Oncological emergencies

Question 1

Criteria for neutropenic sepsis

Answer 1

Patient undergoing systemic anti cancer therapy
Temperature >38
Neutrophil <0.5

Question 2

When does neutropenic sepsis normally occur

Answer 2

10-14 days after systemic anticancer therapy

Question 3

Risk factors for neutropenic sepsis

Answer 3

Prolonged neutropenia (>7 days)
Lower neutrophil count
Significant comorbidities
Progressive cancer
Central line in situ
Mucosal disruption

Question 4

Frequent pathogens causing neutropenic sepsis

Answer 4

Staph aureus
Staph epidermidis 
Enterococcus
Streptococcus 
MRSA
VRE

Question 5

Investigations for neutropenic sepsis

Answer 5

Bloods - FBC, U+Es, LFTs, CRP, lactate
Blood cultures
Urine dip
Sputum culture
Swabs of any lines and wounds
ABG
Imaging

Question 6

Management of neutropenic sepsis

Answer 6

Empiric IV abx within 1 hour
Fluid resuscitation
Call SpR/consultant
Consider ITU
GCSF if severe (avoid in AML)

Question 7

Changes to chemo cycles after neutropenic sepsis

Answer 7

Dose reduction
Prophylactic GCSF
Consider stopping chemo

Question 8

How to prevent neutropenic sepsis

Answer 8

Patient education

Alert card

Question 9

What antibiotics are given for neutropenic sepsis

Answer 9

Meropenem
Tazocin
Vancomycin for suspected line infection
Gentamicin for hypotension

Question 10

Pathophysiology of metastatic spinal cord compression

Answer 10

90% Collapse or compression of a vertebral body with metastatic disease. 10% from primary tumour.
Cord compression causes oedema leading to venous congestion and demyelination (reversible)
Prolonged cord compression leads to vascular injury and cord necrosis (irreversible)

Question 11

Presentation of metastatic spinal cord compression

Answer 11

> 90% back pain
75% limb weakness
50% sensory level
40% bladder and anal sphincter dysfunction

Question 12

Describe the pain experienced in MSCC

Answer 12

Radicular or spinal

Exacerbated by straight leg raising, coughing, sneezing and straining

Question 13

Examination findings in MSCC

Answer 13

Acutely flaccid paralysis 
Hyperreflexia and hypertonia below level of compression 
Babinski reflex positive
Sensory loss below level of compression
Palpable bladder

Question 14

Management of MSCC signs

Answer 14

Treatment within 24 hours!!
Admit
Bed rest - if severe back pain or MRI shows pedicle involvement 
MRI <24 hours
Dexamethasone 16mg 
PPI
Analgesia 
Surgery or supportive care

Question 15

When should you seek advice before giving high dose dexamethasone

Answer 15

Lymphoma

Call haematology

Question 16

When do you treat MSCC with supportive care

Answer 16

No motor function for >48 hours
Not fit for surgery - significant comorbidities 
Multiple spinal levels involved
Low performance status
Visceral mets 
Prognosis <3 months

Question 17

What is the supportive treatment for MSCC

Answer 17

Radiotherapy of abnormal vertebra + 1-2
Analgesia
Laxatives (cord compression, analgesia, poor mobility)
Bladder care
Monitor BMs (high dose steroids)
VTE prophylaxis 
PT/OT

Question 18

What is the definitive treatment for MSCC

Answer 18

Surgery to remove tumour from vertebral body and relieve cord compression
Re-stabilise spine

Question 19

How does radiotherapy work for MSCC

Answer 19

Causes cell death of rapidly dividing cells in the vertebra which relieves cord compression
Relieves pain

Question 20

Prognosis of MSCC

Answer 20

Median survival:
Not walking 1-3 months
Walking 5-8 months

Question 21

Causes of hypercalcaemia in cancer

Answer 21

80% paraneoplastic syndrome - PTHrP release
20% osteolytic mets - cytokine release
Lymphomas produce activated vitamin D

Question 22

Most common cancers to cause hypercalcaemia

Answer 22

Squamous cell e.g lung, renal, cervical, head+neck

Spread to bone - lung, myeloma, breast, thyroid, renal

Question 23

Common symptoms of hypercalcaemia

Answer 23

Thirst
Nausea
Anorexia
Constipation
Confusion
Polyuria

Question 24

Treatment of hypercalcaemia

Answer 24

Rehydration: at least 3 bags normal saline in 24 hours
Bisphosphonates: 60-90mg pamidronate IV

Question 25

What is tumour lysis syndrome

Answer 25

Massive tumour cell death leading to release of large amounts of potassium, phosphate and uric acid

Question 26

Electrolyte disturbances in tumour lysis syndrome

Answer 26

``` Hyperuricaemia Hyperkalaemia Hyperphosphataemia AKI Hypocalcaemia ```

Question 27

Which tumours have a higher risk of tumour lysis syndrome

Answer 27

High grade lymphomas Leukaemia Bulky chemo-responsive tumours

Question 28

Patient risk factors for tumour lysis syndrome

Answer 28

``` Preexisting renal dysfunction Preexisting hyperuricaemia Pre-treatment high LDH Hypovolaemia (pre-treatment diuretic use) Urinary tract obstruction ```

Question 29

Presentation of tumour lysis syndrome

Answer 29

``` Day 3-7 post-chemo N+V Diarrhoea Anorexia Lethargy Haematuria->Anuria HF Arrhythmia/cardiac arrest ```

Question 30

Prevention of tumour lysis syndrome

Answer 30

``` Pre-hydration Vigorous hydration during treatment Monitor electrolytes Monitor fluid balance Allopurinol to reduce hyperuricaemia Rasburicase to convert uric acid to allantoin ```

Question 31

Treatment of tumour lysis syndrome if rasburicase doesn't cure tumour lysis syndrome

Answer 31

Haemodialysis

Question 32

Causes of SVCO

Answer 32

80% lung cancer 10% lymphoma 5% SVC thrombus e.g central line

Question 33

Signs and symptoms of SVCO

Answer 33

``` SOB Facial and neck swelling Plethoric face Trunk and upper limb swelling Dilated veins on chest wall Choking sensation Chest pain Headache Cough Dyspnoea Stridor ```

Question 34

Investigation for SVCO

Answer 34

CT with contrast

Question 35

Treatment for SVCO

Answer 35

Steroids frequently prescribed but no evidence for benefit Stent if not radio/chemo-sensitive Chemo - small cell lung cancer, lymphoma, teratoma Radiotherapy - other malignant cancers