Oncological Emergencies Flashcards
What are the symptoms of spinal cord compression? (6)
- Severe back pain - typically radicular, exacerbated by coughing or straining and not relieved by bed rest
- Weakness of the legs (and arms)
- Sensory loss
- Retention
- Dribbling
- Incontinence of urine/faeces
Why does spinal cord compression occur in people with cancer?
Spinal cord compression occurs when cancer has spread to the bones, particularly the spine, and pressure is placed on the nerves
In which cancers is bone involvement common, and therefore spinal cord compression more likely to occur? (5)
- Breast
- Prostate
- Lung
(first three most common) - Myeloma
- Lymphoma
What tends to happen in the spine to cause spinal cord compression?
A crush fracture and/or soft tissue tumour extension
66% of cases of spinal cord compression occur in which part of the spine?
The thoracic cord
If there is a complete compression of the cord, how will this present? (3)
- Sensory loss just below level of lesion
- Bilateral UMN weakness below lesion
- Bladder and bowel dysfunction
How would an anterior compression of the cord present? (3)
- Partial loss of pain and temperature below the lesion
- Bilateral UMN weakness below lesion
- Bladder and bowel dysfunction
How would posterior compression of the cord present? (3)
- Loss of vibration and position below the lesion
- Relative sparing of pain, temperature and touch
- Band of dysthaesia at level of lesion
How does lateral compression of the spinal cord present (AKA Brown-Sequard syndrome)?
- Contralateral loss of pain and temperature (touch relatively spared)
- Ipsilateral loss of vibration and position
- Ipsilateral UMN weakness
What % of people with cancer develop spinal cord compression?
3-5%
If tumours are below the level of L1 or L2, what my occur?
Cauda equina syndrome
How may caudal equina present? (6)
- Sciatic pain (often bilateral)
- Bladder dysfunction (with retention and overflow incontinence)
- Impotence
- Sacral (saddle) anaesthesia
- Loss of anal sphincter tone
- Weakness/wasting of gluteal muscles
On examination of potential spinal cord compression, what may be palpable/visible? (4)
- Palpable/visible gibbus at the site of a wedged or collapsed vertebra
- Pain and tenderness on palpation or percussion of the vertebra over the site of compression
- Band of hyperaesthesia at the level of the lesion
- Sensory and motor loss at and below level of lesion
What investigations will be carried out on someone with suspected spinal cord compression? (1 in particular, but choice of 3)
- Plain X-ray may demonstrate destruction/collapse of vertebra (although in 15-20% of cases plain films show no abnormality)
- MRI - first-line investigation
- CT
What drug (and dose) is given immediately to someone with spinal cord compression?
Dexamethasone 16mg (sometimes 20mg) + PPI 30mg lansoprasole
What does the dexamethasone aim to do?
Reduce the peri-tumoural oedema
What is the recommended treatment that will yield best results for spinal cord compression? (2)
- Surgery to decompress/stabilise the spine
2. Radiotherapy
Why is surgery sometimes not feasible or appropriate for some patients with spinal cord compression?
As the patient may be too frail, or have extensive bone destruction
When is surgery for spinal cord compression particularly indicated? (6)
- Acute-onset paraplegia
- Patients with good performance status
- Small-volume bone disease
- Fracture dislocation
- Radioresistant tumours
- To provide tissue diagnosis when cord compression is the presenting symptom of malignancy
Bone marrow suppression or myelosuppression, refers to what?
A decrease in the production of cells responsible for providing immunity, carrying oxygen and blood clotting
Normally how many cells are produced by the bone marrow every hour?
1010 - 1012 cells
What occurs as the results of a cytotoxic-induced bone marrow failure?
Pancytopenia
What causes bone marrow suppression?
The toxicity of cancer chemotherapy
When does neutropenia tend to occur after the start of chemotherapy?
7-10 days
When is there a risk of neutropenic sepsis?
The risk of sepsis relates to the severity and duration of neutropenia
What else can chemotherapy cause, that may provide a portal for bacteraemia?
It causes mucosal damage e.g. stomatitis/diarrhoea
At day 10 - 14 after the start of chemotherapy, what can occur?
Thrombocytopenia
At day 14-21 after the start of chemotherapy what is then likely occur due to marrow suppression?
