Oncological Emergencies

Question 1

Definition of neutropenic sepsis

Answer 1

Neutrophil count <1.0 x 10^9 /L
AND either:
Temperature >38 degrees for >1hr
OR - signs/symptoms of sepsis

Question 2

When is neutropenic sepsis most likely to occur?

Answer 2

Day 7-14 post chemotherapy

Nadir = trough in white cell count

Question 3

What is involved in a septic screen in neutropenic sepsis?

Answer 3

FBC, LFTs, U&Es, CRP, lactate
Blood cultures
Sputum culture
Urine analysis and culture
stool analysis and culture
Checking all lines, swabs if necessary
CXR if indicated

Question 4

What is NICE guidance on management of neutropenic sepsis

Answer 4

Broad spec IV Abx within 1hr
(as per local antimicrobial guidelines)

Colony stimulating factors (filgrastin, lenograstin) considered if neutrophils <0.1

Question 5

What scoring system is used in neutropenic sepsis

Answer 5

MASCC - multinational association for supportive care in cancer
Assesses risk of complications in neutropenic sepsis

Question 6

Which cancers are likely to cause MSCC?

Answer 6

Breast, prostate, lung, myeloma, lymphoma

Question 7

Presentation of MSCC?

Answer 7

Back pain - segmental, tight band - worse on lying down
Altered limb sensations - paraesthesia, paralysis
Gait disturbance
Bladder/bowel disturbance - cauda equina
Hyperreflexia, clonus

Question 8

Management of MSCC?

Answer 8

1) Dexamethasone 16mg + PPI cover
2) urgent MRI whole spine (within 1 hour)
3) neurosurgical referral +/- surgery/radiotherapy

Question 9

Prognosis for MSCC?

Answer 9

If treated within 24hrs, 57% regain function

If >24-48hrs, recovery very poor

Question 10

Which cancers likely to cause SVCO?

Answer 10

Lung cancer, lymphoma, oesophageal

Anything involving upper mediastinum

Question 11

Presentation of SVCO?

Answer 11

breathlessness
arm/neck/face swelling
headache, worse on coughing
distended neck/chest veins
cyanosis and visual disturbance

Question 12

Management of SVCO?

Answer 12

16mg Dexamethasone Urgent + PPI cover
Imaging and biopsy if first presentation (CT contrast thorax)
Vascular stenting +/- chemo/radiotherapy
LMWH if thrombus confirmed

Question 13

How does malignancy cause hypercalcaemia?

Answer 13

Bone metastases - increase serum calcium through destruction of bone
Tumour factors - TGF-alpha, PTH related peptide

Question 14

Presentation of hypercalcaemia?

Answer 14

slow, insidious, non-specific
CNS - confusion, seizures, neuropathy, coma
Cardiac - bradycardia, short QT, wide T wave, arrhythmias
GI - N+V, constipation, abdo pain, weight loss
General - dehydration, weakness, fatigue, bone pain
GU - polyuria

Question 15

What investigations to order if suspecting hypercalcaemia?

Answer 15

Serum calcium, corrected for serum albumin

>2.6-3.0 = hypercalcaemia (normal 2.1-2.6)

Question 16

Management of hypercalcaemia?

Answer 16

Rehydration with normal saline - 1-4hly for 24hrs, then 6hrly for 48-72hrs

• supplement K+
• give diuretics if fluid overloaded

Bisphosphonates - IV pamidronate/Alendronic acid

If seizures/arrhythmias
- calcitonin and PO prednisolone