Oncological Emergencies Flashcards
what is malignant cord compression?
radiological evidence of indentation of the thecal sac secondary to cancer
which cancers are associated most bone mets leading to malignant cord compression?
lung
breast
kidney
prostate
thyroid
where in the spine do majority of malignant cord compression occur?
60% thoracic
30% lumbar
10% cervical
clinical features of cord compression?
- pain (severe, progressive)
- weakness (typically symmetrical)
- UMN lesions (increased tone, hyperreflexia, upgoing plantars)
difference in features between cord compression and cauda equina?
cord compression: back pain, paralysis, hyperreflexia, +ve babinskis
cauda equina: back pain radiculopathy, reduced anal tone, saddle anaesthesia, paralysis hyporeflexia, hypotonia
Ix to diagnose cord compression
MRI = gold standard
Mx of cord compression?
- analgesia
- VTE prophylaxis
- high dose dexamethasone
- radiotherapy as adjuvant to surgery (or stand alone if unable to undergo surgery)
what is malignant hypercalcaemia?
serum calcium >2.6mmol/L, secondary to malignant process
what are the most common malignancies associated with hyperparathyroidism?
breast cancer
multiple myelom a
lymphoma
lung cancer
what are the 3 main mechanisms that cause malignant hypercalcaemia?
osteolytic mets
PTH - related protein (PTHrP) secretion
increased 1,25-dihydroxyvitamin D production
clinical features of malignant hypercalcaemia?
‘stones, bones, thrones, abdo groans, psychiatric mones’
renal stones
bone pain
polyuria
abdo pain
psychiatric features
Ix to diagnose malignant hypercalcaemia?
- serum calcium level calcium level >2.6
- identification of underlying cancer
(measure PTH as in malignant hypercalcaemia the PTH should be suppressed compared to primary hyperparathyroidism)
Mx of malignant hypercalcaemia?
IV rehydration, calcitonin and bisphosphonate therapy
admit to hosp if serum calcium >3mmol/L
what is neutropenic sepsis ?
fever >38 degrees OR features of sepsis in a pt with pt w/ neutrophil count of <0.5
causes of neutropenia?
genetic: congenital neutropenia, chediak-higashi syndrome
acquired: malignancy, infections, drugs, autoimmune
clincial features of neutropenic sepsis?
signs of infection: (e.g. pneumonia or UTI)
- temperature
- acute confusion
- tachypnoea
- low BP
- tachycardia
- low urine output
Ix to diagnose neutropenic sepsis?
Ix to identify source of infection + evidence of organ dysfunction and complications
- bedside
- bloods
- cultures
- imagine e.g. CXR, LP, ECHO
Mx of neutropenic sepsis?
SEPSIS 6:
1. give 02
2. IV access, take bloods
3. give IV abx
4. give IV fluids
5. measure urine output
6. measure lactate
what is malignant SVCO?
obstruction to the flow of blood through the superior vena cava secondary to cancer (from direct tumour growth or lymphadenopathy)
most common cancers to cause SVCO?
lung carcinoma (70-80%)
non hodgkins lymphoma (10%)
less common:
- thymic
- breast
- mediastinal germ cell tumours
clinical features of SVCO?
dyspnoea, facial swelling, head fullness, cough, dysphagia, worsening on bending forward, facial plethora, upper limb oedema , distended neck and chest well veins
+ve pembertons sign
Ix to diagnose SVCO?
CXR - showing abnormality e.g. mediastinal widening or malignant pleural effusion
CT = diagnostic
then diagnose malignancy: tissue biopsy + staging CT
Mx of SVCO?
conservative: elevation of head and neck, o2 titrated to sats
stenting, radiotherapy and chemo = main tx but dexamethasone can be to reduce swelling
what is tumour lysis syndrome?
metabolic disturbances arising from breakdown of malignant cells following initiation of treatment for malignancy
what electrolyte abnormalities do you get in tumour lysis syndrome?
hyperkalaemia
hyperphosphataemia
hypocalcaemia
hyperuricaemia
consequences of electrolyte disturbance in tumour lysis syndrome?
AKI, arrythmias, sudden death
what type of malignancy is tumour lysis syndrome common in?
haematological malignancy
what factors are associated with developing tumour lysis syndrome?
- high proliferation rate
- chemosensitivity
- large tumour burden
- pre existing metabolic disturbances
- renal impairment
clinical features of tumour lysis syndrome?
(tend to occur within first 72 hours following initiation of treatment)
lethargy
n+v
diarrhoea
anorexia
muscle cramps
syncope
pruritus
arthritis
fluid overload
heamaturia
tetany + parasthesia
bronchospasm (wheezing)
what Ix are done to diagnose tumour lysis syndrome?
renal function, electrolytes, serum urate
+/-
urine dip
urine microscopy
serum lactate
lactate dehydrogenase
ECG
cardiac monitoring
what monitoring needs to be done if a pt is at high risk of tumour lysis syndrome
renal function, electrolytes and serum urate regularly
how is the diagnosis of tumour lysis syndrome made?
based on the cairo-bishop definition
lab diagnosis: 2 or more needed
- uric acid >476micromol/L
- K+ > 6mmol/L
- phosphate >1.45mmol/L
- calcium <1.75mmol/L
AND
clin diagnosis: 1 or more needed
- serum creatinine >1.5 upper limit normal
- cardiac arrythmia / sudden death
- seizure
what prophylaxis can be given to patient who are at high risk of developing tumour lysis syndrome?
oral or IV hydration
allopurinol
rasburicase
how is tumour lysis syndrome managed?
hyperphosphataemia -> hydration + diet restriction
hyperkalaemia -> IV calcium gluconate, insulin/dextrose infusion and neb salbutamol
hypocalcaemia -> dont treat unless symptomatic in which give IV replacement
renal impairement -> fluids rehydration, adjustment of drug doses, possibly haemofiltration
