Oncological emergencies

Question 1

What is the definition of neutropeunic sepsis?

Answer 1

Neutophil count < 1 x 10'9/L 
AND either
Temperature > 38oC
OR
other signs or Sx consistent with clinically significant sepsis.

Question 2

When does neutropenic sepsis tend to occur?

Answer 2

7-14 days post chemotherapy

Question 3

What is the management of neutropenic sepsis?

Answer 3

Broad spec iv Abx within 1 hour of admission
Tazocin (Tazobactam and piperacillin) or, if pen allergic, teicoplanin and aztreonam.
Rehydrate with iv fluids, monitor vital signs. Give oxygen and blood product support if needed

Question 4

When might you give Granulocyte Colony Stimulating Factor for neutropenic sepsis?

Answer 4

If neutrophil count < 0.1 x 10’9/L
OR predicted duration > 10 days
OR severe sepsis/multiorgan failure/co-morbidities

Question 5

What proteins can some cancers release that lead to hypercalcaemia?

Answer 5

Transforming Growth Factor alpha (TGF-a)

Parathyroid Hormone related peptide (PTHrp)

Question 6

What are the symptoms of hypercalcaemia?

Answer 6

Stones - renal or biliary
Bones - bone pain
Groans - abdo pain, N+V
Thrones - polyuria
Psychiatric overtones - depression, anxiety, cognitive dysfunction, insomnia, coma

Early - lethargy/malaise, weight loss, polyuria, thirst, N+V, constipation
Late - confusion, drowsiness, coma, fits

Question 7

How is hypercalcaemia managed?

Answer 7

Rehydration with normal saline 1L 4 hourly iv for 24 hours then 6 hourly for 48-72 hours with adequate K+.
Bisphosphonates - iv pamidronate or zoledronic acid
If arrhythmias or seizures –> calcitonin and corticosteroids help to lower serum calcium. Rapid action

Question 8

Which cancers are most commonly associated with hypercalcaemia?

Answer 8

NSCLC, breast Ca, prostate Ca, renal cell carcinoma, multiple myeloma and lymphoma, head and neck cancers

Question 9

Where do 2/3 of metastatic spinal cord compressions occur?

Answer 9

Thoracic region

Question 10

Which cancers are most commonly associated with MSCC?

Answer 10

Prostate, breast, lung, myeloma, lymphoma

Question 11

How is the back pain from MSCC classically described?

Answer 11

Radicular/band-like pain

Question 12

What are the red flags for back pain?

Answer 12

Age < 20 or > 55, trauma, weight loss, pyrexia, 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 13

What is the Gold standard investigation for suspected MSCC?

Answer 13

Urgent MRI whole spine within 24 hours.

Question 14

What is the initial management of MSCC?

Answer 14

16mg po Dexamethasone with PPI cover.

Dex. can cause steroid-induced hyperglycaemia so monitor blood glucose

Question 15

What is the definitive management of MSCC?

Answer 15

Radiotherapy - single fraction
Spinal surgery - if limited metastatic disease/good prognosis/few co-morbidities/fit for GA
Chemotherapy - if highly chemo-sensitive cancer

Question 16

What is the prognosis for MSCC?

Answer 16

If treated within 24 hours, 57% will walk again.

If all motor function is lost for 48 hours, recovery is unlikely

Question 17

Which cancers are most commonly responsible for SVCO?

Answer 17

Lung Ca or lymphoma.

Also, germ cell tumours, breast Ca, oesophageal Ca.

Question 18

What is the Gold standard investigation for suspected SVCO?

Answer 18

CT contrast thorax - shows tumour pressing on SVC

Question 19

What is the initial management of SVCO?

Answer 19

16mg po Dexamethasone with PPI cover. Arrange imaging, speak to interventional radiology.

Question 20

What is the definitive management of SVCO?

Answer 20

SVC stent.
For very radiosensitive or chemosensitive tumours, consider radiotherapy or chemotherapy.
LMWH if thrombus seen on CT.