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Yr4 - Cancer Care > Oncological Emergencies > Flashcards

Oncological Emergencies Flashcards

1
Q

Oncological emergencies

A 
Neutropenic sepsis
Metastatic spinal cord compression
Hypercalcaemia of malignancy
SVCO
Tumour lysis syndrome
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2
Q

Nice definition of neutropenic sepsis

A

Patient undergoing systemic anticancer treatment (SACT)
Temp > 38
Neutrophil count < 0.5*10^9/L

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3
Q

Causes of neutropenic sepsis

A

Suspect in all chemo patients who become unwell - some cannot mount fever (corticosteroids)
Typically occurs 10 days post chemo
Newer biological/targeted therapies and RT have less propensity
Haematological malignancy treatment have deeper nadir so greater duration of neutropenia

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4
Q

Clinical features of neutropenic sepsis

A 
Fever
Tachycardia > 90
Hypotension < 90 systolic = urgent
RR > 20
Symptoms related to specific system
- cough
- SOB
Drowsy
Confused
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5
Q

Risk factors for neutropenic sepsis

A 
Prolonged neutropenia - harsher chemo
Severity of neutropenia
Significant comorbidities - COPD, DM, renal/hepatic impairment
Cancer uncontrolled/progressive
Central lines
Mucosal disruption
Inpatient
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6
Q

Responsible pathogens for neutropenic sepsis

A

80% arise from endogenous flora
- staph aureus
- staph epidermis
- enterococcus
- streptococcus
Increasing frequency of gram +ve cocci - indwelling plastic catheters
MRSA and VRE (vancomycin resistant enterococcus) increasing prevalence
Source only identified in 30% of patients - BC often negative

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7
Q

Ix for neutropenic sepsis

A 
Blood counts
- FBC
- U+Es
- LFTs
- Lactate
- CRP
Cultures
- blood - central and peripheral 
- urine
- sputum
Swabs
- lines
- wounds
ABG
CXR
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8
Q

Prevention of neutropenic sepsis

A 
Patient education 
- written and oral information
- how and when to contact 24 hour specialist oncology advice/emergency care
Consider abx prophylaxis
Consider future chemo cycles
- dose reduction (palliative care)
- prophylactic GCSF (curative/adjuvant)
- consider stopping treatment
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9
Q

Mechanism of malignant spinal cord compression

A

Usually caused by collapse or compression of vertebral body that contains metastatic disease (arterial seeding)
10% causes by direct tumour (paraspinal mass) extension into vertebral column
Compression of cord initially causes oedema, venous congestion and demyelination - reversible
Prolonged compression -> vascular injury, cord necrosis - permanent damage

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10
Q

Site of compression in MSCC

A

10% cervical
70% thoracic
20% lumbar and sacral - below L2 = cauda equina compression

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11
Q

Incidence of MSCC

A

5% of all cancer patients
- 15% of advanced cancer patients
Commonly breast, prostate and lung
23% will have no previous Ca diagnosis

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12
Q

Presentation of MSCC

A

> 90% have back pain
- vertebral met, root compression, compression of long tracts of spinal cord
- prolonged often 2-3/12
- spinal or radicular pain
- exacerbated by straight leg raising, coughing, sneezing, straining
- worse after period of lying down
Limb weakness
Sensory level
Bladder and anal sphincter dysfunction
Diminishing performance status/generally unwell

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13
Q

Examination findings of MSCC

A

Acute onset, flaccid paralysis
Progressing over time
- spasticity - increased tone, clonus and hyperreflexia
- plantar reflexes upgoing
- sensory loss with well defined dermatomal level
- palpable bladder

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14
Q

Immediate mx for MSCC

A 
If pain suggestive of spinal mets - MRI within 1 week
Signs of MSCC - MRI within 24 hours
Admit
Bed rest with log rolling
Dexamethasone 16mg + PPI
Adequate analgesia
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15
Q

Definitive mx for MSCC

A

Admit patient - bed rest with log rolling
IV DEXAMETHASONE
Adequate analgesia
Surgical decompression - if fit enough and good prognosis
Local radiotherapy

