Oncological emergencies Flashcards
How can you classify ontological side effects and emergencies? Give examples in each category
Treatment related:
- (pan) Cytopenias (neutropaenic sepsis)
- Electrolyte imbalance (hypercalcaemia)
- Tumour lysis syndrome (rare but examinable)
- Diarrhoea
- Vomiting
- Anaphylaxis
- Extravasation
- Colitis (from immune therapies)
- Radiotherapy side effects
Tumour related
- Spinal cord compression
- SVCO
- Upper airway obstruction
- Brain mets, raised ICP and seizures
- Bowel obstruction
- VTE
What are the risk factors for and presentation of neutropaenic sepsis?
Risk factors:
- Cytotoxic chemo
- Poor nutritional state
- Mucosal barrier defect
- Central venous lines
- Abnormal host colonisation
Presentation:
- Infective symptoms/signs with or without fever
- Asymptomatic yet febrile
- Suspect in any patients presenting with a new clinical deterioration within 6wks of cytotoxic chemo (most often occurs within 7-10 days of a 3wk chemo therapy cycle)
Should be treated for if they have a temp >38c and an absolute neutrophil count of <1x10^9/L
How do you investigate and manage neutropaenic sepsis?
Standard sepsis 6/Bufalo (cultures, urine monitoring, fluids, Abx, lactate, O2)
Investigation:
- FBC, U+E, creatinine, CRP/ESR, coag
- Septic screen = blood + clinically relevant (swabs+) cultures, CXR
Management:
- DO NOT AWAIT CULTURES, GIVE WITHIN 1HR
- Initial Abx - Piperacillin + Tazobactam IV
- Switch to oral - after 24-48hrs of IV if clinically improving
- No improvement after 48hrs - consider adding second line Abx
- No improvement after 5 days - consider opportunistic infections e.g. fungal/PCP
If there are central lines present, consider these as a possible source of infection - identify and remove
How do you prevent neutropaenic sepsis?
Patients having chemo + high risk of developing neutropaenia - offer prophylaxis with fluoroquinolone Abx (e.g. ciprofloxacin), anti-fungals or granulocyte colony-stimulating factor
How do you diagnose malignant hypercalcaemia?
c. 40% of calcium is bound to albumin
The unbound, ionised calcium is physiologically important - CORRECTED CALCIUM should therefore be used to diagnose
Severity:
- Mild - 2.6-3.0 mmol/L
- Moderate - 3.01-3.39 mmol/L
- Severe - >3.4 mmol/L
What are the causes of malignant hypercalcaemia?
Osteolysis - from lytic bone metastases
Humoral - Parathyroid hormone-related protein (or PTHrP) is a protein member of the parathyroid hormone family, secreted by some cancer cells e.g. in squamous cell lung carcinoma, some breast cancers
Dehydration
Other tumour specific mechanisms
How does malignant hypercalcaemia present?
BONES STONES GROANS AND PSYCHIC MOANS:
- GI - abdo pain, vomiting, constipation, anorexia, weight loss
- GU - polyuria, polydipsia
- Neuro - fatigue, weakness, confusion
- Psych - depression
How do you investigate malignant hypercalcaemia?
Repeat blood sample - isolated raised values are often of little use (unless wildly high)
ECG - shortened QT interval
Imaging - for bone mets if appropriate
How do you manage malignant hypercalcaemia acutely?
1) Correct dehydration:
- 0.9% saline, 4-6L depending on clinical condition and PMH (e.g. CHF)
2) IV bisphosphonates
- Inhibits osteoclasts - reducing bone turnover and reducing Ca levels over several days
- Zolendronic acid, pamidronate = commonly used
- SEs: flu-like symptoms, bone pain, myalgia, reduced phosphate levels, N+V, headache, osteonecrosis of the jaw
If persistent/relapsing hypercalcaemia or malignancy:
- Denosumab - monoclonal Ab inhibiting RANK ligand and thus inhibiting the maturation of osteoclasts
What is malignant spinal cord compression?
Spinal cord extends from base of skull - terminating at L1
Cauda equina extends below L1 and contains lumbar, sacral and coccygeal spinal nerves
Cord compression is therefore pressure on the cord above the level of L1 (AND SO NOT THE SAME AS CAUDA EQUINA SYNDROME)
Injury from:
- Primary malignancy
- Secondary malignancy = more common - prostate, lung, breast, kidney, thyroid - most common
- Crush fracture
How does malignant spinal cord compression present?
Worsening back pain
Limb weakness below the level of compression
Sensory loss (sensory level present) below the level of compression
- Sensory level is defined as the lowest spinal cord level that still has normal pinprick and touch sensation
- If there is a spinal cord level below which there is no voluntary motor or conscious sensory function, the person is called a “complete” spinal cord injury
Abnormal neurological examination
- LMN signs at the level of the lesion and UMN signs below that level
E.g. a spastic paralysis with brisk reflexes (unlike the flaccid paralysis and arreflexia of cauda equina syndrome - but both cause sensory and power loss)
Radicular pain
- Radiates from your back and hip into your legs through the spine
- The pain travels along the spinal nerve root
Bowel or bladder dysfunction = a late sign, so do not wait for this…
How do you investigate malignant cord compression?
MRI WHOLE SPINE
As patients may have multiple levels of compression that need addressing
How do you manage malignant cord compression?
High dose corticosteroids
Analgesia
VTE and pressure sore prophylaxis
Definitive treatment will depend on patient and disease factors:
- Surgery - spinal decompression + spinal column stabilisation
- Radiotherapy - for those unsuited to surgery; can be used for pain control
- Chemotherapy - for very chemosensitive tumours
- Hormone deprivation - if newly diagnosed prostate cancer
What is the prognosis of malignant spinal cord compression?
Related to severity of neurological deficit at time of presentation e.g. if paraplegia and sphincter involvement has occurred then recovery is uncommon
What is superior Vena Cava obstruction (SVCO)?
SVC provides venous drainage to the head, neck, upper limbs and thorax - if obstructed, collateral pathways form to provide an alternative route for blood to return to the right atrium
Obstructed by:
- Intravascular - thrombus, intravascular device e.g. central line
- Inside vessel wall - direct tumour invasion
- Outside the vessel - tumour mass effect (lung Ca, lymphoma, germ cell tumour), fibrosing mediastinitis
