Oncological Emergencies

Question 1

Malignancies most commonly associated with hypercalcaemia

Answer 1

Lung
Breast
Renal
Multiple myeloma
Adult T cell lymphoma

Question 2

Sx of hypercalcaemia

Answer 2

Bones: pain
Stones: polydipsia, polyuria
Abdo groans: pain, N+V, constipation
Psychic moans: confusion, lethargy

Question 3

Ix for hypercalcaemia

Answer 3

Ionised calcium
Total calcium
Check PTH (N/L)

Question 4

4 Complications of hypercalcaemia

Answer 4

Coma
Seizures
Renal failure
Cardiac arrhythmias

Question 5

Tx for hypercalcaemia

Answer 5

Intensive rehydration- IV saline

IV bisphosphonates- pamidronate disodium/ Zoledronic acid

Question 6

Tx for calcitriol mediated hypercalcaemia

Answer 6

IV saline

Prednisolone PO

Question 7

ECG change in hypercalcaemia

Answer 7

Shortened QT interval

Question 8

Which cancers most commonly metastasise to bone and cause spinal cord compression?

Answer 8

Breast
Thyroid
Renal
Prostate
Lung
Multiple myeloma

Question 9

5 Sx of spinal cord compression

Answer 9

Back pain
Paresis/ Paralysis
Paraesthesias
Sphincter dysfunction (urinary or anal)
Hyper-reflexia

Question 10

Ix for spinal cord compression

Answer 10

MRI Spine

Question 11

Tx for spinal cord compression

Answer 11

Dexamethasone IV
Enoxaparin SC
Maintenance of volume + BP
Omeprazole PO (prevent gastric stress ulcer)
Catheter
Bowel regimen prophylaxis

Question 12

What motor symptoms may be caused by spinal cord compression?

Answer 12

Weakness or paralysis
UMN signs BELOW the level of the lesion
LMN signs AT the level of the lesion

Question 13

What is Brown-Sequard Syndrome?

Answer 13

HEMISECTION of the spinal cord (due to tumour)
Ipsilateral spastic paralysis
Ipsilateral loss of vibration + proprioception
Contralateral pain + temperature sensation loss from 1-2 segments below lesion.

Question 14

What is Cauda equine syndrome?

Answer 14

Compression of nerves caudal to the level of spinal cord termination

Question 15

List 7 signs and symptoms of caudal equine syndrome

Answer 15

Low back pain + pain in legs
LL motor weakness + sensory deficits: usually asymmetrical with loss of reflexes
Saddle anaesthesia.
Loss of anal tone + sensation.
Urinary dysfunction (retention, difficulty starting or stopping, overflow incontinence, decreased bladder + urethral sensation)
Bowel disturbances: incontinence + constipation.
Sexual dysfunction.

Question 16

What may suggest spinal cord compression rather than cauda equine syndrome?

Answer 16

Increased lower limb reflexes + other UMN signs e.g. extensor plantars indicate spinal cord involvement + excludes CES

Question 17

What is febrile neutropenia?

Answer 17

Raised temperature
Neutrophils (ANC) <500 cells/microlitre
In chemotherapy patients

Question 18

RFs for febrile neutropenia

Answer 18

Recent +/- high dose chemotherapy
Age >65
Pre-existing organ dysfunction
Haematological Ca

Question 19

3 Sx of febrile neutropenia

Answer 19

Fever
Tachycardia
Hypotension

Question 20

Ix for febrile neutropenia

Answer 20

Give empirical Abx before Ix
Bloods
Blood cultures
Septic screen

Question 21

Tx for febrile neutropenia

Answer 21

Piperacillin/ Tazobactam IV
+/- Amikacin
+ Vancomycin if MRSA or viridan’s group streptococci

Question 22

Tx for febrile neutropenia with penicillin allergy

Answer 22

Meropenem

Question 23

Aetiology of superior vena cava obstruction

Answer 23

Lung cancer: NSCLC 50%, SCLC 25%
Lymphoma
Thrombosis e.g. from central venous catheters, Multiple pacemaker leads

Question 24

RF for superior vena cava obstruction

Answer 24

Smoking hx
Central venous catheter
Multiple pacemaker leads

Question 25

4 Sx of superior vena cava obstruction

Answer 25

SOB
Cough
Dysphagia
Dizziness/ headaches

Question 26

5 Signs of superior vena cava obstruction

Answer 26

Oedema of face + extremities 
Facial plethora
Distended neck/ chest veins
Hoarse voice
Stridor

Question 27

Ix for superior vena cava obstruction

Answer 27

CT CAB + IV contrast

Transthoracic needle aspiration biopsy

Question 28

Immediate tx for superior vena cava obstruction with acute airway obstruction

Answer 28

Intubate
Dexamethasone +/- anticoagulant (if clot)
+/- Radiotherapy (precludes subsequent biopsy in 1st presentations)
+/- Stenting (if haemodynamically unstable)

Question 29

Tx for superior vena cava obstruction

Answer 29

Chemotherapy (Lymphoma, germ cell + SCLC)

Radiotherapy

Question 30

What is tumour lysis syndrome?

Answer 30

Metabolic abnormalities that can occur as a complication during tx where large amounts of tumour cells lyse at the same time releasing contents

Question 31

Characteristics of tumour lysis syndrome

Answer 31

High phosphate
High potassium 
High urate
Low calcium
Acidosis

Question 32

Sx of tumour lysis syndrome

Answer 32

N+V

Diarrhoea

Question 33

Tx for tumour lysis syndrome

Answer 33

IV Fluids
Furosemide (PO4)
Rabicurase (urate)
Calcium gluconate, insulin + glucose (K+)
Aluminium hydroxide (PO4)

Question 34

Complications of tumour lysis syndrome

Answer 34

AKI
Cardiac arrhythmia
Seizure
Neuromuscular dysfunction
Death

Question 35

`Most common cancers with occurrence of tumour lysis syndrome

Answer 35

Highly proliferative, bulky, chemosensitive haematological malignancies:
High-grade non-Hodgkin’s lymphoma (e.g., Burkitt’s lymphoma)
Acute lymphoblastic leukaemia

Question 36

Ix for tumour lysis syndrome

Answer 36

Bloods: metabolic + biochemical profile

Question 37

Tx for tumour lysis syndrome if resistant to medical management

Answer 37

Dialysis

Question 38

RF for tumour lysis syndrome

Answer 38

High tumour burden with rapid response to tx

Question 39

Prevention of tumour lysis syndrome

Answer 39

Prophylactic allopurinol/ rabicurase (CI in G6PD deficiency)
Hydration
Monitor electrolytes, urate, lactate, LDH