Oncological Emergencies

Question 1

What are the serum disturbances in tumour lysis syndrome

Answer 1

Renal failure (intrinsic) from calcium phosphate deposition
Hyperuricaemia
Hyperphosphataemia
Hyperkalaemia
Elevated LDH

Hypocalcaemia from binding to phosphate

Question 2

What are the risk factors for tumour lysis syndrome

Answer 2

High tumour burden/WCC 50,000
High proliferative rate
Tumours highly sensitive to cytotoxics
Haematological malignancies (high grade lymphomas, ALL)
Initiation of chemotherapy
Extensive marrow involvement
Dehydration
Renal failure
Specific chemo
- cisplatic, paclitaxel, IT methotrexate
Adjunct medications
- Glucocorticoids, ionizing radiation, monoclonal antibodies (ie rituximab), hormonal agents (ie tamoxifen)

Question 3

What are the drugs used to treat hyperuricaemia in TLS?

Answer 3

Treatment
- Rasburicase 0.2mg/kg
- IV fluids aiming UO 1-2ml/kg/hr
- Anti-hyperkalaemia Mx
- Phsophate binders
- RRT

Controversial
- Frusemide for K/Urea clearance, only if patient isn’t dehydrated and no obstructive uropathy
- SodiBic urinary alkalinzation (improves Urea excretion but cause CaPh crystal precipitation_
- Calcium only if symptomatic hypocalcaemia and ECG changes of hyperkalaemia (risks Calcium phosphate crystal precipitation

Question 4

What are the symptoms/signs of TLS?

Answer 4

N/V/D
Haematuria
Cardiac dysrhythmias
Seizures
Muscle cramps/Tetany
Syncope
Death

Question 5

What is the medical definition of TLS?

Answer 5

The Cairo-Bishop definition
- 2 or more serum abnormalities above normal or >25% from patients baseline
- Occurring 3 days before or 7 days after instituting chemo

Question 6

What is the medical definition of TLS?

Answer 6

The Cairo-Bishop definition
- 2 or more serum abnormalities above normal or >25% from patients baseline
- Occurring 3 days before or 7 days after instituting chemo

Question 7

Indications for RRT in TLS?

Answer 7

• Severe oliguria/anuria
• Severe fluid overload
• Persistent Hyperkalaemia
• Symptomatic hypocalcaemia or a clacium phosphate >70mg/dl
• Severe acidosis
• Severe hyperuricaemia with complications (serositis, encephalopathy etc)

Question 8

What are the drugs used to prevent TLS?

Answer 8

Prevention
- Rasburicase 0.2mg/kg daily
- Allopurinol 10mg/kg TDS
- Adequate hydration

Question 9

What is the definition of Neutropaenic sepsis?

Answer 9

• A single temp of 38.5C
  OR
• A sustained temp >38C for more than 1 hour

+

• Absolute neutrophil count (ANC) < 0.5 x 10^9
  OR
• ANC <1 x 10^9 but expected nadir <0.5 in the next 48hrs

Question 10

What is the typical antibiotic therapy for Febrile Neutropaenia?

Answer 10

A beta lactam
- Tazocin 4.5gm Q 6-8hrs
- Cefepime 2gm TDS
- Cirpofloxacin 400mg BD if a penicillin allergy present
+
An aminoglycoside
- Gentamicin 5-7mg/kg IV
+/-
Vancomycin IV 30mg/kg (max 1.5gm) of MRSA suspected

Question 11

What are the main paraneoplastic syndromes with lung cancer?

Answer 11

Small Cell Carcinoma
- Hyponatraemia from SIADH
- Eaton-Lambert syndrome (paraneoplastic myaesthenia)

Squamous Cell
- Hypercalcaemia (The most common cause of humoral related hypercalc, pTH excretion)

Question 12

What are the features of Eaton-Lambert Syndrome?

Answer 12

Paraneoplastic myaesthenia from Small cell lung cancer
- Slowly progressive proximal muscle weakness
- Pathognomonic sign is improvement in strength and return of DTR’s with exercise

Question 13

What is Carcinoid syndrome and what is the most commonly associated tumours?

Answer 13

Tumours
- Small bowel neuroendocrine
- Gastric/lung neuroendocrine

Cause
- Release of vasoactive and bronchospastic mediators, taken up into the portal circulation
- Causes flushing, bronchospasm and damage to R) heart structures ie TV
- Treate with surgical removal and Octerotide