Anaemia
Which specific cytotoxic can cause damage to stem cells, leading to delayed and prolonged myelosuppression?
CCNU
How is neutropenic sepsis defined?
A temperature of higher than 38 degrees or any signs/symptoms of sepsis in a person with a neutrophil count of 0.5X10>9/L or lower
In an adult patient, what signs/symptoms of sepsis may be present? (6)
- Temperature higher than 38 degrees
- Heart rate greater than 90 bp
- Resp rate greater than 20
- New onset confusion/drowsiness
- Raised or low WBC counts
- Blood glucose greater than 7.7 mmol/L (in non-diabetic)
For someone being treated with chemotherapy, what additional risk factors can contribute to developing neutropenic sepsis? (5)
- Inpatient chemotherapy regimens, especially those used to treat haematological malignancies as they tend to produce a greater severity and duration of neutropenia
- Exposure to prior chemotherapy
- Current immunosuppression (e.g. oral corticosteroids)
- Pre-treatment elevations of alkaline phosphatase, bilirubin, aspartate aminotransferase liver function test levels.
- Reduced eGFR
What is the prognosis for neutropenic sepsis?
It is a medical emergency and a major cause of death in people with neutropenia (NICE CKS - no statistics)
What is neutropenia associated with?
- Poor nutrition
- Mucosal barrier defects
- Central venous lines
- Abnormal host colonisation
What are the various mechanisms in which the superior vena cava (SVC) can be obstructed?
- External compression of the SVC
- Direct invasion of the SVC
- Thrombus within the SVC
What % of cases of SVC obstruction are due to external compression?
> 80%
Often external compression of the SVC is due to a primary tumour, which is the most common site?
Right paratracheal region
What is a thrombus within the SVC most commonly caused by?
A central venous catheterization (Hickman or peripherally inserted central catheter (PICC) line)
Which cancer is most commonly the underlying cause of SVC obstruction (SVCO)?
Bronchogenic carcinoma
In addition to bronchogenic carcinoma, which other form of cancer is a frequent cause of SVCO due to it developing centrally as opposed to peripherally?
Small cell lung cancer (SCLC) - this develops within the central airways and often has extensive lymph node spread
What other tumours involve mediastinal nodes, and therefore can cause SVCO? (3)
- Non-Hodgkin’s lymphoma
- Thymoma
- Mediastinal germ cell tumours
What are the symptoms of SVCO? (5)
- Dyspnoea - due to associated compression of the trachea/bronchus
- Swelling of the neck, face and arms - especially in the morning and exacerbated by bending forwards/lying down
- Cough
- Headache
- Visual disturbance
What are the signs of SVCO? (4)
- Fixed engorgement of external and internal jugular veins
- Collateral veins over anterior and lateral chest wall
- Facial plethora
- Papilloedema (late feature)
What are the differential diagnoses for SVCO? (3)
- Heart failure
- Cardiac tamponade
- External jugular vein compression
What % of patients with SVCO and an underlying cancer, present without knowing of their malignancy?
60%
How does SVCO appear on CXR?
Right paratracheal mass, mediastinal lymphadenopathy, or other indications of lung cancer e.g. pleural effusion
Why is a CT useful in someone with SVCO?
Ideally it is performed with contrast, and the can help define the level and degree of venous blockage and assist in identifying the cause of the SVCO
What is the management of SVCO? (7 ish)
- Sit patient up
- Establish IV access
- Give O2 if necessary
- Dexamethasone 8mg bd PO/IV
- CXR and CT thorax is essential
- Stenting
- Thrombolysis - if there is a clot
If someone presents with SVCO do they need to be treated immediately?
Most patients present with symptoms of insidious onset and there is time to establish the diagnosis and extent of disease prior to commencing treatment. However if there is a stridor present due to tracheal compression then treatment needs to begin imminently
Treatment for SVCO is dependent upon the cancer causing it, if it is Non-Hodgkin’s lymphoma or mediastinal germ cell tumour, what is the usual treatment?
Chemotherapy
What is held within the brain and what % does each make up?
