Oncological Emergencies Flashcards
Hypercalcaemia of malignancy is a medical emergency. What is the corrected calcium level that classifies hypercalcaemia?
1 - >1.5 mmol/L
2 - >2 mmol/L
3 - >2.6 mmol/L
4 - >4 mmol/L
3 - >2.6 mmol/L
What % of patients with solid tumours experience hypercalcaemia of malignancy?
1 - 1-2%
2 - 12-20%
3 - 20-30%
4 - 50-70%
3 - 20-30%
Most common cause of hypercalcaemia
Malignancy with metastasis typically cause hypercalcaemia by which of the following mechanisms?
1 - tumour stimulate osteoblasts to degrade bone and release Ca2+
2 - tumour stimulate osteoclasts to build bone but release Ca2+
3 - direct osteolysis of the bone by bone metastasis
4 - all of the above
3 - direct osteolysis of the bone by bone metastasis
Osteolysis causes release of Ca2+ into the blood stream
IL-1 and TNF-a in malignancy are also linked with stimulating osteoclast maturation and more breakdown
Some patients can develop hypercalcaemia, even in the absence of metastasis. What is the most common thing secreted by tumours that can cause hypercalcaemia?
1 - ace inhibitor
2 - calcitonin
3 - parathyroid hormone related peptide
4 - erythropoietin
3 - parathyroid hormone related peptide
Binds to PTH receptors and acts in the same way as PTH
Some patients can develop hypercalcaemia, even in the absence of metastasis. Tumours secrete parathyroid hormone related peptide (PHTP). This can then cause which of the following?
1 - increases Ca2+ absorption in GIT
2 - increases Ca2+ reabsorption in kidney
3 - increases Ca2+ release from bones
4 - all of the above
4 - all of the above
In bone PTHP binds to osteoblast, releases RANK and M-CSF that stimulates osteoclasts and breaks down bone, releasing Ca2+
All of the following cancers have been shown to increase parathyroid hormone related peptide (PHTP), causing hypercalcaemia, EXCEPT which one?
1 - squamous cell carcinoma
2 - breast cancer
3 - renal cancer
4 - colon cancer
5 - prostate cancers, melanoma
6 - neuroendocrine tumours
4 - colon cancer
In addition to boney metastasis and parathyroid hormone related peptide (PHTP) that can cause hypercalcaemia, overexpression of 1-alpha hydroxylase, the enzyme responsible for converting 25-hydroxyvitamin D to calcitriol leads to excessive production of calcitriol (the active form of vitamin D), resulting in increased intestinal absorption of calcium and increased osteoclast activity. Which malignancy is this common in?
1 - breast cancer
2 - lung cancer
3 - lymphomas
4 - ovarian cancer
3 - lymphomas
Hypercalcaemia is an increased level of Ca2+ in the plasma. Which of the following are acute affects on the body caused by hypercalcaemia?
1 - polydipsia (thirst in an attempt to dilute)
2 - polyuria (bodies attempt to remove Ca2+)
3 - abdominal pain
4 - all of the above
4 - all of the above
Which of the following is NOT a chronic effects of hypercalcaemia?
1 - diarrhoea
2 - musculoskeletal aches / weakness
3 - neurobehavioral symptoms
4 - renal calculi (kidney stones)
5 - osteoporosis (weak, painful, fragile bones)
6 - raised blood pressure
1 - diarrhoea
- typically causes constipation
Use the mnemonic:
- Bones = pain and osteoporotic bones
- Stones = renal calculi
- Abdominal Groans = constipation and pancreatitis
- Psychiatric Moans = confusion and hallucinations
If left untreated is hypercalcaemia dangerous?
- yes
Can cause coma and death
MEDICAL EMERGENCY
In a tumour, which of the following would be correct in the blood sample suggesting hypercalcaemia?
1 - high PTH and Ca2+
2 - low PTH and high Ca2+
3 - low PTH and Ca2+
4 - high PTH and low Ca2+
1 - high PTH and Ca2+
PTH as tumour releases this
Ca2+ as PTH causes this
If a patient presents with >3mmol/L of Ca2+ but is asymptomatic, do they need hospital admission all the time?
- No
May just need fluids, assessment and discharged
Which 2 of the following may we see on an ECG in a patient if they have suspected hypercalcaemia?
1 - shortened PT interval
2 - prolonged PR interval
3 - widened QT interval
4 - shortened QT interval
2 - prolonged PR interval
4 - shortened QT interval
If a patient presents with potential hypercalcaemia, all of the following should be stopped, EXCEPT which one?
