Oncological Emergencies

Question 1

Mx of neutropenic sepsis (4)

Answer 1

Take culture before Abx

IV Abx w/i 1 hr:

• tazocin+/-gent
• if pen allergic (rash), give meropenem/cetazidine+gent
• if pen anaphylaxis give cipro+gent/amikacin

Will also want to perform rest of sepsis 6

Also need to identify source of infection, bloods for FBC and CXR.

NB don’t give G-CSF (filgrastim) in NS.

Question 2

Common causes of SVC obstruction (6)

Answer 2

NSCLC-most common
SCLC
lymphoma
germ cell tumours>mediastinal enlargement
thymus malignancy
metastatic ca.

Question 3

Signs and Sx of SVC obs (8)

Answer 3

SOB-main one
cough
syncope
headache
facial plethora/facial/arm oedema
distended neck veins/superficial chest veins
hoarseness
\+ve pemberton's sign-lift up arm for 1min>congestion and cyanosis

(NB only emergency i there is airway compromise)

Question 4

Mx of SVC obs (6)

Answer 4

Unless there is airways obs, find cause before Rx

high dose dex which buys time for:

• contrast-enhanced CT
• biopsy and histology

radiotherapy for primary Rx of tumour, chemo if sensitive

can stent palliatively but do this after systemic Rx to prevent stent slipping out.

Question 5

Common Ca. causing cord compression (4)

Answer 5

Breast
Lung
Prostate
Kidney, thyroid, melanoma

Question 6

Common sites for cord compression (3)

Answer 6

Thoracic (60%)
Lumbar (30%)
Cervical (10%)

Question 7

Pathology and prognosis of cord compression

Answer 7

compression>oedema, venous congestion and demyelination>vascular injury>cord infarction

recovery unlikely after infarction

if there is slow onset of Sx then recovery may be possible

Question 8

Presentation of cord compression (4)

Answer 8

Back pain often first Sx

Limb weakness

bladder/bowel dysfunction

sensory loss in a root distribution

Question 9

Ix for cord compression

Answer 9

urgent MRI of whole spine w/i 24hr of admission

Question 10

Mx of cord compression

Answer 10

urgent dexamethasone

Definitive Mx w/i 24hr:

• Surgery+RT
• radiotherapy for patients unfit for surgery or who have already completely lost sensation/motor function

important to keep pt. flat and perform log rolls w. neutral spine

Question 11

Commonest causes of brain mets and raised ICP (5)

Answer 11

Lung
Breast
Colorectal
Melanoma
Carcinoma of unknown origin

(seen in 40%, has poor prognosis)

Question 12

Presentation of brain mets and raised ICP (10)

Answer 12

headache-worse in morning/coughing/leaning forward
focal weakness
nausea/vomitting
ataxia
seizures
hemianopias
drowsiness/confusion
personality change
papilloedema
CN palsies

Question 13

Ix for brain mets (2)

Answer 13

CT w. contrast:

• not good at imaging cerebellum and brainstem
• if there are signs from these areas and a clear CT then do MRI

Another CT for staging

Question 14

Mx of brain mets (5)

Answer 14

Immediate steroids

valproate for seizures

MDT to decide between:

• neurosurgery:=/<3mets, palliation for hydrocephalus of for biopsy
• whole brain irradiation:can cause fatigue, alopecia, scalp erythema and impaired cognitive function
• stereotactic radiosurgery: high dose RT delivered to local area

Question 15

Malignant causes of bowel obs (2)

Answer 15

colorectal ca.

gynae ca.: poorer prognosis as often have widespread abdominal disease

Question 16

Dx of bowel obs (3)

Answer 16

Hx+Ex

plain AXR

CT abdo

Question 17

Mx of bowel obs (3)

Answer 17

Conservative methods 1st line:

• drip and suck
• enemas for impaction

drugs:

• steroids to reduce oedema
• anti-emetics
• motility agents

surgery:

• consider if conservative measures not helping after 48hr
• resection, bypass, stoma, stenting

Question 18

RFs for VTE in malignancy (5)

Answer 18

Ca. is a hyper-coagulable state
Chemotherapy
hormonal Rx
central venous catheters
Recent surgery

(VTE occurs in 20% of ca. and can precede Dx of ca. by several mo.)

Question 19

Mx of VTE in ca.

Answer 19

LMWH for 6mo, may need to be lifelong

do not use warfarin-hard to control lvls.

Question 20

Commonest malignant causes of hypercalcaemia (4)

Answer 20

Breast
Lung-squamous ca. secreting PTH-like hormone
multiple myeloma
lytic bone mets

(hypercalcaemia in malignancy is a v. poor prognostic indicator)

Question 21

Sx of hypercalcaemia (6)

Answer 21

(stones, bones, moans, groans)
lethargy
confusion
nausea
anorexia
constipation
polydipsia/polyuria

Question 22

Mx of hypercalcaemia (3)

Answer 22

acutely:

• aggressive fluid rehab
• IV bisphosphonates (pamidronate). NB adjust dose to renal function

May need IV bisphosphonate maintenance.

(poor prognosis)

Question 23

Features of carcinoma of unknown origin (2)

Answer 23

most present as emergency

tend to be more agressive and have very poor 1yr survival

Question 24

Ix for carcinoma of unknown origin

Answer 24

tumour markers NOT useful

PET-CT

Question 25

Rx of carcinoma of unknown origin

Answer 25

“best guess” chemo-often platinum containing

often don’t even survive 1st round of chemo

Question 26

Features of tumour lysis syndrome (3)

Answer 26

due to rapid cell death upon starting chemo for rapidly proliferating leukemia, lymphoma, myeloma and certain germ cell tumours

mainly seen in NHL

often present 72hr after commencing chemo

Question 27

Presentation of tumour lysis syndrome (4)

Answer 27

abdo pain
dysuria
Sx of hypocalcaemia-tetany, cramps, vomitting, seizures
Sx of hyperkalaemia-weakness, paralysis

Question 28

Ix for tumour lysis syndrome (2)

Answer 28

Bloods:

• HYPOCALCAEMIA
• raised urate, potassium, phosphate, LDH, blood urea nitrogen
• > renal failure>raised Cr

ECG

(calcium lowered due to high phosphate binding free calcium>calcium phosphate precipitating into tissues)

Question 29

Prevention of tumour lysis syndrome (2)

Answer 29

start 24hr before chemo:

• good hydration
• allopurinol

Question 30

Rx of tumour lysis syndrome (3)

Answer 30

if renal failure:

• haemodialysis
• rasburicase-urolytic agent, CI in G6PD and pregnancy

Mx hyperkalaemia