Oncological Emergencies

Question 1

Oncological emergencies (4)

Answer 1

• Neutropenic sepsis
• Spinal cord compression
• Superior vena cava (SVC) syndrome
• Malignancy associated hypercalcaemia

Question 2

Neutropenic sepsis: Overview

Answer 2

• Temperature >38
• Neutrophil count <0.5
• Suspect in all patients who are unwell and within 6wks of receiving chemotherapy
• Localizing signs may be absent
• Examine indwelling catheter sites.
• Immediate treatment saves lives

Question 3

Spinal cord compression: Overview

Answer 3

• 3–5% of cancer patients have spinal metastases.
• ~15% of those with advanced cancers develop metastatic spinal cord compression.
• Most commonly associated with lung, prostate, breast, myeloma, melanoma.
• Urgent treatment is required to preserve neurological function and relieve pain.

Question 4

Spinal cord compression: Causes

Answer 4

• Common: Collapse or compression of a vertebral body due to metastases
• Rare: Direct extension of a tumour into vertebral column

Question 5

Spinal cord compression: Signs and symptoms

Answer 5

• Back pain in ~95%.
• Ask about nocturnal pain and pain with straining.
• Worry if there is cervical/thoracic pain.
• Also limb weakness, difficulty walking, sensory loss, bowel/bladder dysfunction.
• Maintain a high index of suspicion.

Question 6

Spinal cord compression: Management

Answer 6

• Bed rest
• Urgent (within 24 hr) MRI of spine
• Dexamethasone 16mg/24hr PO
• w/ prophylactic gastroprotection e.g. PPI
• Consider thromboprophylaxis (compression stockings, LMWH) if reduced mobility
• Refer urgently to cancer/oncology MDT
• Radiotherapy (commonest treatment) should be given within 24 hrs of MRI diagnosis
• Decompression surgery + radiotherapy may be appropriate depending on prognosis

Question 7

Superior Vena Cava (SVC) syndrome: Overview

Answer 7

• A clinical condition that occurs as a result of obstruction of the SVC.
• Reduced venous return from head, neck, and upper limbs.
• Due to extrinsic compression (most common), or venous thrombosis (consider if current or past central venous access).
• SVC syndrome with airway compromise requires urgent treatment.

Question 8

Superior Vena Cava (SVC) syndrome: Signs and symptoms (9)

Answer 8

Diagnosis is made clinically:

• SOB
• Orthopnoea
• Stridor
• Plethora/cyanosis
• Oedema of face and arm
• Cough
• Headache
• Engorged neck veins (non- pulsatile ↑JVP)
• Engorged chest wall veins.

Pemberton’s test: elevation of the arms to the side of the head causes facial plethora/cyanosis.

Question 9

Superior Vena Cava (SVC) syndrome: Management

Answer 9

• Prop up. Assess for hypoxia (pulse oximetry, blood gas) and give oxygen if needed.
• Dexamethasone 16mg/24h.
• CT is used to define the anatomy of the obstruction.
• Balloon venoplasty and SVC stenting provide the most rapid relief of symptoms.
• Treat with radiotherapy or chemotherapy depending on the sensitivity of the underlying cancer.

Question 10

Malignancy associated hypercalcaemia: Overview

Answer 10

• Most common metabolic abnormality in cancer patients:
• (~10–20% of patients with cancer, ~40% of myeloma)
• It is a poor prognostic sign: 75% mortality within 3 months.
• Calcium is highly protein-bound and needs correcting to the serum albumin concentration.
• PTH levels should be suppressed.

Question 11

Malignancy associated hypercalcaemia: Causes (3)

Answer 11

• PTH-related protein produced by the tumour
• Local osteolysis, eg myeloma
• Tumour production of calcitriol.

Question 12

Malignancy associated hypercalcaemia: Signs + symptoms

Answer 12

• Weight loss
• Anorexia
• Nausea
• Polydipsia
• Polyuria
• Constipation
• Abdominal pain
• Dehydration
• Weakness
• Confusion
• Seizure
• Coma

Question 13

Malignancy associated hypercalcaemia: Management

Answer 13

• Aggressive rehydration.
• Bisphosphonates (if eGFR ≥30),
• Calcitonin produces a more rapid (2h) but short-term effect and tolerance can develop.
• Long-term treatment is by control of the underlying malignancy.

Question 14

Brain metastases: Overview

Answer 14

• Affect up to ~40% of patients with cancer.
• Most commonly: lung, breast, colorectal, melanoma.
• Poor prognosis: median survival 1–2 months; better prognosis with single lesion, breast cancer.

Question 15

Brain metastases: Signs and symptoms

Answer 15

• Headache (~50%, often worse in the morning, when coughing or bending)
• Focal neurological signs (~30%)
• Ataxia (~21%), fits (~18%)
• Nausea
• Vomiting
• Papilloedema.

Question 16

Brain metastases: Management

Answer 16

• Urgent CT/MRI depending on underlying diagnosis, disease stage, and performance status.
• Dexamethasone 16mg/24h to reduce cerebral oedema.
• Stereo- tactic radiotherapy.
• Discuss with neurosurgery, especially if large lesion or associated hydrocephalus.

Question 17

Tumour lysis syndrome: Overview

Answer 17

Definition: a condition that occurs when a large number of cancer cells die within a short period, releasing their contents into the blood.

Chemotherapy for rapidly proliferating tumours (leukaemia, lymphoma, myeloma) leads to cell death and ↑urate, ↑K+, ↑phosphate, ↓calcium.

Risk of arrhythmia and renal failure.

Management: Prevent with hydration and uricolytics, eg rasburicase, allopurinol.