Oncological Emergencies Flashcards
What are the main emergencies we need to know about?
Neutropenic sepsis Metastatic spinal cord compression Hypercalcaemia Tumour lysis syndrome SVC obstruction RICP
What is neutropenic sepsis?
Sepsis with a neutrophil count below 0.5 x 10^9/L (and a temperature above 38 degrees)
Why does neutropenic sepsis occur?
As a side effect of chemotherapy, typically 7-10 days afterwards
What is the onset of neutropenic sepsis?
Very rapid, often within 7-10 days post-chemo
How should neutropenic sepsis be treated immediately?
IV antibiotics within 1 hour of admission (no need to wait for blood results) and IV fluids
Who should neutropenic sepsis be watched for in?
Any pt who has had chemo in the last 6 weeks
What are the symptoms of neutropenic sepsis?
Fever Drowsiness Confusion Tachycardia (technically a sign) Any specific system signs e.g. abdo pain, haematruia etc
What increases the risk of developing neutropenic sepsis apart from chemo in the past 6 weeks?
- Prolonged neutropenia (over 7 days)
- Co-morbidities
- Poor cancer response to chemo
- Central lines
- Mucositis
- Being an inpatient
What organisms cause neutropenic sepsis?
Mostly endogenous flora.
Increasing incidence of MRSA and VRE
What are the differentials for neutropenic sepsis and when should you consider them?
Chemo or cancer related fever
PE
If the neutrophils aren’t low. This should be after treatment is commenced anyway. If symptoms of PE are also present.
What else can we do to treat/prevent neutropenic sepsis?
GCSF to stimulate neutrophil production
Abx prophylaxis
Patient education on how to avoid it (infection control)
What is metastatic spinal cord compression?
The name pretty much explains it - spinal cord compression due to spinal mets, or direct paraspinal tumour extension.
Which cancers are most commonly associated with spinal mets and cord compression?
Lung Prostate Breast Myeloma Melanoma
How many cancer pts get spinal mets?
3-5%
Where are spinal mets most common?
Thoracic spine
Do all MSCC pts who present already have a cancer diagnosis?
No - 1/4 don’t have a diagnosis of cancer
What is the pathogenesis of MSCC?
Metastasis causing oedema, venous obstruction, and demyelination.
Chronicly leads to vascular injury and cord necrosis
How does MSCC present?
Over 90% of pts have back pain.
May also have limb weakness, sensory changes, &/or bladder/anal sphincter dysfunction.
If MSCC is suspected, what are the initial management steps?
Try to get rapid diagnosis.
In between, admit, bed rest, analgesia, and dexamethasone+PPI.
How is MSCC diagnosed?
MRI
How is MSCC managed?
Radiotherapy (within 24 hours of MRI diagnosis).
Decompression with surgery can be considered.
Which MSCC pts can we consider for surgery?
If pt is fit enough with good prognosis
Single level of spinal disease with good motor function
How can we medically support pts with MSCC?
Analgesia Laxatives Bladder care VTE PT/OT
What is the prognosis for MSCC?
1-3 months if mobility isn’t regained
5-8 months if mobility is regained.
Longer if MSCC is due to myeloma/lymphoma
How common is hypercalcaemia in cancer?
Most common metabolic abnormality in cancer.
10-20% of cancer pts, and 40% of myeloma pts.
What is the most common pathogenesis of hypercalcaemia in cancer pts?
Osteolytic metastasis causing calcium release from bones into blood
What are the symptoms of hypercalcaemia?
In cancer patients, they are very non specific.
Look out for new onset nausea, thirst, constipation, or confusion.
What is important about the symptoms of hypercalcaemia in cancer pts?
As they are non specific, you need to have a low threshold for testing.
How do we treat hypercalcaemia in cancer pts?
Hydrate with IV fluids - 3L over 24 hours
IV Bisphosphonates
What is the prognosis like with hypercalcaemia in cancer pts?
Poor, many may die within 3/12
What is tumour lysis syndrome?
Syndrome that occurs as a side effect of tumour cell breakdown
What is the pathogenesis of tumour lysis syndrome?
Tumour cell breakdown -> efflux of K+, phosphate, and uric acid into systemic circulation
When does tumour lysis syndrome often occur?
After the commencement of chemo, within the first 3-7 days
Which malignancies is tumour lysis syndrome most commonly associated with?
Haematological malignancies
What are the symptoms of tumour lysis syndrome?
N&V Diarrhoea Anorexia Lethargy Gout Haematuria HF Cardiac complications
How do we manage tumour lysis syndrome?
IV hydration
Monitor electrolytes
Allopurinol
If serum electrolytes do not go back to normal after initial management of tumour lysis syndrome, what might the pt need?
Haemodialysis
Why might SVC obstruction occur?
Due to external compression or an internal clot.
Which condition is SVC obstruction most common in?
Lung cancer
What are the symptoms of SVCO?
Swollen face/neck Breathlessness Headache Choking sensation dysphagia
What are the signs of SVCO?
Red face
Oedema of face and neck
Distended veins of neck and arms
Elevated but non-distended JVP
If SVCO is left untreated, what further symptoms might a pt have?
Hallucinations or seizures
How can we investigate SVCO?
CXR
CT
Both will show the presence of a tumour/mass
Where will the mass be usually in SVCO?
Upper zone of the lungs or thereabouts i.e. the mediastinum
How can we manage SVCO?
Everyone gets steroids for swelling (no evidence)
Stent the SVC
If radio/chemo-therapy sensitive, use that.
What is the onset of SVCO usually like?
Insidious, over weeks/months
Can be acute.
Which pt group is particularly at risk for thrombus formation -> SVCO?
Pts with central IV catheters
What simple things can we do for pts with SVCO?
Sit them up
Oxygen for breathlessness
Opioids for pain and potentially breathlessness
How quickly can radiotherapy + stenting work for SVCO?
Symptom relief within 2 weeks (in 90% of pts)
Other than the big ones, what are some additional/rarer oncological emergencies?
Catastrophic haemorrhage Pericarditis Coagulopathies Haemoptysis Hypoglycaemia Obstructive emergencies
What obstructive emergencies can occur in oncology?
Gastric outlet Small Bowel Large bowel Biliary tract Ureteric
Why is RICP a problem for cancer patients?
Cranial mets, usually from lung, breast, or melanoma tumours, can cause RICP, small bleeds, and acute symptoms.
What are the symptoms of RICP?
Headache
Nausea and Vomiting
Behavioural changes
Seizures
What are the sigs of RICP?
Focal neurological deficit Falling level of consciousness Papilloedema Unilateral ptosis/CNIII or VI palsies Bradycardia(late)
How should suspected RICP be investigated in a cancer patient?
Urgent CT/MRI to delineate lesion if that is likely to affect managament.
How should RICP be managed?
ABCDE Mx esp. if loss of consiousness to protect airway and aim for higher than average resp rate
Mannitol with dexamethasone to reduce risk of cerebral herniation
High dose dexamethasone appropriate for palliative solution
Further Mx - cranial irradiation, or surgery depending on type and number of mets
