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Oncology > Oncological Emergencies > Flashcards

Oncological Emergencies Flashcards

1
Q

What are the 4 main oncological emergencies?

A

Neutropenic sepsis
Spinal cord compression
Superior vena cava obstruction
Hypercalcaemia

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2
Q

How are most chemotherapy regimes delivered?

A

3 weekly basis

Often at around day 7-14 of each 3 weekly cycle

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3
Q

Normal neutrophil count

A

> 1.5x109

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4
Q

What neutrophil count is an increased risk of infection?

A

< 1 x 109

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5
Q

Symptoms of infections

A

Feeling hot or feverish or feeling cold and shivery
Aching joints or muscles or flu like symptoms
Symptoms of focal infection (e.g. cough, sore throat, UTI etc)

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6
Q

Criteria for neutropenic fever or febrile neutropenia

A

Patient is febrile
Neutrophil count < 1.0 x109
No haemodynamic compromise

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7
Q

Criteria for diagnosing neutropenic sepsis

A

Evidence of sepsis

Prescence of neutrophil count < 1.0 x 109 (with or without fever)

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8
Q

Pathogenic microbiological causes of neutropenic sepsis

A

85% endogenous flora (especially from gut, biliary and urinary tracts)
75% of cases are due to gram -ve bacilli
Fungal infection in patients with prolonged neutropenia (especially in haematological malignancies)

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9
Q

Symptoms of neutropenic symptoms

A 
Anorexia 
Malaise 
Lethargy 
Sweats 
Fever, chills rigors
Symptoms related to a focus of infection 
Symptoms related to 
- chest infection 
- GI tract
- UTI
- CNS infection 
- skin / abscess
- sore throat
- recent interventions e.g. dental work
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10
Q

What vital signs have to be checked if suspect neutropenic sepsis?

A 
Temp 
Pulse
BP
O2 sats 
RR 
Full examination for each system for potential source of infection
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11
Q

Investigations for neutropenic sepsis

A 
FBC, serum biochemistry 
CRP
Blood cultures
MSSU
Stool culture if diarrhoea
Throat swabs if suspected pharyngitis 
Sputum culture if productive cough 
Skin swabs of infected skin lesions 
CXR
Others as guided by clinical status e.g. LP, CT etc
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12
Q

Treatment of neutropenic sepsis

A 
Supportive care
- volume resuscitation 
O2 if indicated 
Mouthcare 
Broad spectrum Antibiotics 
- IV piperacillin with tazocin 
Consider G-CSF to boost neutrophil count
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13
Q

What broad spectrum antibiotics would be used to treat neutropenic sepsis stage 1?

A

Piperacillin/tazocin 4.5 IV every 6 hours plus gentamicin 7mg/kg IV (with level taken to determine dosing interval)
If mild penicillin allergy - use ceftazidime 2g IV every 8 hours plus gentamicin 7mg/kg IV
If severe penicillin allergy - consider vancomycin and gentamicin +/- metronidazole

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14
Q

When would you consider transferring to ITU in neutropenic sepsis?

A

If hypotension does not resolve with supportive measures at ward level

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15
Q

What antibiotics would be used to treat neutropenic sepsis stage 2?

A

Meropenem 1g IV every 8 hours unless cultures suggest another more rational antibiotic regime

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16
Q

What is involved in reviewing the treatment in neutropenic sepsis?

A 
Fluid requirements
Response to antibiotic therapy 
Completion of antibiotic course
- at least 3 days IV 
- if improving and no longer neutropenic, a switch to oral ciprofloxacin is feasible, assuming cultures do not suggest a more rational regimen
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17
Q

What is done to monitor response to antibiotic therapy?

A 
Temp
BP
HR
CRP 
Neutrophil count
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18
Q

What cancers are malignant spinal cord compression (MSCC) most commonly seen in?

A

Cancers which typically spread to bone

  • breast cancer
  • carcinoma of the bronchus
  • prostate cancer
  • myeloma
  • renal cancer
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19
Q

What does MSCC stand for?

A

Malignant spinal cord compression

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20
Q

Causes of MSCC

A

Vertebral collapse
or
Extradural metastases

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21
Q

Common site of MSCC

A

Thoracic spine

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22
Q

Presentation of MSCC

A 
Pain 
- thoracic back pain 
Sensory/motor symptoms 
- progressive leg weakness and sensory loss 
Autonomic symptoms
- urinary incontinence or retention 
- faecal incontinence
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23
Q

Features of the pain in MSCC

A

Radicular in distribution
Worsening over the preceding weeks/months
Worse on coughing, sneezing, movement, weight bearing

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24
Q

What is radicular pain?

A

Radiating along the affected dermatome

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25
Q

Clinical signs of MSCC

A

Spinal tenderness
UMN signs (hypertonia, hyperflexia, clonus, upgoing plantars)
Sensory level i.e. loss of sensation below the dermatomal level of compression
Bladder
- urine retention/incontinence
Reduced anal tone

26
Q

Investigations of MSCC

A

MRI of whole spine
CT scan may be required
Check serum calcium

27
Q

When would a CT scan be required when investigating MSCC?

A

MRI is contraindicated e.g. pacemaker

The patent is not previously known to have a diagnosis of cancer, in order to identify a primary site

28
Q

Management of MSCC

A 
Supportive 
Steroids - dexamethasone 8mg b.d. initially 
Surgery 
Radiotherapy
Chemotherapy
29
Q

Supportive management of MSCC

A

Keep patient lying flat until stability of spine determined
Urinary catheter if urinary retention
Monitor bowel function and commence bowel regimen if required (laxatives/enemas)
Physio
Consider prophylactic deltaparin if bed bound

30
Q

What is deltaparin?