- Brain and interstitial fluid (80%)
- Intravascular blood (10%)
- Cerebrospinal fluid (10%)
What are the clinical signs of the early stages of raised ICP? (2)
- Headache
- Nausea and vomiting
Symptoms worse in the morning due to cerebral venous congestion associated with lying supine, and coughing/sneezing may aggravate the headache
As raised ICP increases, what further symptoms/signs will develop? (1)
- Cognitive impairment and drowsiness
As pressure continues to increase, what will happen next?
- Herniation of cerebral tissue through the tentorium may cause midbrain compression with coma associated with pupillary and occulomotor signs
- Bradycardia
- Hypertension
In 50% of people with raised ICP, what will fundoscopy show?
Papilloedema
Specific signs may suggest the site of the pathology, for example if there is a limited ability to gaze upwards, what is this called and which tumour is this associated with?
Parinaud’s syndrome
Pineal tumours
What are the three commonest causes of increased ICP?
- Space-occupying lesion
- Hydrocephalus (due to obstruction of CSF circulation)
- Benign intracranial hypertension
If the raised ICP is due to cancer, what % are due to metastatic disease?
50%
50% of raised ICP due to cancer are caused by primary brain tumours, which is the most common one?
Gliomas
What is the treatment for raised ICP?
Dexamethasone 16mg daily and PPI for gastro protection
If the patient has raised ICP and is not responding, what is the treatment instead of dexamethasone?
Osmotic diuresis with IV mannitol (100ml 20% solution over 1-2 hours)
Hypercalcaemia is another oncological emergency. Urgent intervention is required when free calcium raises above what level?
> 3mM
In what type of cancers does hypercalcaemia occur?
Solid tumours and leukaemias
In which specific cancers does hypercalcaemia tend to occur? (5)
- Breast
- Myeloma
- Lung (especially squamous cell)
- Prostate
- Lymphoma
To calculate free calcium, what else is taken into consideration? (2)
Serum albumin and arterial pH
How is free calcium mM measured?
[measured calcium (mM)] + [(40 - albumin g/l) x 0.02]
What are the causes of malignant hypercalcaemia? (4)
- Osteolysis
- Humoral mediators
- Dehydration
- Tumour-specific mechanisms
Often more than one mechanism contributes
What is osteolysis and why does it cause hypercalcaemia?
Local increased bone resorption induced by lytic bone metastases. Attributed to activation of osteoclasts via tumour cell cytokine production (particularly interleukins and tumour necrosis factor). Likely to be the dominant mechanism in certain malignancies including lymphoma, non-small cell lung cancer.
Why do humoral mediators cause hypercalcaemia?
Systemic release of factors activating oestoclasts even in the absence of bony metastases e.g. parathyroid hormone-related peptide (PTHrP) seen particularly with squamous cell carcinoma of the lung
Why does dehydration lead to hypercalcaemia?
Dehydration exacerbates hypercalcaemia as calcium is a potent diuretic causing salt and water loss. As diuresis continues, calcium levels increase, causing further volume depletion
How can tumours cause hypercalcaemia?
For example myeloma secretes an osteoclast-activating factor which leads to renal impairment, leading to a decrease in calcium excretion. Whereas lymphomas produce active metabolites of vitamin D leading to an increase in the intestinal absorption of calcium.
What are the neurological signs/symptoms of hypercalcaemial? (8)
- Malaise
- Fatigue
- Drowsiness
- Weakness
- Depression
- Cognitive dysfunction
- Seizures
- Coma
What are the GI presentations of hypercalcaemia? (6)
- Nausea and vomiting
- Anorexia
- Abdominal pain
- Constipation
- Pancreatitis
- Peptic ulceration
What are the renal associated symptoms of hypercalcaemia? (5)
- Polydipsia
- Polyuria
- Dehydration
- Signs of uraemia
- Renal colic (secondary to renal calculi)
What are the cardiac associated symptoms/signs of hypercalcaemia? (3)
- Arrhythmias
- Hypertension
- Postural hypotension
What investigations are carried out in someone with suspected hypercalcaemia?
- U&E’s, LFTs, amylase
- FBC
- ECG
- Plasma PTH
What are the range of treatments for people with hypercalcaemia (unless they are in the last few hours of life)? (8)
- Rehydration is priority
- Monitor U&Es
- Bisphosphonates
- Loop diuretics
- Steroids
- Dietary calcium restriction
- Salmon calcitonin
- Treat the underlying malignancy (if appropriate)
What is the recommended dose of fluid to rehydrate a patient with hypercalcaemia?
