Oncological emergencies Flashcards
When do oncological emergencies occur?
Oncological emergencies occur when the balance between disease control and cancer therapy is upset - too much cancer or too much therapy
2 of the most common and dangerous oncological emergencies to look out for?
- Neutropenic sepsis
- Spinal cord compression
Neutropenic sepsis clinical presentation:
Temperature >38 degrees
Neutrophil count <0.5x10^9/L
Suspect in all patients who are unwell within 6wks of receiving chemotherapy
Localising signs may be absent
Examine indwelling catheter sites, immediate treatment saves lives
Use local guidelines or treat empirically with piperacillin/tazobactam
Oncological emergency: spinal cord compression may present when?
3-5% of patients have spinal metastases
15% of those with advanced cancers develop metastatic spinal cord compression
most commonly associated with lung, prostate, breast, myeloma, melanoma
Urgent treatment is required to preserve neurological function and relieve pain
Causes of spinal cord compression?
Collapse or compression of a vertebral body due to metastases (common)
direct extension of a tumour into vertebral column (rare)
Signs and symptoms of spinal cord compression?
Back pain in 95%
Ask about nocturnal pain and pain with straining
Worry if there is cervical/thoracic pain
Limb weakness, difficulty walking, sensory loss, bowel/bladder dysfunction
maintain high index of suspicion
Management for spinal cord compression?
- admit for bed rest and arrange urgent (within 24hrs) RMI of the whole spine
- give dexamethasone 16mg/24h PO with prophylatic gastroprotection (eg PPI and blood clucose monitoring)
- if reduced mobility consider thromboprophylaxis (compression stockings, LMWH)
- Refer urgently to clinical oncology/cancer MDT
- Radiotherapy is the commonest treatment and should be given within 24hrs of MRI diagnosis
- Decompressive surgery +/- radiotherapy may be appropriate depending on prognosis
- patients with loss of motor function after >48h are unlikely to recover function
What is Superior Vena Cava (SVC) syndrome?
Reduced venous return from head, neck and upper limbs - due to extrinsic compression (most common), or venous thrombosis (consider if current or past central venous access).
SVC syndrome with airway compromise requires urgent treatment.
Causes of SVC syndrome?
<90% results from malignancy
most common cancers: lung (75%), lymphoma, metastatic, thymoma, germ cell
Signs and symptoms of SVC syndrome?
Diagnosis is made clinically.
sob, orthopnoea, stridor, plethora/cyanosis, oedema of the face and arm, cough, headache, engorged neck veins (non pulsatile raiised JVP), engorged chest wall veins.
Pemberton’s test: elevation of the arms to the side of the head causes facial plethora/cyanosis
Management of SVC syndrome?
prop up
assess for hypoxia (pulse oximetry, blood gas) and give o2 if needed
dexamethasone 16mg/24hrs
CT is used to define the anatomy of the obstruction
balloon venoplasty and SVC stenting provide the most rapid relief of symptoms
Treat with radiotherapy of chemotherapy depending on the sensitivity of the underlying cancer
What is malignancy-associated hypercalcaemia?
most common metabolic abnormality in cancer patients
10-20% of patient with cancer
It is a poor prognostic sign: 75% of mortality within 3 months
Calcium is highly protein-bound and needs correcting to the serum albumin concentration. PTH levels should be suppressed
Causes of malignancy-associated hypercalcaemia?
PTH related protein produced by the tumour, local osteolysis e.g. myeloma, tumour production of calcitriol
Signs and symptoms of malignancy-associated hypercalcaemia?
Weight loss
Anorexia
Nausea
Polydipsia
Polyuria
Constipation
Abdominal pain
Dehydration
Weakness
Confusion
Seizure
Coma
Management of malignancy-associated hypercalcaemia?
Aggressive rehydration
Bisphosphonates (if eGFR 30 or more), eg zoledronic acid iv
long term treatment is by control of underlying malignancy
