Oncological emergencies Flashcards
What is the most common site for MSCC?
Thoracic (70%)
Lumber (20%) > cervical > sacral
Why should doctors be suspicious of thoracic back pain in all patients?
Thoracic back pain is less common in general population than pain originating from cervical and lumbar regions
~25% of patients with MSCC have no cancer diagnosis (i.e. this is their first presentation)
Three types of pain that occur inn MSCC?
- Local pain (at rest)
- Mechanical pain (received by rest)
- Radicular pain (dermatomal neuropathic)
Additional symptoms of MSCC?
Lower extremity weakness and hyperreflexia (hyporeflexcia if cauda equina compressed)
Sensory loss - typically in same dermatome as motor weakness
Bladder, bowel, sexual organ dysfunction (40-64%) - difficulty controlling bladder/bowel, urinary retention, loss of anal tone
Investigations into MSCC?
Urgent Spinal MRI (within 24 hours)
Management of MSCC?
16mg dexamethasone + PPI cover
Radiotherapy
(Neurosurgery + radiotherapy for those who are fit enough)
Cancers associated with MSCC?
Common: Prostate, breast, lung, myeloma, lymphoma
Less common: renal, thyroid
Symptoms of Superior vena cava obstruction?
Breathless Headache (worse when coughing) Facial/arm/neck swelling Distended neck veins Cyanosis Visual disturbance
Malignant causes of SVCA?
Lung, oesophageal, mediastinal, germ cell, lymphoma, thymoma
Tumour associated thrombus
Non-malignant causes of SVCA?
Non-malignant tumours Mediastinal fibrosis (post radiotherapy) Infection - TB Aortic aneurysm Thrombi
Investigations into SVCA?
CXR
Contrast CT thorax
If new diagnosis consider: tumour markers, bronchoscopy, mediastinoscopy, biopsy
Management of SVCA?
16mg dexamethasone + PPI cover
Depending on cause: Vascular stenting Chemotherapy Radiotherapy LMWH (if thrombus confirmed)
Definition of neutropenic sepsis?
Absolute neutrophil count (ANC) of <1x10^9 /L \+ Single temp of >38.5 or temp of >38 for >1hr
Important info in Hx for neutropenic sepsis
Chemo:
Drugs and timings
Line and access
Stents
Previous episodes
Localising symptoms - try to find a source
Allergies
Important physical examinations for neutropenic sepsis?
Temp and circulatory status (ABC)
MEWS
Focus on potential site of infection - remember lines, catheters and peri-anal areas
What screening tool can be used to assess the risk of longterm complication in febrile neutropenia (FN)
MASCC
Investigations for FN?
Septic screen: FBC, U+E, LFT, CRP, lactate Blood culture (x 2 - aerobes and anaerobes) for line (all ports) + peripheral Swabs as indicated Sputum culture Urinalysis + culture Stool analysis + culture (if diarrhoea) CXR (if respiratory symptoms or pt has lung Ca)
Common pathogens in neutropenia?
Gram +ve (70%):
S aureus
Coagulase negative staphylococcus
a/B haemolytic streptococcus
Gram -ve (30%)
E. coli
Klebsiella
Pseudomonas
Fungi - aspergillus, candida
Management of FN?
START ABx ASAP - empirical (immediately after blood cultures and other diagnostic procedures)
Common malignant causes of hypercalcaemia?
NSCLC (squamous) Breast Ca Renal cell Ca Multiple myeloma and lymphoma Head and neck Ca
Pathophysiology of hypercalcaemia in cancer?
Tumours produce:
- Transforming growth factor alpha (TGFa) = powerful bone resorption stimulator
- PTH related peptides = stimulate bone resorption and increase calcium serum levels
Clinical presentation of hypercalcaemia?
General: dehydration, weakness, fatigue
CNS: confusion, seizure, proximal neuropathy, hyporeflexia, coma
GIT: Weight loss, N+V, pain, conitpation, ileus, dyspepsia, pancreatitis
Genitourinary: polyuria
Cardiac: bradycardia, short QT interval, wide t wave, prolonged PR interval, BBB, arrhythmia, arrest
Management of hypercalcaemia?
- IV fluids 0.9% saline:
1L 4hrly for 24hrs
1L 6hrly for 48-72hrs + adequate K+ - Bisphosphonates - IV Pamidronate (inhibits bone resorption)
3. Calcitonin + corticosteroids: Salmon calcitonin (S/C or IM) + Prednisilone (PO)
What should you consider doing to avoid fluid overload when administering IV fluids in hypercalcemia?
Furosemide