A

LMWH

31
Q

What do steroids do when managing MSCC?

A

To reduce oedema around the lesion

32
Q

What must be done when prescribing dexamethasone?

A

Prescribe with gastroprotectin (e.g. omeprazole)
Monitor blood sugar (daily BM)
Minimise duration of high dose steroids - aim to reduce dose once definitive therapy started

33
Q

When is surgery preferred in MSCC?

A

Fit with low volume metastatic disease, with life expectancy > 3 months
Isolated posterior cord compression (such that decompression laminectomy may suffice)
Good sensory and motor function prior to this episode
No prior history of cancer
Remainder of the spine is sufficiently strong to allow stabilisation

34
Q

Why is radiotherapy given after surgery in MSCC?

A

To reduce the risk of recurrence

35
Q

When is surgery generally avoided in management of MSCC?

A

Frailer patients with large volume metastatic disease with prior poor mobility
If anterior compression i.e. due to the tumour within the vertebral body compressing the spinal cord

36
Q

How is radiotherapy delivered in MSCC?

A

Targeted at the level of spinal cord compression

Usually 4 fractions delivered over 4 consecutive days

37
Q

When would primary chemotherapy be used in MSCC?

A

If primary tumour is highly chemosensitive e.g.
- germ cell tumours
- lymphoma
No surgical or radiotherapy option

38
Q

Prognosis of MSCC

A

If fully ambulant at diagnosis of cord compression, 90% remain ambulant
If not fully weight bearing or mobile with walking aid, most unable to walk again independently
If paraplegic, only 10% become ambulant after treatment

39
Q

Causes of Superior vena cava obstruction

A 
Bronchogenic carcinoma (typically non small cell lung cancer)
Lymphoma 
Metastatic tumours e.g. 
- renal cancer
- germ cell tumours 
SVC thrombosis
Mediastinal fibrosis 
Goitre 
Aortic aneurysm
40
Q

Presentation of SVC obstruction

A

Facial swelling/fullness of head
Arm swelling
Dysphagia and dyspnoea - may coexist due to mediastinal compression
Other features of malignancy

41
Q

Clinical signs of SVC obstruction

A 
Distention of neck and chest wall veins
Fixed (i.e. non pulsatile) elevated JVP
Facial oedema / puffiness 
Oedema of the arms
Plethora of the face 
Peripheral cyanosis 
Other signs of malignanc
42
Q

Investigations of SVC obstruction

A

CXR
CT
Superior venocavogram
Bronchoscopy if lung primary suspected

43
Q

Management of SVC obstruction

A 
Steriods and supportive measures 
Radiotherapy 
Chemotherapy 
Stenting of SVC 
Thrombolysis and anticoagulation if SVCO due to thrombosis of SVC
44
Q

What supportive measures are used for SVC obstruction?

A

High dose corticosteriods - dexamethasone 8mg b.d. with gastroprotectin and daily BMs
Encourage patient to sit up in bed (oedema will worsen on lying flat)

45
Q

When would you do SVC stenting?

A

Recurrent SVCO

Benign causes

46
Q

Treatment of catheter induced SVC thrombosis

A

Remove catheter
Thrombolysis
Anticoagulation

47
Q

How do you work out corrected calcium?

A

Measured calcium + [0.02 x (40 - alb)]

48
Q

Causes of hypercalcaemia

A

Bone mets

Paraneoplastic syndrome; production of PTH-rp (parathyroid hormone related peptide)

49
Q

What is PTH-rp typically produced by?

A

Squamous cancer

HTLV-1 related T cell lymphomas

50
Q

Presentation of hypercalcaemia

A 
Osmotic features
- dehydration 
- polydipsia
- polyuria
Cognitive impairment 
Fatigue
Lethargy 
Psychosis
Constipation 
Nausea and vomiting 
Renal failure 
Cardiac arrythmias
51
Q

Management of hypercalcaemia

A

Check PTH if cause unclear
Rehydration
- 4-6 litres 0.9% saline / 24 hours if no contraindication
- loop diuretic if required e.g. furesimide
Biphosphonates
- zoledronate 4mg IV if renal function normal
Calcitonin rarely required
Steriods may be of benefit

52
Q

What would the PTH level be if there if hypercalcaemia caused by a PTH-rp producinig tumour?

A

PTH suppressed

53
Q

What is tumour lysis syndrome?

A

Potentially deadly condition related to the treatment of high grade lymphomas and leukaemias

54
Q

What can tumour lysis syndrome be trigged by?

A

Introduction of combination chemotherapy

however can occur in the absence of chemo

55
Q

Prophylaxis of tumour lysis syndrome

A

High risk - IV allopurinol or IV rasburicase immediately prior to and the days following first chemo
Lower risk - oral allopurinol during chemo cycles

56
Q

Pathology of TLS

A

Breakdown of tumour cells and the subsequent release of chemicals from the cell

57
Q

What does TLS result in?

A

Hyperkalaemia
Hyperphosphataemia
Hypocalcaemia

58
Q

When should TLS be suspected?

A

Any patient presenting with an acute kidney injury in the prescence of a high phosphate and high uric acid level

59
Q

What is clinical TLS?

A

Laboratory tumour lysis syndrome plus one of;

  • increased serum creatinine 1.5x normal
  • cardiac arrhythmia or sudden death
  • seizure
60
Q

Prophylaxis of neutropenic sepsis

A

If neutrophil count < 0.5x10^9; give flouroquinolone

Oncology (5 decks)

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