1 - zoledronic acid
2 - indapamide
3 - Ca+2 and vit D supplements
4 - vitamin A
1 - zoledronic acid
This stops bone break down, all others contribute to increasing serum Ca2+
Fluids are important to give in hypercalcaemia. How much of 0.9% saline should be given over 24h?
1 - 500ml - 1L
2 - 1-2L
3 - 3-4L
4 - 6-7L
3 - 3-4L
Slower rehydration rates in elderly and heart failure
In addition to addressing Ca2+ in hypercalcaemia, which 2 of the following are likely and need correcting?
1 - hyperkalcaemia
2 - hypermagnesaemia
3 - hypomagnesaemia
4 - hypokalcaemia
3 - hypomagnesaemia
4 - hypokalcaemia
If a patients hypercalcaemia remains above 3 mmol/L, which of the following medications should be given?
1 - indapamide
2 - vitamin A
3 - zolendronic acid
4 - spironolactone
3 - zolendronic acid
Give 4mg over 15 mins
Avoid if Creatinine >400 µmol/L (unless benefit outweighs potential risk
Side effects: GI upset, flu like symptoms, exacerbation of metastatic bone pain.
Chronic use can cause osteonecrosis of the mandible
How long does it typically take zolendronic acids to reduce Ca2+ in hypercalcaemia?
1 - <12h
2 - <48h
3 - <72h
4 - <120h
2 - <48h
Do not give further bisphosphonates until at least 4 days after previous dose
If a patient has refractory hypercalcaemia/life-threatening symptoms, which of the following can be given?
1 - Calcitonin
2 - Denosumab
3 - Glucocorticoids
4 - Dialysis
5 - all of the above
5 - all of the above
What is the definition of hyponatraemia?
1 - <120 mmol/L
2 - <135 mmol/L
3 - <150 mmol/L
4 - <200 mmol/L
2 - <135 mmol/L
Normal range is 135-145 mmol?L
Which of the following are symptoms of hyponatraemia?
1 - stupor/coma
2 - anorexia
3 - lethargy/confusion
4 - tendon reflexes reduces
5 - limp muscles (weak)
6 - orthostatic hypotension
7 - seizures/headaches
8 - stomach cramping
9 - all of the above
9 - all of the above
Although there are a number of causes of hyponatraemia, which of the following is most common?
1 - chemotherapy (nausea and vomiting)
2 - small cell lung cancer
3 - brain metastases
4 - medications (opioids, tricyclic antidepressants, SSRIs, NSAIDs, antiepileptics)
2 - small cell lung cancer
Excess production of Antidiuretic hormone by the tumour leading to SIADH
Does syndrome of inappropriate antidiuretic hormone (SIADH) cause water retention or excretion?
- retention
Causes a dilution effect of the blood and Na+
Hyponatraemia must be corrected slowly to reduce the risk of what?
1 - AKI
2 - splenomegaly
3 - oligodendrocyte degeneration and CNSmyelinolysis
4 - DKA
3 - oligodendrocyte degeneration and CNSmyelinolysis
Osmotic demyelination
Severe neurological sequelae, may be permanent
Alcoholics & malnourished are particularly at risk
In syndrome of inappropriate antidiuretic hormone (SIADH) which of the following is correct?
1 - euvolaemic
2 - hypervolemic
3 - hypovolemic
1 - euvolaemic
In syndrome of inappropriate antidiuretic hormone (SIADH) which 2 of the following are correct?
1 - low plasma sodium (<135mmol/L)
2 - low plasma osmolality (<270mmol/kg)
3 - high plasma sodium (>145mmol/L)
4 - high plasma osmolality (<295mmol/kg)
1 - low plasma sodium (<135mmol/L)
2 - low plasma osmolality (<270mmol/kg)
ADH causes retention of DH2O, which dilutes everything
In syndrome of inappropriate antidiuretic hormone (SIADH) which 2 of the following are correct?
1 - low urine sodium
2 - low urine osmolality (<100mmol/kg)
3 - high urine sodium
4 - high urine osmolality (>100mmol/kg)
3 - high urine sodium
4 - high urine osmolality (>100mmol/kg)
Na+ levels may not be high, but because body is retaining water, they appear higher
In syndrome of inappropriate antidiuretic hormone (SIADH) there is an increase in fluid volume, which stretches the blood vessels. Does this cause an increase or decrease in aldosterone?
- decrease
Aldosterone is released during low BP
Aldosterone is reduced during high BP
Low aldosterone means less Na_ retained by kidneys that increases Na+ urine content
When treating hyponatraemia, which of the following are treatment options?
