Oncological Emergencies

Question 1

Spinal cord compression is an oncological emergency and affects up to 5% of cancer patients. Extradural compression accounts for the majority of cases, usually due to vertebral body metastases.

How does it present?

Answer 1

back pain: may be worse on lying down and coughing

lower limb weakness

sensory changes: sensory loss and numbness

neurological signs depend on the level of the lesion: tendon reflexes tend to be increased below the level of the lesion and absent at the level of the lesion

Question 2

What are the different causes of malignant spinal cord compression?

Answer 2

It can result from direct pressure, vertebral collapse or instability due to metastatic or local spread of tumours.

Question 3

Give some risk factors for developing malignant spinal cord compression

Answer 3

some cancers carry a higher risk than others

Prostate cancer (20%)
Lung cancer (20%)
Breast cancer (17%)
Renal cancer (12%)
Multiple myeloma

Question 4

How should suspected spinal cord compression (MSCC) be investigated and managed?

Answer 4

Investigation
urgent MRI: whole MRI spine within 24 hours of presentation

Management
high-dose oral dexamethasone
urgent oncological assessment for consideration of radiotherapy or surgery

Question 5

What bedside and lab investigations should be considered for MSCC?

Answer 5

Bladder scan: to assess for urinary retention

Baseline blood tests (FBC, U&Es, LFTs): to assess general fitness and for imaging
Clotting and group & save: if the patient is likely to require surgery

Bone profile: to assess for hypercalcaemia
LDH: higher levels are associated with poor prognosis
Myeloma screen: if the patient does not have a known cancer diagnosis

Tumour markers: may help with the assessment of cancer stage and suitability for treatment or diagnosis if MSCC is the initial presentation

Question 6

What should be considered in the rehabilitation of patients with MSCC?

Answer 6

Weaning of dexamethasone
Pain control
Thromboprophylaxis
Breathing exercises and forced expiratory techniques to aid chest clearance
Prevention of contractures/spasticity
Prevention of pressure ulcers
Mobility aids
Continence management

Question 7

Give some complications of MSCC

Answer 7

Pressure ulcers
DVT / PE
Falls
Urinary tract infections

Emergency:
Autonomic dysreflexia - uncontrolled htn and arrythmias due to spinal cord injury

Question 8

Superior vena cava (SVC) obstruction is an oncological emergency caused by compression of the SVC. It is most commonly associated with lung cancer.

How does it present?

Answer 8

dyspnoea is the most common symptom
swelling of the face, neck and arms - conjunctival and periorbital oedema may be seen
headache: often worse in the mornings
visual disturbance
pulseless jugular venous distension

Question 9

What is Pemberton’s sign?

Answer 9

The Pemberton manoeuvre may worsen the signs and symptoms of SVCO. The patient should lift both arms until they touch the side of the face. A positive Pemberton’s sign is the presence of facial congestion, cyanosis and respiratory distress after ~1 minute.

Question 10

What can cause SVCO?

Answer 10

external pressure, malignant infiltration, or thrombus formation within the vessel

Question 11

What are the risk factors for developing SVCO?

Answer 11

Lung cancer: particularly small-cell lung cancer
Lymphoma
Metastatic disease: particularly breast cancer, colon cancer and oesophageal cancer
Smoking: due to the increased risk of lung cancer, rather than a direct association
Central venous catheter use: may be used in cancer patients for the administration of medication
Radiation to the mediastinum

Question 12

How can SVCO be investigated?

Answer 12

Chest X-ray: may show a widening of the superior mediastinum and right hilar prominence to indicate a mediastinal mass

CT chest with contrast: imaging modality of choice; shows the location and severity of obstruction and may help with identification/staging of underlying malignancy

Doppler ultrasound: may help to identify the presence of obstruction

Diagnosis can be made clinically or based on contrast CT

Question 13

How can SVC obstruction be managed?

Answer 13

securing the airway : endotracheal intubation, surgical airway

endovascular stenting is often the treatment of choice to provide symptom relief

certain malignancies such as lymphoma, small cell lung cancer may benefit from radical chemotherapy or chemo-radiotherapy rather than stenting

the evidence base supporting the use of glucocorticoids is weak but they are often given

Question 14

Symptomatic treatment for SVCO includes:

Answer 14

Elevating the head
Loosening restrictive clothing
Benzodiazepines and opioids to relieve breathlessness and agitation
Oxygen to maintain oxygen saturations if required

Question 15

Give some complications of SVCO

Answer 15

Laryngeal oedema
Acute upper airway obstruction

Question 16

Give some complications of endovascular stenting

Answer 16

Stent thrombosis
Stent migration
Superior vena cava dissection or perforation
Infection
Volume overload/acute decompensation of heart failure: due to the sudden increase in venous return after relief of the obstruction

Question 17

What is Tumour lysis syndrome (TLS)?

Answer 17

an oncological emergency that occurs when malignant cells rapidly break down, releasing their contents into the bloodstream. This causes significant changes to the levels of electrolytes within the blood and can be life-threatening if not recognised and treated.

It most commonly occurs in patients with lymphoproliferative malignancies after initiation of treatment (usually after 12-72 hours)

Question 18

What electrolyte abnormalities may be seen in tumour lysis syndrome?

Answer 18

Hyperkalaemia
Hyperuricaemia
Hyperphosphataemia
Hypocalcaemia (secondary to hyperphosphataemia)

Question 19

What are some of the main risk factors for developing TLS?

Answer 19

Poorly differentiated lymphomas

Leukaemia

Fast-growing solid tumours (e.g. hepatocellular carcinoma, small cell lung cancer, breast cancer)

Large tumour burden

LDH >1,500 IU

High tumour sensitivity to chemotherapy

Pre-existing renal impairment
Concurrent use of nephrotoxic agents
Dehydration

Question 20

Symptoms of TLS are vague and non-specific.

