Oncological emergencies

Question 1

What are the oncological emergencies

Answer 1

Neutropenic sepsis
Metastatic spinal cord compression
Superior vena cava obstruction
Hypercalcaemia
Tumour lysis syndrome

Question 2

Management for neutropenic sepsis

Answer 2

Immediate assessment and vigorous resuscitation
Septic screen - CXR< blood cultures, Urine MC&S
Empirical antibiotics: Piperacillin-Tazobactam
Discuss with oncology re GCSF

Question 3

What is used to prevent neutropenic sepsis

Answer 3

Dose reduction of chemo
Prophylactic GCSF

Question 4

Symptoms and signs of spinal metastases

Answer 4

Back (worse on lying down and coughing)
Lower limb weakness
Sensory loss and numbness
Above L1: UMN
below L1: LMN
Tendon reflexes increased below the level of the lesion and absent at the level

Question 5

Investigations for metastatic spinal cord compression

Answer 5

Neurological exam - assess leg weakness + perineal sensation and anal tone
MRI whole spine
CT for staging

Question 6

Management for metastatic spinal cord compression

Answer 6

1. high dose PO dexamethasone
2. Analgesia

Spinal protection: log-roll, bed rest
urgent oncological assessment for consideration of radiotherapy or surgery

Question 7

Aetiology of superior vena cava obstruction

Answer 7

Malignant
- Cancer responsible for 90%
- NSLC (50%), SCLS (20%) (2-4% patients with lung cancer develop SVCO )
- Lymphoma (10%)
- Germ cell tumours (3%)
- Kaposi’s sarcoma
Non-malignant
- Central venous catheter thrombosis
- aortic aneurysm
- mediastinal fibrosis
- goitre

Question 8

Symptoms and signs of superior vena cava obstruction

Answer 8

Dysphagia
Dyspnoea
Dizziness
Headaches
Congestion
Swelling

Upper limb and facial oedema
Neck vein engorgement
Dilated superficial veins

Question 9

management for superior vena cava obstruction

Answer 9

Dexamethasone ± anticoagulation
Stenting (If haemodynamically unstable and/or chemotherapy or radiotherapy is not possible)
Chemotherapy for lymphoma, germ cells, and SLCL, response rate up to 80%
Radiotherapy for symptomatic improvement within 48 hours

Question 10

Causes of hypercalcaemia of malignancy

Answer 10

PTHrP production (80%)
Osteolytic bone mets (20%)
Ectopic PTH secretion or vit D secreting lymphoma (1%)

Question 11

Symptoms of hypercalcaemia of malignancy

Answer 11

Fatigue
Anorexia
Muscle weakness
Nausea
Abdo pain
Constipation
Confusion

Question 12

Management of hypercalcaemia of malignancy

Answer 12

Rehydration with normal saline
Review medications and stop and thiazides of Ca supplements
Consider bisphosphonates - Zometa - zoledronic acid
- Response within 2-4 days, Nadir 7-10 days, effective 90%
Refractory cases: Repeat bisphosphonates | Denosumab | calcitonin | steroids

Question 13

What is tumour lysis syndrome

Answer 13

Group of metabolic abnormalities that can occur as a complication during the treatment of cancer, where large amounts of tumour cells are killed off (lysed) at the same time as treatment, releasing contents into the bloodstream

Raised potassium, phosphate, and uric acid
Low calcium
Acidosis

Question 14

Management for tumour lysis syndrome

Answer 14

1. ECG (hyperkalaemia)
2. Fluids

Treat electrolyte abnormality
Phosphate: phosphate binder
potassium: calcium gluconate + insulin/detrose
Uric acid: Allopurinol/rasburicase

Early discussion regarding dialysis/renal replacement therapy

Question 15

What is used for prophylaxis of tumour lysis syndrome

Answer 15

Important in all intermediate/high risk patients e.g. high tumour burden with rapid treatment response
Prophylactic treatment e.g. allopurinol/rasburicase + test for G6PD deficiency
Hydration
Monitor electrolytes