Oncological Emergencies

Question 1

What are the four oncological emergencies?

Answer 1

Neutropenic Sepsis
Metastatic Spinal Cord Compression
Hypercalcaemia
Superior Vena Cava Obstruction (SVCO)

Question 2

What defined neutropenic sepsis?

Answer 2

Patients having cancer treatment whose neutrophil count is less than 1 × 10^9 per litre and who have either:

• a temperature higher than 38 degrees
• or other signs or symptoms consistent with clinically significant sepsis.

Question 3

When does neutropenic sepsis typically occur?

Answer 3

occurs between 7 and 14 days post chemotherapy

Question 4

What investigations would you perform to screen for the source of sepsis?

Answer 4

Bedside: Swab and culture any Lines (all ports) and peripheral (or 2 peripheral sets if no line)

• Sputum culture and viral swabs
• Urine analysis and culture.
• Stool analysis and culture (if diarrhoea)

Bloods: FBC, U&Es, LFTs, CRP, Lactate
- Blood culture (paired): x 2 (Aerobes, Anaerobes).

Imaging: Chest Radiograph - if ?respiratory
+ Atypical pneumonia serology/ urine for legionella if indicated

Question 5

What are the common bacteria causes of neutropenic sepsis?

Answer 5

Gram positive organisms (70%)

• Staphylococcus aureus
• Coagulase-negative staphylococcus
• alpha and beta haemolytic streptococcus

Gram negative organisms (30%)

• Escherichia coli
• Klebsiella pneumoniae
• Pseudomonas aeruginosa

Question 6

What are the common fungal causes of neutropenic sepsis?

Answer 6

Candida, Aspergillus, Pneumocystis (PCP)

Question 7

What is the management of neutropenic sepsis?

Answer 7

1. Broad spectrum antibiotics, in line with local guidelines, within 1 hour of admission
2. MASCC score to assess risk of complications
   (Multinational Association for Supportive Care in Cancer patients)
3. Consider G-CSF if neuts <0.1, predict >10 days, severe sepsis/ multiorgan failure, co-morbidities

Question 8

What is the normal homeostatic response to high blood calcium?

Answer 8

Thyroid releases Calcitonin

Calcitonin promotes osteoblasts to deposit calcium in the bones and reduces absorption of calcium in the kidneys

Question 9

What is the normal homeostatic response to low blood calcium?

Answer 9

Parathyroid release PTH

• Promotes osteoclasts to release calcium from the bones
• Stimulates kidney to absorb calcium
• Kidneys convert 25-hydroxy Vitamin D to 1-25 dihydroxy Vitamin D, which stimulates the bowels to absorb calcium

Question 10

What can tumours produce that lead to hypercalcaemia ?

Answer 10

Transforming growth factor Alpha (TGF-a)
- a polypeptide stimulator of cell growth and replication that is produced by many tumor cells. It is a powerful stimulator of bone resorption

Parathyroid hormone (PTH) related peptides

Question 11

Which cancers are most commonly associated with hypercalcaemia?

Answer 11

Non small cell lung cancer (squamous cell)
Breast cancer
Prostate cancer
Renal cell carcinoma
Multiple myeloma and lymphoma
Head and Neck cancers

Question 12

What are the symptoms and signs of hypercalcaemia?

Answer 12

Stones, 
Bones - pain 
Groans - lethargy, fatigue 
Moans - Abdominal pain, constipation
Thrones - Polyuria and polydipsia 
and Psychiatric Overtones - confusion, seizures

Question 13

What is the management of hypercalcaemia?

Answer 13

1. Saline 0.9% - 1L / 4 hourly for 24 hours
   - then 1L / 6 hourly for 48-72 hours with adequate K+
   - consider giving furosemide if at risk of fluid overload
2. Biphosphonates:
   - IV Pamidronate or Zolendronic Acid

If arrhythmia or seizures:
3. Calcitonin and Corticosteroids

Question 14

What are the red flag symptoms for metastatic spinal cord compression?

Answer 14

Leg weakness
Sensory loss 
Thoracic back pain
Constant pain at night and at rest
Urinary retention/ faecal incontinence
Saddle anaesthesia & loss of anal tone

Question 15

What cancers are associated with MSCC?

Answer 15

• Prostate
• Breast
• Lung
• Myeloma
• Lymphoma

Less common: Renal, Thyroid

Question 16

What is the immediate management for a patient with suspected MSCC?

Answer 16

1. 16mg Dexamethasone + PPI cover

2. Urgent MRI spine within 24 hours

Question 17

What is the definitive management for MSCC?

Answer 17

Consider neurosurgical intervention

Radiotherapy

Question 18

What are the red fag symptoms of Superior Vena Cava Obstruction (SVCO)?

Answer 18

Breathlessness
Headache (worse on coughing)
Facial/ neck/ arm swelling
Distended neck and chest veins
Cyanosis
Visual disturbance
Pembertons sign - raise arms above the head

Question 19

What is the Immediate management of SVCO?

Answer 19

1. Lie flat, bed rest
   16mg Dexamethasone + PPI cover
2. Arrange urgent chest x-ray
3. Contrast CT and speak to interventional radiologist

Question 20

What is the definitive management of SVCO?

Answer 20

Depending on the cause:

• Vascular stent (radiological guidance)
• Radiotherapy
• Chemotherapy
• LMWH (if thrombus confirmed)

Question 21

What are the malignant causes of SVCO?

Answer 21

Lung cancer
Lymphoma
Mediastinal lymphadenopathy
Germ cell tumours
Thymoma
Oesphageal
Tumour associated thrombus

Question 22

What are the benign causes of SVCO?

Answer 22

Non-malignant tumours (goiter)
Mediastinal fibrosis - Post-radiotherapy, iIdiopathic
Infection - TB
Aortic aneurysm
Thrombus associated with indwelling catheters etc