ONCOLOGICAL EMERGENCIES Flashcards
A 50-year-old woman with early breast cancer presented with fatigue to the accident and emergency department on day 7 of her first adjuvant chemotherapy cycle. On examination, her temperature was 38.5°C, her pulse was 110 beats per minute and her blood pressure was 110/70 mmHg. A full blood count was requested. What is the most appropriate next step?
Await FBC results
IV broad spectrum antibiotics
IV broad spectrum antibiotics and granulocyte colony-stimulating factor (G-CSF)
Oral broad spectrum antibiotics
Oral broad spectrum antibiotics and granulocyte colony-stimulating factor (G-CSF)
This person should be treated as having neutropenic sepsis until proven otherwise. The answer is IV broad spectrum antibiotics.
How long after chemotherapy is someone most likely to suffer from neutropenia?
7-10 days but this can be earlier or later
What are the first line antibiotics that you would give to a chemotherapy patient in whom you suspected neutropenic sepsis?
Piperacillin with tazobactam 4.5g QDS
What are the first line antibiotics that you would give to a chemotherapy patient who was hypotensive and in whom you suspected neutropenic sepsis?
Piperacillin with tazobactam 4.5g QDS
PLUS
Gentamicin 7 mg/kg OD
What are the first line antibiotics that you would give to a chemotherapy patient who is allergic to penicillin and in whom you suspected neutropenic sepsis?
Reaction to penicillin is rash only:
Meropenem 1g TDS or Cetazidime 2g TDS
PLUS
Gentamicin 7 mg/kg OD
Documented anaphylaxis:
Ciprofloxacin 400 mg BD
PLUS
Amikacin 7.5 mg/kg OR Gentamicin 7 mg/kg
What are the sepsis six?
High flow oxygen
Take blood cultures
IV antibiotics
Measure serum lactate and FBC
IV fluids
Insert catheter to measure accurate urine output
A 26 year old presents with a short history of facial swelling, headache and shortness of breath. What oncological emergency might this be?
Superior vena cava obstruction
What are the clinical features of vena cava obstruction?
Shortness of breath
Face or arm swelling or oedema
Headache
Hoarseness
Venous distention in the neck and distended veins in the upper chest and arms
Lightheadedness
Cough
Edema of the neck, called the collar of Stokes
What types of cancer most commonly cause superior vena cava obstruction?
Non small cell lung cancer - 50%
Small cell lung cancer - 22%
Lymphoma - 12%
Metastatic - 9%
Breast cancer
Kaposi’s sarcoma
What are the non-cancerous causes of superior vena cava obstruction?
Aortic aneurysm
Mediastinal fibrosis
Goitre
SVC thrombosis
How life threatening is superior vena cava obstruction?
Often not immediately, so an attempt should be made to make a definitive diagnosis and obtain tissue samples.
How do you treat superior vena cava obstruction caused by malignancy?
High dose steroids results in symptomatic relief
Intravascular stenting can be good palliative treatment
Removal or shrinking of tumour is clearly best course, however, surgical removal is almost impossible in these situations.
Small cell lung cancer: chemotherapy + radiotherapy
Non-small cell: radiotherapy
What are the red flags for spinal cord compression?
Cauda equina:
Bladder dysfunction
Sphincter disturbance
Saddle anaesthesia
Lower limb weakness
Gait disturbance
Lying flat increases pain
Worse at night
Refractory to treatment
Thoracic or cervical back or neck pain
What percentage of cancer patients are affected by metastatic spinal cord compression?
5-10%
What are the three cancers most commonly associated with metastatic spinal cord compression?
Lung
Breast
Prostate
How does spinal cord compression lead to nerve damage?
Direct compression leads to oedema, venous congestion and demyelination
Prolonged compression leads to vascular injury and hence infarction of spinal cord.
What imaging should you order for someone with suspected spinal cord compression?
Whole spine MRI
How do you manage someone with spinal cord compression?
Corticosteroids (dexamethasone 16 mg loading dose and until treatment is planned) are routinely given to reduce tumour bulk or spinal cord swelling
Surgery is the initial treatment of choice for patients with spinal cord compression as radiotherapy will not treat structural failure and so decompression and/or stabilisation (with or without bone graft, instrumentation, and vertebral reconstruction) is needed to prevent further neurological damage.
Surgery not always appropriate though
What are the factors that would indicate a good prognosis following treatment for spinal cord compression?
Breast cancer as the primary site
Solitary or few spinal metastases
Absence of visceral metastases
Ability to walk unaided
Minimal neurological impairment
No previous radiotherapy
What are the factors that would indicate a poor prognosis following treatment for spinal cord compression?
Lung or melanoma as primary
Multiple spinal metastases
Visceral metastases
Unable to walk
Severe weakness
Recurrence after radiotherapy
What percentage of cancer patients are affected by brain metastases?
Up to 40%
What is the prognosis of a patient once brain metastases have been diagnosed?
1-2 months
What are the most common primary sites for cancers leading to brain metastases?
