Oncological emergencies Flashcards
What are the 4 oncological emergencies?
- Metastatic spinal cord compression
- Neutropenic sepsis
- Hypercalcaemia
- Superior vena cava obstruction
How does Metastatic spinal cord compression happen?
A tumour enforces direct pressure on the spinal cord, causing vertebral collapse
How does Metastatic spinal cord compression present?
- Saddle paraesthesia
- Incontinence
- Thoracic back pain and paraesthesia
- Pain is worse when laying flat as it causes more compression
- Paraplegia
What cancers is MSCC associated with?
It is commonly associated with prostate, breast, lung and haematological cancers
How is MSCC diagnosed?
- Urgent MRI. Within 24 hours of onset of symptoms and signs
- Digital rectal exam
- Full spinal and peripheral nerve exam
What is the immediate management for MSCC?
- 16mg dexamethasone commenced if MSCC is suspected, before any investigations
- a PPI e.g. lansoprazole 30mg
What is the management if MSCC is confirmed after investigations?
Surgery, radiotherapy, chemo or a combination. Surgery is favoured when collapse of a vertebral body. Surgery easier when the cancer is local.
What are the risks if MSCC not treated in time?
- Prognosis is significantly shortened
- If treated within 24 hours, 57% of patients will be able to walk again
- If all motor function is lost for 48 hours, recovery is unlikely
What is superior vena cava obstruction? (SVCO)
Defined as the extrinsic compression, thrombosis or invasion of the wall of the superior vena cava
Which cancers most commonly cause SVC?
- Lung cancers
- Lymphomas
What are the symptoms and signs of SVCO?
- Plethoric and oedematous face
- Headache and visual disturbances
- Breathlessness
- Pulseless Jugular venous distension
- Cough and / or hoarse voice
- Papilloedema
What investigations are done to confirm diagnosis of SVCO?
- CXR
- High resolution CT (with contrast if renal function okay)
Management of SVCO
A-E approach:
1. Raise head off bed, dyspnoea worse when laying flat
2. If hypoxic, give oxygen
3. Dexamethasone 16mg daily with PPI cover
4. Vascular stenting
5. LMWH if thrombosis is present
Management of the SVCO dependent on the cancer that causes it
- Lymphoma: chemotherapy (very chemo-sensitive)
- Small cell lung cancer: chemo & radiotherapy (very chemo-sensitive)
- Non-small cell lung cancer: radiotherapy
What is hypercalcaemia of malignancy?
A serum concentration of calcium above 2.65mmol/L.
Mild: 2.65- 3.00
Moderate: 3.00 - 3.40
Severe: above 3.40mmol/L
What causes hypercalcaemia in cancer?
- Caused by bone metastases itself or caused by a PTH secreting tumour
Calcium homeostasis in a healthy individual: When calcium is too high…
- The thyroid releases calcitonin
- Calcitonin promotes deposition of calcium into the bones (by action of osteoblasts)
- As a result, there is reduced calcium absorption in the kidneys
- This causes blood calcium concentration to fall
Calcium homeostasis in a healthy individual: when calcium level is too low…
- Parathyroid releases PTH
- PTH stimulates osteoclasts to release calcium from the bones
- Reabsorption of calcium in the kidneys increases and vitamin D increases absorption in the bowel
- Blood calcium increases
How does hypercalcaemia present?
“Moans, groans, bones and stones”
1. kidney stones, polyuria and polydipsia
2. bone pain, muscular weakness
3. anxiety and depression
4. arrhythmias
5. abdo pain, N/V, pancreatitis, constipation and peptic ulcers
Management of hypercalcaemia
- Fluid challenge - give saline 0.9% NaCl over 24 hours for diuresis to encourage explusion of calcium
- Bisphosphonates e.g. IV Pamidronate
(mode of action is to inhibit osteoclastic bone resorption, inhibits bone from pushing Ca into blood and thus reduces bone pain) - Calcitonin (in very severe, advanced cases where there are arrhythmias and tachyphylaxis
What is neutropenic sepsis?
Infection of a patient with neutropenia due to chemotherapy / immunotherapy that has damaged their bone marrow
Why is neutropenic sepsis dangerous?
It can lead to multiple organ failure and septic shock
Potential sources of infection in neutropenic sepsis
- Lines e.g. hickmann’s
- Catheter in situ
- Cellulitis, rashes, skin changes are key to look for too
What is the full septic screen for neutropenic sepsis?
Bloods and blood cultures - get a FBC, LFTs, U&Es, CRP.
Urinalysis - get MSU culture
Fluids
Antibiotics
LACTATE
Oxygen if hypoxic
Swabs of infection site(s)
Vital signs e.g. blood pressure and temperature
What is the most important management if neutropenic sepsis is suspected?
🚨 Broad-spectrum IV antibiotics within 1 hour in all suspected cases.
Tazocin (piperacillin + tazobactam) for 5 days
(vancomycin if penicillin allergic)
What are the most important vital signs to monitor in neutropenic sepsis?
- urine output
- blood pressure
- oxygen
- pulse
If the patient is still febrile after 48 hours of abx, what is the next step in management?
Prescribe meropenem +/ vancomycin
Persistent fever despite abx treatment requires consideration of antivirals and antifungals
What is the MASCC score?
Multinational Association for Supportive Care in Cancer patients
Used to determine how long a patient should be on antibiotics for neutropenic sepsis