1 - Fluid restriction (<1000ml/24h with daily U& E
2 - Demeclocycline
3 - Vasopressin (V2 receptor)antagonists
4 - slow NaCl infusion 1.8%, on HDU, caution with osmotic demyelination
5 - consult endocrinologist
6 - all of the above
6 - all of the above
Malignant spinal cord compression (MSCC) and cauda equina syndrome is a structural/obstructive emergency. What is the incidence of this in cancer patients?
1 - >45%
2 - 25-35%
3 - 5-10%
4 - 1-2%
3 - 5-10%
Early diagnosis and treatment can prevent functional loss and preserve quality of life
In 20% of patients this is 1st sign of cancer
All of the following are common places are primary cancers that can cause metastatic disease, EXCEPT which of the following?
1 - prostate
2 - lung
3 - testicular
4 - breast
5 - multiple myeloma
3 - testicular
Which part of the spine doe the majority of malignant spinal cord compression (MSCC) and cauda equina syndrome occur?
1 - thoracic spine
2 - lumbosacral spine
3 - cervical spine
4 - sacral spine
1 - thoracic spine
Accounts for 60-70%
The spinal cord ends at L1, if there is compression above L1, does this cause LMN or UMN symptoms?
- UMN (everything is heightened)
Below L1 causes lower motor neuron symptoms
Which of the following is NOT a sign of malignant spinal cord compression (MSCC)?
1 - pain is 1st symptom and precedes neurology symptoms by by several weeks
2 - pain is felt generally throughout the spine
3 - localisation of pain can be misleading e.g T10 –L1 met causing lower lumbar pain
4 - pain worse at night
5 - pain can develop into radicular quality
6 - pain may be worse on movement and cause mechanical instability
2 - pain is felt generally throughout the spine
Severe and worsening local pain at level of the lesion
Which of the following is NOT a red flags for cauda equina?
1 - Saddle anaesthesia
2 - Loss of sensation in the bladder and rectum
3 - Urinary retention or incontinence
4 - Faecal incontinence
5 - Bilateral sciatica
6 - Unilateral or severe motor weakness in the legs
7 - Reduced anal tone on PR examination
6 - Unilateral or severe motor weakness in the legs
Typically bilateral in nature
What imaging must be performed within 24 hours if you suspect cauda equina?
1 - spinal CT
2 - spinal MRI
3 - whole body MRI
4 - PET-CT
3 - whole body MRI
Request as “suspected cord compression” and discuss request
Which medication should be given to patients alongside adequate analgesia?
1 - Memantine
2 - Dexamethasone
3 - Haloperidol
4 - Alendronic acid
2 - Dexamethasone
Always prescribe PPI and monitor blood glucose
Patients with malignant spinal cord compression (MSCC) and cauda equina are advised bed rest and to lie flat or maximum 30◦ upright with spinal precautions until stability assessed. What should they be given as they are likley to be emobilised for prolonged periods?
1 - tranexamic acid
2 - asprin
3 - thromboprophylaxis
4 - all of the above
3 - thromboprophylaxis
Patients with malignant spinal cord compression (MSCC) and cauda equina will need to be staged using CT CAP. All of the following markers will be checked. Match the marker with the malignancy:
- CEA, CA125, CA19-9, PSA, myeloma screen
- multiple myeloma, pancreatic, ovarian, colon, prostate
- CEA = colon
- CA125 = ovarian
- CA19-9 = pancreatic
- PSA = prostate
- myeloma screen = multiple myeloma
What is the most common management of malignant spinal cord compression (MSCC)?
1 - chemotherapy
2 - surgical incision
3 - systemic anti-cancer treatment
4 - radiotherapy
4 - radiotherapy
Surgery should be explored if surgical fit
Systemic anti-cancer treatment may be more appropriate than radiotherapy for some malignancies, for example, lymphomas, plasma-cell tumours, germ cell tumours or untreated small cell cancers.
Which of the following may cause syncope, SOB, stridor, neck and facial swelling, dizziness and headaches, collateral development on the chest?
1 - heart failure
2 - superior vena cava obstruction
3 - pancost tumour
4 - COPD
2 - superior vena cava obstruction
Can occur following surgery for lung cancer
Cancer has come back and caused an obstruction that grows insidiously
Which of the following would NOT be part of treatment for a patient presenting with superior vena cava obstruction?
1 - sit the up
2 - O2 as required
3 - antibiotics
4 - dexamethasone (steroids)
5 - stenting
6 - anticoagulant
7 - CT scan
3 - antibiotics
Steroids can affect patients sleep
Always prescribe PPI with steroids as they can cause ulcers
Which of the following are common symptoms that present in superior vena cava obstruction?
