Oncological Emergencies

Question 1

Neutropenic Sepsis clinical features

Answer 1

potentially life threatening complication of chemotherapy (chemo has been very toxic e.g. lacks an enzyme to properly excrete the chemotherapy)

• metabolic acidosis (high lactate)
• neutrophils = <0.5 x 109
• pyrexia >38’C (call if >37.5’C)

Question 2

Neutropenic sepsis management

Answer 2

admission to hospital
IV antibiotics upon arrival (within 1 hr)

fluid balance (catheter)

Question 3

Symptoms and signs to look for neutropenic sepsis

Answer 3

pyrexia >38
mucositis
cough, SOB
diarrhoea
urinary symptoms
signs of sepsis (GCS, hypoxia, hypotensive, shock)
TEP
rash, lines, cellulitis, UTI, LRTI, prev hx of MRSA
Blood pressure 
Confusion / LOC
Tachycardia

if they do not have neutrophils they might not have the symptoms of an infection e.g. no sputum

no immune system so random infections:
Mucositis
Cough
SOB
Diarrhoea
TEP (treatment escalation plan)
**Rash**
Lines (PIC line)
Cellulitis
UTI
LRTI
Previous hx of MRSA or C.Diff

Question 4

Management of neutropenic sepsis

Answer 4

A-E and correct as you go

Arrange for nurse be drawn up IV antibiotics if no penicillin infection

Question 5

MASCC score

risk index for patients with neutropenic fever to work out if needs abx

Answer 5

scoring system

>21/26 indicates likely at low risk of significant bacterial illness

Question 6

What are the investigations for Neutropenic Sepsis

Answer 6

bloods: FBC, U+E, LFT, CRP
Blood cultures (peripheral and culture TIVAD)
swabs
urinalysis- MSU
CXR
sputum culture
stool culture
covid swab

Question 7

What is the 1st line treatment for neutropenic sepsis

Answer 7

Tazocin 4.5g TDS
+ gentamicin if severe sepsis

penicillin allergy:
ascertain the allergy status

1. anaphylaxis from penicillin give:
   levofloxacin +/- gentamicin _/- metronidazole
2. non severe allergy: meropenem

Question 8

Further mx/ix if no improvement after 3 days from neutropenic sepsis

Answer 8

atypical or fungal infection
PCP if been on dexamethasone or steroids for a long time (haematology chemotherapy)

investigations:
CT scan
echo (infective endocarditis)
osteomyelitis ( (staph aureus infection)
discitis ('')
repeat bloods culture when spiking

discuss with microbiology
anti fungals

Question 9

Neutropenic enterocolitis / typhlitis

Answer 9

fever
abdominal pain
diarrhoea
common in haematological malignancies

affects the ileocecal region to ascending colon

often caused by polymicrobial ifnection- candida, aspergillus.

higher risk with certain chemotherapies e.g. taxanes, vinorelbin…

Question 10

Typhlitis mx

Answer 10

non surgical - bowel rest, NG, IVF, broad spec antibiotics

surgical mx if perforation or bowel resection necessary

Question 11

Diarrhoea- IO toxiciy

Answer 11

Pembrolizumab
Iplilmumab
Iplilimumab and nivolumab

fatigue, pruritus, rash, diarrhoea, arthralgia
toxic drugs= pembroliumab, ipilimumb, nivolumab

any potential auto immune effect:
pneumonitis, uveitis, colitis, neuropathy, hepatitis, adrenal dysfunction, thyroid dysfunction..