Lung cancer - 42%
Breast cancer - 19%
Colorectal - 9%
Melanoma - 7%
Unknown primary - 7%
What are the most common presenting symptoms of brain mets?
Headache
Focal weakness
Ataxia
Seizures
Nausea and vomiting
Drowsiness
Confusion
Altered personality
Cranial nerve palsies
What investigations would you want to do for someone in whom you suspected brain metastases?
CT head with IV contrast
MRI may help with resectability
How do we manage confirmed brain metastases?
High dose steroids
Treat seizures with anticonvulsants
MDT - neurosurgeons, radiotherapists, palliative care
Whole brain radiotherapy - standard palliative treatment
Neurosurgery
Stereotactic radiosurgery
What are the side effects of whole brain radiotherapy in the treatment of brain metastases?
Fatigue
Alopecia
Scalp erythema
Impaired cognitive function
What are the indications for performing neurosurgery on someone with brain metastases rather than palliation with whole brain radiotherapy?
Resection of solitary or 3 or less accessible metastases
Palliation of hydrocephalus / debulking of large metastases
Biopsy for histological diagnosis
What is stereotactic radiosurgery?
Gamma-knife and linear particle accelerator-based systems that deliver high dose RT with mm accuracy to a sharply defined target, sparing surrounding normal tissue
What are the primary cancers most commonly responsible for bowel obstruction?
Colorectal
Gynaecological
What are the clinical features of bowel obstruction?
Abdominal pain
Vomiting
Constipation
What investigations should be done to confirm bowel obstruction?
Plan X-ray
CT
What are the factors that would indicate a poor prognosis following treatment for malignant bowel obstruction?
Chemoresistance
Large volume ascites
Multiple site disease
Albumin of less than 25g/L
What are the factors that would indicate a good prognosis following treatment for malignant bowel obstruction?
Chemosensitivity
No/small volume ascites
Single-site disease
Albumin of more than 25g/L
How do we manage someone with malignant bowel obstruction?
Drip and suck - NG tube and IV fluids
Enema if faecal impaction is thought to be contributing
Steroids - reduce bowel wall oedema
Anti-emetics
Motility agents (if sub-acute) - metoclopramide
Antisecretory agents (octreotide) to reduce GI secretion
Surgery
When would we decide to take a patient with bowel obstruction to surgery?
If symptoms fail to resolve after 48 hours of conservative management
What are the surgical options for management of malignant bowel obstruction?
Resection of tumour
Bypass
Formation of stoma
Stenting
What percentage of cancer patients will develop a VTE?
20%
Why are cancer patients more at risk of VTE?
Hypercoagulable state - tumour cells release factors that activate the coagulation system
Sick patients in bed leads to venous stasis
More likely to have surgery
What are the cancer related risk factors for developing a VTE?
Extensive disease
Chemotherapy
Hormonal treatment
Central venous catheter
Recent surgery
What is the long term treatment for VTE associated with malignancy?
NOT warfarin
LMWH
Why do we not give cancer patients warfarin to prevent recurrent VTEs?
Unstable INRs as a result of changeable nutrition, liver function and drug interactions.
What proportion of cancer patient will develop hypercalcaemia?
10-30%
What are the cancers most commonly associated with hypercalcaemia?
Breast
Lung
Melanoma
What are the clinical features of hypercalcaemia?
Lethargy
Confusion
Anorexia
Nausea
Constipation
Polyruria and polydipsia - severely volume deplete
Hypotensive
Tachycardia
How do we treat hypercalcaemia in a cancer patient?
Address volume depletion with IV fluids - may require large amounts
Bisphosphonates (pamidronate or zoledronic acid) - block osteoclastic bone reabsorption
Steroids
SC calcitonin - short lived effect
Treat underlying disease
What are the cancers most commonly associated with tumour lysis syndrome?
Leukaemia
Lymphoma
What are the characteristic electrolyte imbalances of tumour lysis syndrome?
Hyperkalaemia
Hyperphosphataemia
Hypocalcaemia
Hyperuricaemia
What are the clinical features of tumour lysis syndrome?
Nausea and vomiting
AKI
Seizures
Cardiac arrhythmias
Why does tumour lysis cause hypocalcaemia?
Because the sudden rise in phosphate causes high levels of calcium phosphate to be made and calcium is therefore used up.
What is the name of the classification system for tumour lysis syndrome?
Cairo-Bishop definition
How does the Cairo-Bishop system classify tumour lysis syndrome?
Laboratory tumour lysis syndrome is an abnormality in two or more of the following:
Uric acid of more than 475umol/l or 25% increase
Potassium of more than 6 mmol/l or 25% increase
Phosphate of more than 1.125mmol/l or 25% increase
Calcium of less than 1.75mmol/l or 25% decrease
Clinical tumour lysis syndrome is lab tumour lysis syndrome factors plus one or more of:
Increased serum creatinine (1.5 times upper limit of normal)
Cardiac arrhythmia or sudden death
Seizure