0.9% saline aiming for 3-6L per 24 hours, in cardiac function and urine output permit
What may fall and require replacement with rehydration in treating hypercalcaemia? - hence why it is important to monitor U&Es
Potassium and magnesium levels
Which bisphosphonate(s) are recommended to treat hypercalcaemia?
- Pamidronate (60-90mg infused in a litre of saline over 2-24 hours)
- Zolendronic acid (4mg IV over 15 minutes) is sometimes preferred in malignant hypercalcaemia due to its shorter infusion time and greater potency
What does salmon calcitonin do?
It leads to an increase in renal calcium excretion and a decrease in reabsorption into the bones. Can be administered IM or subcut (this is used very uncommonly)
What is the cause of acute (pre-renal) renal failure in malignancy?
Hypovolaemia
What can cause hypovolaemia in malignancy? (3)
- Dehydration due to vomiting or hypercalcaemia
- Haemorrhage
- Concomitant sepsis causing impaired renal perfusion
What are the renal causes of acute renal failure? (3)
- Renal parenchymal damage due to cytotoxic agents e.g. platinum-based chemotherapy
- Tumour lysis syndrome (calcium phosphate crystals) or myeloma (Bence-Jones proteins) causing deposition within the tubules
- Glomerulonephritis
What are the post-renal causes of acute renal failure due to malignancy? (4)
- Obstruction secondary to a pelvic tumour for example
- Retroperitoneal fibrosis
- Pathological lymphadenopathy
- Renal vein thrombosis
Treatment for spinal cord compression? (3)
- Dexamethasone 16mg OD PO
- PPI 30mg
- Pain relief
What is the classification for neutropenic sepsis?
Patients having cancer treatment whose neutrophil count is less than 1x10>9 per litre and who have either:
1. a temperature higher than 38 degree c
OR
2. other signs or symptoms consistent with clinically significant sepsis
What is PAIRED blood cultures?
Taking two sets, one direct from vein, and one from indwelling line e.g. PICC or Hickman
How do you search for sites of infection?
FBC, U&Es, LFTs, skin swabs, CXR, blood culture, lactate, CRP
What questions would you ask a patient, when taking a history, from someone presenting with possible neutropenic sepsis?
History:
- Chemo drugs and timing, line and access, stents etc?
- Previous episodes
- Localising symptoms - what’s the source?
- Allergies?
What are the NICE guidelines for managing neutropenic sepsis?
Broad spectrum IV antibiotics (per local guidelines) must be given within 1 hour of admission to hospital in all suspected cases
What % of neutropenic fevers are of an unknown origin?
60-70%
What is the MASCC score?
Multinational Association for Supportive Care in Cancer patients
What does the MASCC score assess?
The risk of complications during a febrile neutropenic episode
What does the MASCC score take into consideration? (8)
- Burden of infection
- Co-morbidities
- BP
- COPD
- Tumour type haematological/solid tumour
- Fluid status
- Age <60 years
- In-patient vs out-patient
What are colony stimulating factors?
G-CSF e.g. Filgrastim promotes haematopoitic growth factors that promote stem cell proliferation and shorted the duration of neutropenia
What can dexamethasone treatment cause?
Can cause steroid induced hyperglycaemia (even in someone who is not diabetic)
What % of patients regain motor function after radiotherapy treatment for metastatic spinal cord compression?
57%
What are the malignant causes of SVCO? (7)
Malignant causes:
- Lung
- Lymphoma
- Mediastinal lymphadenopathy
- Germ cell tumours
- Thymoma
- Oesophageal
- Tumour associated thrombus
What are the benign causes of SVCO? (5)
- Non-malignant tumours (goitre)
- Mediastinal fibrosis - idiopathic, post-radiotherapy
- Infection - TB
- Aortic aneurysm
- Thrombus associated with indwelling catheters etc.
Which scan is the gold standard for suspected spinal cord compression?
MRI
Which cancers most commonly spread to bone?
Breast Lung Myeloma Lymphoma Prostate (and rarely thyroid, renal)
