Oncological Emergencies Flashcards
1
Q
What are the aims of palliative radiotherapy?
A
- Keeping symptoms under control.
-
From metastases:
- Reduce pain
- Reduce risk of pathological fracture
- Reduce neurological complications such as paralysis
-
From local progression of primary:
- Stop bleeding
- Reduce obstructions / swelling
- Induce healing in exulcerated tumours / lesions
2
Q
What are the reasons for emergency treatment (irradiation takes place on the same day)?
A
- Cord compression presenting with neurological defecits such as paralysis, loss of sensation, loss of control over bowel/bladder function - every hour counts!
- Vena cava superior syndrome.
- Total or large partial atelektasis.
- Acute diffuse bleedings.
3
Q
What are the indications for urgent radiotherapy?
A
- Not emergency, but Rx should be carried out ASARA:
- Unstable / painful bone metastases
- In some cases of brain metastases
- Cord compression without any neurological defecits
- Vena cava inferior syndrome
- Chronic bleedings with effect on red cell count
- Threat of obstruction (i.e. gullet, trachea, lung)
4
Q
What should you do immediately if a patient presents with malignant spinal cord compression (MSCC)?
A
- Commence oral Dexamethasone 16mg IMMEDIATELY (Iv has no greater benefit) until start of treatment, then continue on 8mg OD.
- Depending on health board - trigger cord compression pathway immediately.
By not doing this you can cause irreversible harm.
5
Q
Describe the prognosis of a patient who presents with MSCC.
A
- Favourable - patient can still walk at the start of RT.
- Important - keep interval between onset of symptoms and 1st RT as short as possible:
- 6-24h - chance for complete remission.
- <72h - chance for partial remission.
- >72h - maintaining present state, stopping situation from getting worse but remission of symptoms is no longer likely.
- If they present with no sensation and are completely plaegic, it is not sensible to treat because it will not make any difference.
6
Q
What can cause MSCC?
A
- MSCC can be due to:
- One metastasis with soft tissue component.
- Paravertebral soft tissue mass extending through neuroforamen.
- Pathological fracture with dislocated fragment.
- Intraspinal or droplet metastases.
- Meningeosis carcinomatosa.
7
Q
What is tumour lysis syndrome (TLS)?
A
- Lysis is greek for dissolving / disintegrating.
-
Dangerous and potentially fatal metabolic abnormality.
- Any patients at increased risk fr TLS should be closely monitored before, during and after their course of chemotherapy or radiotherapy.
8
Q
What is treatment-related tumourlysis?
A
As a complication during cancer treatment if large amounts of tumour cells are killed off, releasing debris and cell contents into the bloodstream.
9
Q
What is autotumourlysis?
A
- Occurs if tumour mass is very large or systemic tumour burden is very high, especially if this happens very quickly.
- Tumour basically starts dying on its own due to insufficient blood / oxygen.
10
Q
What are the tumour characteristic risk factors for TLS?
A
- Tumour characteristics:
- High cell turnover
- Rapid growth rate
- High tumour bulk
- Tumours most commonly associated with TLS:
- Poorly-differentiated lymphomas (such as Burkitt’s lymphoma).
- Other NHL / cutaneous lymphomas.
- All 4 main types of leukaemia.
- Other cancers (such as melanoma) less commonly cause TLS.
- Generally slow-growing tumours like moderately differentiated adenocarcinomas are at much lower risk than fast-growing tumours like SCLC, neuroendocrine carcinomas or poorly differentiated / dedifferentiated carcinomas, germ cell tumours.
- Elevated serum lactate dehydrogenase (LDH) level is a surrogate marker for rapid cell turnover and is important for TLS risk assessment, but not an absolute diagnostic criterion.
11
Q
What are the patient characteristic risk factors for TLS?
A
- Patient characteristics:
- Some conditions can make TLS more likely
- Elevated baseline serum creatinine.
- Renal insufficiency / existing CKD.
- Dehydration.
- Other issues affecting urinary flow or acidity of urine.
- Some conditions can make TLS more likely
12
Q
What are the treatment characteristic risk factors for TLS?
A
- Chemosensitive tumours are at a high risk for TLS, especially with combination chemotherapy, most common with lymphoma and leukaemia or germ cell tumours.
- TLS can also be caused by steroid treatment alone.
- Patients undergoing total skin irradiation, total body irradiation, large field radiotherapy (i.e. mantle field or total abdominal cavity) or RT of an enlarged spleen are at moderate to high risk to develop TLS.
13
Q
Describe TLS prevention in low-risk patients.
A
- Adequate hydration
- Urine output goals listed
- Monitor for signs and symptoms of TLS
- Low threshold for IV fluids
- Consider allopurinol on an individual basis
14
Q
Describe TLS prevention in intermediate-risk patients.
A
- Aggresive hydration + allopurinol prophylaxis (or febuxostat) up to 7 days.
- Urine output goals listed.
- Monitor for signs and symptoms of TLS (starting 8h after treatment initiation, lab tests every 8-12h).
15
Q
Describe TLS prevention in high-risk patients.
A
- Aggressive hydration + rasburicase prophylaxis.
- Urine output goals listed.
- Monitor for signs and symptoms of TLS (starting 4-6h after initiation of treatment, lab tests every 6-8h).
- Consider ‘preventive’ admission to ICU, especially in the case of pre-existing cardiac or renal dysfunction.
16
Q
What happens in chemo/radio therapy TLS?
A
17
Q
What happens in autotumourlysis syndrome?
A
