Oncological Emergencies

Question 1

Why can spinal cord compression occur in the setting of cancer?

Answer 1

Extradural metastases

Question 2

What is the commonest site for extradural metastases?

Answer 2

Thoracic spine

Question 3

Which primary cancers commonly metastasise to the spine?

Answer 3

Lung
Breast
Unknown primaries
Prostate
Renal
Lymphoma
Myeloma
Nasopharyngeal carcinoma

Question 4

What are the symptoms and signs of spinal cord compression?

Answer 4

Early > pain
Intermediate > weakness
Late > autonomic dysfunction
- Bladder
- Bowel

Question 5

How is spinal cord compression diagnosed?

Answer 5

MRI spine

Question 6

What is the prognosis for spinal cord compression caused by metastasis?

Answer 6

Extent of neurological impairment prior to therapy

Question 7

What is the treatment for spinal cord compression caused by metastasis?

Answer 7

Steroids
Surgery
Radiotherapy
Chemotherapy for chemosensitive tumours

Question 8

How is febrile neutropaenia defined?

Answer 8

Fever >38 degrees for >1 hour/single reading of 38.3 degrees

Absolute neutrophil count <500 cells/uL

Question 9

What are the causes of febrile neutropaenia?

Answer 9

Infective
- Bacteria
- Fungi
- Viruses
Non-infective
- Tumour-related
- Drug-induced

Question 10

What are the signs and symptoms of febrile neutropaenia?

Answer 10

Absence of inflammatory response, in presence of low neutrophil count and fever

Question 11

What are the risk factors for neutropaenic fever?

Answer 11

Age
Gender
Poor performance status
Poor nutrition
Elevated LDH
Bone marrow failure
Lymphopaenia
Advanced malignancy
Dose intense/dose dense high dose chemotherapy
Failure to administer prophylactic growth factors in high risk regimes

Question 12

What are the investigations for febrile neutropaenia?

Answer 12

Blood cultures
- Central
- Peripheral
- Including fungal
CXR
\+/-
- Urine microscopy and cultures
- Stool examination
- Cultures of drainage from catheter sites
\+/- CT scan

Question 13

What is the treatment for febrile neutropaenia?

Answer 13

Depends on low/high risk

Low risk patients may be managed as outpatients

Question 14

What indices are used to commonly stratify whether febrile neutropaenia is low or high risk?

Answer 14

Infectious Diseases Society of America (IDSA) > high/low risk
National Comprehensive Cancer Network (NCCN) > high/intermediate/low risk
Multinational Association for Supportive Care in Cancer (MASCC) > risk of medical complications - high risk <21

Question 15

What is the initial empirical antibiotic therapy in febrile neutropaenia?

Answer 15

Monotherapy with
- Ceftazidime
- Cefepimee
- Imipenam
Combination therapy with anti-pseudomonal beta lactam + aminoglycosides
Vancomycin added if 
- Catheter-related infections
- Mucosal damage
- Quinolone prophylaxis
- Positive blood cultures
Antifungals when indicated
GCSFs not routinely indicated

Question 16

What is the outpatient treatment of febrile neutropaenia?

Answer 16

Ciprofloxacin + amoxicillin-clavulanate
Monotherapy with
- Levofloxacin
- Ciprofloxacin
Ciprofloxacin + clindamycin

Question 17

How would you acutely manage a patient with acute promyelocytic leukaemia (APML) who presents to ED with a severe nosebleed (4 tea towels), feels nauseated, and feels lightheaded?

Answer 17

Emergency resuscitation
Management of coagulopathies
Transfusion
- Red cells and platelets
- Alloimmunisation
- CMV precautions
- ABO compatibility
- Infections

Question 18

What are the possible causes of acute brain syndrome?

Answer 18

Electrolyte abnormalities
- Hypercalcaemia
- Hyponatraemia
- Hypo-/hyperglycaemia/ketosis
Sepsis
- Chest
- UTI
Brain metastases
Cardiac
- Heart failure
- Silent infarct
Depression
Dementia