1 - face and neck swelling
2 - headaches/dizziness
3 - syncope
4 - conjunctival oedema
5 - compensatory collaterals on the chest
6 - all of the above
6 - all of the above
Raised intracranial pressure can be a medical emergency. Is this always acute in presentation?
- no
Acute =head trauma
Chronic = tumour
What is the normal pressure inside skull for adults?
1 -1-2 mmHg
2 - 3-7 mmHg
3 - 7-15 mmHg
4 - 20-30 mmHg
3 - 7-15 mmHg
Anything above this is classed as increased intracranial pressure
Which of the following contribute to the intracranial pressure (ICP)?
1 - CSF
2 - blood
3 - brain
4 - all of the above
4 - all of the above
If one of these 3 increases, there must be a compensatory reduction in the others to maintain normal ICP of 7-15 mmHg
There are a myriad of causes of raised intracranial pressure (ICP). Which of the following patients is most likely to experience idiopathic intracranial hypertension, a cause of raised ICP?
1 - pregnant obese female
2 - weight training male aged 35
3 - pregnant women with normal BMI
4 - patient aged >65
1 - pregnant obese female
Which of the following is NOT a common cause of raised intracranial pressure (ICP)?
1 - idiopathic intracranial hypertension
2 - traumatic head injuries
3 - hypotension
4 - infection
5 - meningitis
6 - tumours
7 - hydrocephalus
3 - hypotension
Raised intracranial pressure (ICP) can present with a variety of symptoms, but which 2 of the following are considered indicative of raised ICP?
1 - papilledema
2 - headache
3 - vomiting
4 - reduced levels of consciousness
5 - cushings triad
6 - seizures
7 - slow pupil reflexes
1 - papilledema
3 - vomiting
Is ICP more likely to be due to metastatic disease or space occupying lesion?
- metastatic disease
Common causes include:
- Lung, renal, melanoma, breast, colorectal
Which of the following is the main location of a space occupying lesion in the brain due to metastatic disease
1 - cerebral hemispheres
2 - cerebellum
3 - brainstem
1 - cerebral hemispheres
Accounts for 80% of cases
Raised intracranial pressure (ICP) can present with a variety of symptoms, including cushings triad. Which of the following is not part of the Cushing triad?
1 - widened pulse pressure (increasing systolic, decreasing diastolic)
2 - papilledema
3 - bradycardia
4 - irregular respirations
2 - papilledema
Cushings triad is a late sign
Which cranial nerve plasy is most likely to occur following a space occupying lesion due to metastatic disease?
1 - CN II
2 - CNIII
3 - CN VII
4 - CN X
2 - CNIII
- Patients eye will be down and out
Ptosis and Mydriasis - Nerve runs close to facila bones and is vulnerable to disruption from ICP
In patients with suspected raised intracranial pressure (ICP), what is the first line test?
1 - lumbar puncture
2 - head CT/MRI
3 - blood microbiology
4 - invasive invasive ICP monitoring
2 - head CT/MRI
Helps identify cause, before more invasive tests.
Although normal intracranial pressure is 7-15 mmHg, what is the cut off used to determine if patients need treatment?
1 - >15 mmHg
2 - >20 mmHg
3 - >30 mmHg
4 - >45 mmHg
2 - >20 mmHg
What is the most effective way of measuring intracranial pressure?
1 - estimate from BP
2 - invasive catheter placed into lateral ventricles
3 - estimate from optic disc
4 - lumbar puncture
2 - invasive catheter placed into lateral ventricles
Lumbar puncture can be used to reduce ICP, but not long term suitable
Which 2 of the following can be effective at reducing intracranial pressure?
1 - head elevation
2 - leg elevation
3 - controlled hyperventilation
4 - cardiovascular exercise
1 - head elevation
3 - controlled hyperventilation
How can 3 controlled hyperventilation reduce intracranial pressure (ICP)?
1 - increases CO2 levels
2 - increases O2 levels
3 - reduces O2 levels
4 - reduces CO2 levels
4 - reduces CO2 levels
- CO2 acts as a vasodilator
- lower CO2 vasoconstricts cerebral arteries and reduces ICP
- rapid reduction in ICP but only temporary, need to fix cause
Which of the following medications can be used to lower intracranial pressure?
1 - Memantine
2 - Mannitol
3 - Furosemide
4 - Bendroflumethiazide
2 - Mannitol
Supposably works as an osmotic diuretic
Which of the following medications can be used to reduce ICP due to space occupying lesion?
