Oncological emergencies

Question 1

What is the most common site for MSCC?

Answer 1

Thoracic (70%)

Lumber (20%) > cervical > sacral

Question 2

Why should doctors be suspicious of thoracic back pain in all patients?

Answer 2

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)

Question 3

Three types of pain that occur inn MSCC?

Answer 3

1. Local pain (at rest)
2. Mechanical pain (received by rest)
3. Radicular pain (dermatomal neuropathic)

Question 4

Additional symptoms of MSCC?

Answer 4

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

Question 5

Investigations into MSCC?

Answer 5

Urgent Spinal MRI (within 24 hours)

Question 6

Management of MSCC?

Answer 6

16mg dexamethasone + PPI cover
Radiotherapy
(Neurosurgery + radiotherapy for those who are fit enough)

Question 7

Cancers associated with MSCC?

Answer 7

Common: Prostate, breast, lung, myeloma, lymphoma

Less common: renal, thyroid

Question 8

Symptoms of Superior vena cava obstruction?

Answer 8

Breathless
Headache (worse when coughing)
Facial/arm/neck swelling
Distended neck veins
Cyanosis
Visual disturbance

Question 9

Malignant causes of SVCA?

Answer 9

Lung, oesophageal, mediastinal, germ cell, lymphoma, thymoma
Tumour associated thrombus

Question 10

Non-malignant causes of SVCA?

Answer 10

Non-malignant tumours
Mediastinal fibrosis (post radiotherapy)
Infection - TB
Aortic aneurysm
Thrombi

Question 11

Investigations into SVCA?

Answer 11

CXR
Contrast CT thorax

If new diagnosis consider: tumour markers, bronchoscopy, mediastinoscopy, biopsy

Question 12

Management of SVCA?

Answer 12

16mg dexamethasone + PPI cover

Depending on cause:
Vascular stenting
Chemotherapy
Radiotherapy
LMWH (if thrombus confirmed)

Question 13

Definition of neutropenic sepsis?

Answer 13

Absolute neutrophil count (ANC) of <1x10^9 /L
\+ 
Single temp of >38.5
or
temp of >38 for >1hr

Question 14

Important info in Hx for neutropenic sepsis

Answer 14

Chemo:
Drugs and timings
Line and access
Stents

Previous episodes
Localising symptoms - try to find a source
Allergies

Question 15

Important physical examinations for neutropenic sepsis?

Answer 15

Temp and circulatory status (ABC)
MEWS
Focus on potential site of infection - remember lines, catheters and peri-anal areas

Question 16

What screening tool can be used to assess the risk of longterm complication in febrile neutropenia (FN)

Answer 16

MASCC

Question 17

Investigations for FN?

Answer 17

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)

Question 18

Common pathogens in neutropenia?

Answer 18

Gram +ve (70%):
S aureus
Coagulase negative staphylococcus
a/B haemolytic streptococcus

Gram -ve (30%)
E. coli
Klebsiella
Pseudomonas

Fungi - aspergillus, candida

Question 19

Management of FN?

Answer 19

START ABx ASAP - empirical (immediately after blood cultures and other diagnostic procedures)

Question 20

Common malignant causes of hypercalcaemia?

Answer 20

NSCLC (squamous)
Breast Ca
Renal cell Ca
Multiple myeloma and lymphoma
Head and neck Ca

Question 21

Pathophysiology of hypercalcaemia in cancer?

Answer 21

Tumours produce:

1. Transforming growth factor alpha (TGFa) = powerful bone resorption stimulator
2. PTH related peptides = stimulate bone resorption and increase calcium serum levels

Question 22

Clinical presentation of hypercalcaemia?

Answer 22

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

Question 23

Management of hypercalcaemia?

Answer 23

1. IV fluids 0.9% saline:
   1L 4hrly for 24hrs
   1L 6hrly for 48-72hrs + adequate K+
2. Bisphosphonates - IV Pamidronate (inhibits bone resorption)

3. Calcitonin + corticosteroids:
Salmon calcitonin (S/C or IM) + Prednisilone (PO)

Question 24

What should you consider doing to avoid fluid overload when administering IV fluids in hypercalcemia?

Answer 24

Furosemide