tetany/seizures
investigations and there results are done in TLS?
serum uric acid - raised
serum phosphate - raised
potassium - raised
calcium - low
elevated WBC
lactate dehydrogenase - raised
serum creatinine - raised
serum urea - raised
ECG - may have an arrhythmia
what ECG abnormalities may be seen in tumour lysis syndrome?
hyperkalaemia - peaked T waves, prolonged PR and QRS, flattening P waves
hypocalcaemia - QT prolongation may be seen, predisposes to ventricular arrhythmias
how is tumour lysis syndrome managed?
- hydration
- allopurinol prophylaxis
- rasburicase
- dialysis
what is the management of a cancer related VTE?
DOAC for at least 6 months