1 - Memantine
2 - Dexamethasone
3 - Furosemide
4 - Bendroflumethiazide
2 - Dexamethasone
Also do the following:
- Document GCS score and monitor regularly
- Give an anticonvulsant if seizure
- Analgesia
Which of the following is NOT a red flag for sepsis?
1 - SBP < 90mmHg or MAP <65mm Hg
2 - Respiratory rate >25/min
3- Needs O2 to keep sats >92%
4 - Heart rate >90bpm
5 - voice or pain or unresponsive
6 - Lactate >2mmol/L
7 - Urine output< 0.5ml/L
8 - Not passed urine in last 18 hours
9 - Non blanching rash, mottled/ ashen/ cyanotic
1 - Chemotherapy/ SACT within past 4 weeks (neutropenic sepsis)
4 - Heart rate >90bpm
This is HR >130bpm
Which 2 are part of the criteria that make up neutropenic sepsis?
1 - temp >38
2 - lactate >1.8
3 - neutrophils <0.5 x 109/L
4 - mottled rash
1 - temp >38
3 - neutrophils <0.5 x 109/L
If a patient has chemotherapy, they may be at increased risk of neutropenic sepsis. Which of the following is NOT one of the sepsis 6?
1 - take blood sample
2 - take lactate sample
3 - measure urine output
4 - take lumbar puncture sample
5 - give antibiotics
6 - give oxygen
7 - give fluid challenge
4 - take lumbar puncture sample
Patients must be given broad spectrum antibiotics to cover infection using trust guidelines
Blood cultures must be taken, but do not delay antibiotics
If someone is suspected of having neutropenic sepsis, how quickly should the sepsis 6 be completed?
1 - <30 mins
2 - <60 mins
3 - <120 mins
4 - <360 mins
2 - <60 mins
If suspect sepsis do not hold back on any of the sepsis 6, even if patient appears well
If a patient has neutropenic sepsis, what treatment can be given in an attempt to raise the neutrophil count?
1 - Granulocyte colony stimulating factor (GCSF)
2 - Erythropoietin
3 - Anti-diuretic hormone
4 - All of the above
1 - Granulocyte colony stimulating factor (GCSF)
Called Filgrastim
MUST STOP ONCE NEUTROPHIL COUNT IS >1
Tumour lysis is when there is a rapid cancer cell death (lysis). Is this dangerous?
- Yes
Can be life threatening
Tumour lysis is when there is a rapid cancer cell death (lysis), which can be life threatening. During tumour lysis, which of the following are released in high amounts?
1 - uric acid
2 - phosphate
3 - K+
4 - all of the above
4 - all of the above
Can lead to hypocalcaemia and then hyperphosphataemia.
Essentially, causes acute nephropathy and acute renal failure
Patients who experience tumour lysis will typically have
- Hyperkalaemia
- Hyperphosphataemia
- Hyeruricaemia
- Hypocalcaemia
Which of the following can be caused by this electrolyte imbalance:
1 - arrhythmias
2 - neuromuscular irritability
3 - seizures
4 - death
5 - all of the above
5 - all of the above
Need to do an ECG to monitor cardiac rhythm
Renal failure can occur in tumour lysis but this is typically secondary due to what?
1 - Hyperkalaemia
2 - Hyperphosphataemia
3 - Hyeruricaemia
4 - Hypocalcaemia
3 - Hyeruricaemia
Patients with tumour lysis are typically given which of the following?
1 - rifampicin
2 - cyclizine
3 - omalizumab
4 - allopurinol
4 - allopurinol
This is given in low risk patients.
High risk patients given Rasburicase
High urate is common in malignancy due to lysis of tumours, which is the same medication used in acute gout
Tumour lysis is when there is a rapid cancer cell death (lysis) can be life threatening, causing acute nephropathy and acute renal failure. What is the treatment for this?
1 - Na+ infusion to balance electrolytes
2 - blood drain to dilute
3 - hyperdiuresis via excessive and often forced fluids
4 - all of the above
3 - hyperdiuresis via excessive and often forced fluids
3L/24hr to maintain urine output > 100ml/m2/hour
If required diuretics to maintain urine output > 100ml/m2/hour
Given alongside allopurinol
Nearly all cytotoxics can cause GIT irritation and diarrhoea, which can lead to dehydration and AKI. If the diarrhoea is caused by chemotherapy/radiotherapy, which 2 of the following should be prescribed to patients?
1 - loperamide
2 - codeine
3 - opioids
4 - senna
1 - loperamide
2 - codeine
Loperamide is an anti-diarrhoeal