Patients will present generally unwell with symptoms related to the electrolyte disturbances found in TLS such as :

Answer 20

D + V
Reduced urine output
Confusion, Lethargy
Muscle cramps and tetany
Syncope
Chest pain
Palpitations

Question 21

What may be found on examination of a patient with TLS?

Answer 21

signs of underlying malignancy e.g. masses, organomegaly, lymphadenopathy, pallor

Peripheral oedema: due to renal failure
Trousseau’s sign: due to hypocalcaemia
Chovstek’s sign: due to hypocalcaemia
Tachycardia: due to cardiac arrhythmias

Question 22

How should TLS be investigated?

Answer 22

Bedside:
* ECG
* Urine pH: if hyperuricaemia; urine pH < 5 = increased risk of precipitation of uric acid crystals, which may cause obstruction

Laboratory investigations:
* FBC: leukocytosis correlates with tumour burden
* U&Es: to identify renal impairment and electrolyte abnormalities
* Bone profile: hyperphosphataemia and hypocalcaemia.
* Uric acid: raised uric acid is both a risk factor for and a feature of TLS
* LDH: raised LDH is a risk factor for TLS

Question 23

Preventative measures for patients at high risk of developing TLS?

Answer 23

Intravenous hydration with normal saline for two days before treatment (aim to maintain urine output 100 mL/m²/hour)

Regular monitoring of blood tests (U&Es, bone profile, uric acid, LDH), including 3-4 times daily after starting treatment

Rasburicase should be given to patients with hyperuricaemia

Question 24

How can TLS be managed?

Answer 24

Intravenous fluids: aiming to maintain urine output >100 mL/m²/hour (monitor urine output hourly)

Observations should be monitored at least 4-6 hourly, including fluid balance assessment

Daily weights

Blood tests every 6 hours after diagnosis of TLS

ECG at baseline, consider cardiac monitor if hyperkalaemia/hypocalcaemia

Question 25

How can hyperuricaemia in TLS be corrected?

Answer 25

intravenous rasburicase for 3-7 days (use maximum dose allopurinol if rasburicase contraindicated)

Question 26

How can hyperkalaemia in TLS be corrected?

Answer 26

calcium gluconate for cardiac protection, followed by a glucose/insulin infusion

Question 27

How can hypocalcaemia in TLS be corrected?

Answer 27

symptomatic hypocalcaemia should be treated with IV calcium gluconate; seizures can be managed with anticonvulsant medication according to local guidelines

Question 28

Give some complications of TLS

Answer 28

AKI: due to calcium phosphate deposition and uric acid
Cardiac arrhythmias: due to hyperkalaemia and/or hypocalcaemia
Seizures: due to hypocalcaemia and/or hyperphosphataemia
Lactic acidosis: due to chemotherapy-induced cell death and AKI

Question 29

What type of pleural effusion does malignancy more commonly cause?

Answer 29

exudative

Question 30

Typical symptoms of a pleural effusion include:

Answer 30

Breathlessness
Cough
Pleuritic chest pain

Clinical findings may include reduced chest expansion, reduced air entry and a stony dull percussion note on the affected side.

Question 31

How might malignant pleural fluid appear once aspirated?

Answer 31

bloody

Question 32

Define neutropenic sepsis

Answer 32

a neutrophil count of 0.5 × 109 per litre or lower, plus one of the following:

Temperature ≥ 38°C or
Other signs or symptoms consistent with significant sepsis

Question 33

What can cause neutropenia?

Answer 33

Recent chemotherapy (most commonly within 7 – 10 days) causes neutropenia through bone marrow suppression and is the major cause of neutropenic sepsis

Extensive radiotherapy

Malignant bone marrow infiltration

Bone marrow failure secondary to non-malignant disease (e.g. aplastic anaemia)

Hypersplenism

Megaloblastic anaemia

Drug-induced (e.g. clozapine)

Question 34

Give some risk factors for neutropenic sepsis

Answer 34

Previous neutropenic sepsis
Patients over the age of 60
Significant co-morbidities
Advanced malignancy
Prolonged hospital admission
Mucositis (chemotherapy can induce mucosal damage and allow bacterial translocation)
Indwelling central venous catheters
Corticosteroids (causes immunosuppression)

Question 35

How should neutropenic sepsis be investigated?

Answer 35

Urinalysis: to look for UTI
ECG: all acutely unwell patients
Capillary blood glucose: to exclude hypoglycaemia

• Baseline blood tests (FBC, U&E, LFTs coagulation, CRP)
• Serum lactate
• Group and save
• Blood cultures: at least two sets from a peripheral vein plus a set from an indwelling line if present to look for a causative organism
• ABG: respiratory failure
• Microbiological cultures: wounds, urine, stool, sputum, and line tip (if indwelling line infection suspected).
• Viral respiratory swab

Question 36

How should neutropenic sepsis be managed?

Answer 36

Patients with suspected or confirmed neutropenic sepsis should receive empirical antibiotic therapy within one hour of arrival at hospital. Antibiotic therapy must not be delayed to wait for confirmation of neutropenia

Tazocin first line

Start sepsis 6!!!

Question 37

Give some complications of neutropenic sepsis

Answer 37

Single or multi-organ failure
VTE (e.g. pulmonary embolism)
DIC
Opportunistic or hospital-acquired infections
Delirium
Delays in chemotherapy leading to worse cancer outcomes
Psychological complications (e.g. anxiety regarding future infections and chemotherapy treatment)