Oncological Emergencies Flashcards
What are the 6 oncological emergencies?
1) Brain mets
2) Neutropenic sepsis
3) Spinal cord compression
4) SVC syndrome
5) Malignancy-associated hypercalcaemia
6) Tumour lysis syndrome
What are the diagnostic features of neutropenic sepsis?
- Temp > 38
- Neutrophils < 0.5
When should you suspect neutropenic sepsis?
In all patients unwell after < 6 weeks of chemo
How to you treat neutropenic sepsis?
- Take blood cultures
- Empirical IV abx e.g. tazobactam/piperacillin
Which 4 cancers typically metastasise to the brain?
- Lung
- Breast
- Colorectal
- Melanoma
What are symptoms of brain mets?
- Headache - worse in the morning/cough/bending over
- Focal neurological symptoms
- Ataxia
- Fits
- Signs of raised ICP (N&V, papilloedema)
What is first line management of brain mets?
- Urgent CT/MRI
- Dexamethasone 16mg/24h to reduce cerebral oedema
What is definitive treatment for brain mets?
- Refer to oncology
- Stereotactic radiotherapy
- Neurosurgery esp. if large lesion or associated hydrocephalus
What is spinal cord compression in the context of oncology?
Collapse/compression of vertebrae due to bony metastases (common) or direct extension of tumour into vertebral column (rare)
Which cancers typically cause spinal/bony mets?
- Lung
- Prostate
- Breast
- Myeloma
- Melanoma
What are the symptoms of spinal cord compression?
- Back pain esp. cervical/thoracic and nocturnal pain/pain with straining
- Limb weakness
- Bowel/bladder dysfunction
What investigation do you do for spinal cord compression?
Urgent MRI whole spine (<24h) + admit for bed rest
What is first line treatment for spinal cord compression?
Urgent treatment to preserve neurological function and relieve pain
- Dexamethasone 16mg/24h PO with GI prophylaxis (PPI) + blood glucose monitoring
- ± thromboprophylaxis (compression stockings, LMWH) if reduced mobility
What is definitive treatment for spinal cord compression?
Refer urgent to oncology
- Radiotherapy within 24h of MRI diagnosis ± decompressive surgery
What is tumour lysis syndrome?
Cell death and release of cellular components into circulation due to cytotoxic treatment for rapidly proliferating tumours
In which cancers is tumour lysis syndrome common?
Haematological malignancy (leukaemia, lymphoma, myeloma)
What are symptoms of tumour lysis syndrome?
- N&V
- Diarrhoea
- Muscle weakness and cramps
- Abdominal pain
What are complications of tumour lysis syndrome?
- Arrhythmia
- Renal failure (AKI)
What investigations do you do in tumour lysis syndrome?
- Bloods
- ECG
What would you see on blood test results in tumour lysis syndrome?
- Increased urate
- Hyperkalaemia
- Hyperphosphateaemia
- Hypocalcaemia
How do you manage/treat tumour lysis syndrome?
- Fluid resuscitation with IV 0.9% sodium chloride
- Prevent with hydration and uricolytics (allopurinol, rasburicase)
What is superior vena cava (SVC) syndrome?
Decreased venous return from head, neck and upper limbs
- > 90% due to SVCO (extrinsic compression by malignancy)
- Some due to venous thrombosis
What are the commonest cancers causing SVCO?
- Lung
- Lymphoma
- Breast met
- Thymoma
- Germ cell
What are symptoms of SVC syndrome?
- SOB
- Orthopnoea
- Stridor
- Plethora/cyanosis
- Face/neck/arm oedema
- Neck/chest/abdo vascular distension - non-pulsatile raised JVP
- Cough
- Headache
What test is positive in SVC syndrome?
Pemberton’s test
How do you diagnose SVC syndrome?
Clinical diagnosis ± CT
What is first line management for SVC syndrome?
Prop up ± O2 if hypoxic + IV dexamethasone
How do you definitively treat SVC syndrome?
- Balloon valvuloplasty + SVC stenting
- Refer to oncology - radio or chemo
What is the most common cancer causing malignancy-associated hypercalcaemia?
Myeloma
How do you define malignancy-associated hypercalcaemia?
Ca > 2.6
What causes malignancy-associated hypercalcaemia?
- Tumour production of PTH-related protein (squamous cell lung carcinoma)
- Tumour production of calcitriol (lymphoma or granulomatous diseases as sarcoidosis or TB)
- Local osteolysis (myeloma)
What are the symptoms of malignancy-associated hypercalcaemia?
- Stones - abdo pain
- Groans - constipation
- Moans - confusion
- Bones - bone pain
What are complications of malignancy-associated hypercalcaemia?
- Renal failure
- Ectopic calcification
What investigation do you do for malignancy-associated hypercalcaemia?
Bloods
How do you treat malignancy-associated hypercalcaemia?
1) IV fluids FIRST - aggressive rehydration
2) Bisphosphonates (if eGFR > 30) e.g. IV zoledronic acid OR calcitonin (short term - more rapid, 2h)
3) Refer to oncology - control of underlying malignancy
What is the most common metabolic abnormality in cancer pts?
Malignancy-associated hypercalcaemia - poor prognostic sign
What do you need to check first in SVC syndrome?
That the airway is not compromised - if is, this needs urgent treatment
When are patients unlikely to recover from spinal cord compression?
If they have loss of motor function after > 48h