Question 12

History and examination for diarrhoea (toxicity)

Answer 12

blood
dehydration

hypotensive
tachycardia
fluid balance
electrolyte imbalances

Question 13

Immune mediated diarrhoea management

Answer 13

Steroids (to suppress T cell activation)
moderate 0.5-1mg/kg prednisolone OD
severe 1-2mg/kg methyl prednisolone/OD

Involve relevant specialist teams

Persistent >3 days steroids- sigmoidoscopy, infliximab a steroid sparing agent.

do not give loperamide or codeine- the risk of perforation.

stool diary

Question 14

irAEs

Answer 14

Immune-related adverse events

can occur up to 12 months after completion of treatment

Question 15

fluid assessment

Answer 15

cap refill
mucous membranes
heart rate
UO
BP
JVP
peripheral oedema
creatinine and urea

Question 16

resuscitation of fluid

Answer 16

IV sodium chloride 500ml bolus in 15 minutes

Question 17

Metastatic spinal cord compression

Answer 17

older age
gradual onset
severe unremitting pain
aching night pain
localised spinal tenderness
no symptomatic improvement after 4-6 weeks conservative bowel back pain therapy
unexplained weight loss
past hx of cancer

Urine incontinence
Back pain (cervical / thoracic back pain)
saddle anaesthesia (cauda equina syndrome)

Question 18

Cauda equina syndrome

Answer 18

severe progressive bilateral neurological deficit in legs
major motor weakness
knee extension, ankle eversion, foot dorsiflexion weakness

recent onset of urinary retention
urinary incontinence (loss of sensation)
faecal incontinence
perianal or perineal sensory loss
unexplained laxity of the anal sphincter.

Question 19

metastatic spinal cord compression investigations

Answer 19

MRI of the whole spine within 24 hours

if planning neuro/radio want to be able to identify where in the spine there is cancer. treat one vertebra above and one below.

Question 20

Metastatic spinal cord compression management

Answer 20

pain relief- oramorph 10mg PO
improve neurological symptoms

dexamethasone at least 16mg per day PO or IV (then 8mg morning, 8mg evening with PPI cover)
gradually reduce / wean off slowly

laxatives- enema every 3 days
catheterise if necessary

definitive treatment starts quickly- neurosurgery, radiotherapy

prognostic factor- walking.

nursed in beds if spine looks unstable and not mobilised until after definitive treatment

Question 21

Hypercalcaemia

Answer 21

CCa >2.6 and symptoms
20-30 % of pt with malignancies

corrected calcium (low albumin so very high ca2+)

Question 22

causes of hypercalcaemia

Answer 22

• osteolytic bone mets
• PTHrP- SCC’s (cancer is - secreting a protein which is mimicing parathyroid hormone)
  increased calciriol (hodgkins disease, non hodkgins lymphoma)
  production
• primary hyperparathyroidism- higher incidence amongst patients with malignancy
• ca2+ supplementation. (bisphosphonates reduce ca2+ so pt are put on supplementation which can sometimes increase the caa2+)

Question 23

hypercalcaemia signs and symptoms

Answer 23

“stones, bones, groans and moans”

confusion
muscle weakness
polyuria and thirst
anorexia
nausea/vomiting
constipation
abdominal pain
fatigue/lethargy
mood disturbance
cognitive dysfunction

Question 24

investigations for hypercalcaemia

Answer 24

• cancer diagnosis?
• taking anti cancer drugs?
• previous hx of hypercalcaemia
• meds

ECG (shortened QT conduction)
vitamin D
U+E’s

Question 25

pathophysiology of hypercalcaemia

Answer 25

bone disease
los of bone resorption
dehydrated patients
PTH hormone related peptide acts like PTH causes more ca2+ to be taken from bone into blood and more resorption from the kidneys

Question 26

hypercalcemia mx

Answer 26

rehydrate
3-4L of 0.9% saline over 24 hours
stop thiazides (benzo) ca2+ supplements

if cca>3 following hydration
- pamidronate 90mg in 500ml saline over 2 hours
60mg if less severe or zolendronate

if renal impairment- reduce dose and prolong infusion
caution if eGFR <30ml/min

treat underlying malignancy

Question 27

most causes of cancer hypercalcaemia

Answer 27

prostate

lungs (paraneoplastic)