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16
Q

Supportive care of MSCC

A 
Good nursing care - pressure areas
Analgesia
Laxatives
Bladder care
Monitor BMs
VTE prophylaxis
Physiotherapy
Occupational therapy
17
Q

MSCC prognosis

A

Dictated by timing
- 80% of patients ambulatory at presentation remain so
Radiosensitive tumour types have improved functional capacity

18
Q

Causes of hypercalcaemia

A

Normal range 2.2-2.6
Most common in squamous cell cancers (lung, H+N, kidney, cervix), multiple myeloma and breast cancer
Humoral cause - 80%
- production of PTH-related protein and increased vitamin D3 (lymphoma)
- increased bone resorption and renal reabsorption
Bone invasion - 20%
- osteolytic metastases with local release of cytokines
- increased bone resorption and calcium release form bone (local bone destruction)

19
Q

Symptoms of hypercalcaemia

A 
Nausea
Thirsty
Constipated
Confused
Anorexia
Polydipsia and polyuria
Fatigue and weakness
Poor concentration
Drowsy
20
Q

Mx of hypercalcaemia

A

Rehydration - 24hrs of normal saline
Bisphosphonates
- pamidronate or zoledronic acid
- can cause renal failure so ensure rehydrated
- takes 4 days to work
Systemic treatment of malignancy
Likely to recur in future - monitoring with 2-4 weekly blood tests

21
Q

Define tumour lysis syndrome

A

Metabolic emergency that presents as severe electrolyte abnormality
Massive tumour cell lysis -> release of large amounts of potassium, phosphate and uric acid into systemic circulation
- hyperuricemia
- hyperkalaemia
- hyperphosphatemia
- AKI - uric acid or calcium phosphate crystals
- hypocalcaemia

22
Q

Risk factors for tumour lysis syndrome

A

Risk greatest for haematological malignancies
Bulky chemo-responsive tumours
Most common with high grade lymphomas and leukaemia
Generally following initiation of cytotoxic therapy
Patient specific factors
- pre-existing renal dysfunction/nephropathy
- pre-treatment hyperuricaemia
- hypovolaemia
- pre-treatment diuretic use
- pre-treatment LDH high
- urinary tract obstruction from tumour

23
Q

Presentation of tumour lysis syndrome

A 
3-7 days post chemo
N+V
Diarrhoea
Anorexia
Lethargy
Haematuria -> oliguria -> anuric
Heart failure
Cardiac arrhythmia/arrest - peaked T waves, QTc derangement
Primary presentation of malignancy
24
Q

Features of SVCO

A

Compression or obstruction of SVC
90% extrinsic compression
- intrathoracic primary lung cancer or mesothelioma
Occurs in 3-8% of cancer patients

25
Q

Clinical features of SVCO

A 
Breathlessness
Swelling of face + neck
Trunk and arm swelling
Sensation of choking
Feeling of fullness
Headache
Lethargy
Chest pain
Cough
Dysphagia
Cognitive dysfunction
Hallucinations
Seizures
Stridor
Coma
26
Q

Ix for SVCO

A 
CXR
Chest CT with contrast
- extensive collateralisation
- intraluminal thrombus of SV
- evidence of extrinsic compression
27
Q

Mx of SVCO

A 
Steroids - DEXAMETHASONE
Stent - if not radio or chemo sensitive
- 95% response rate
- rapid relief of symptoms
Anticoagulation if thrombus
Chemo
- SCLC, lymphoma and teratoma
Radiotherapy
28
Q

Symptom relief in SVCO

A 
Sit upright
Opioids
Benzodiazepines
O2
Psychological and emotional support
29
Q

Causes of SIADH

A 
Tumour cells secreting ADH
- commonest in SCLC
Drug related
- SSRIs
- Pneumonia
Meningitis/encephalitis
Alcohol
30
Q

Clinical features of SIADH

A 
Hyponatraemia with intracellular cellular oedema
Anorexia
N+V
Drowsiness
Confusion
Seizures
Coma
31
Q

Ix for SIADH

A

Serum Na < 130
Low plasma osmolality < 270
Urine osmolality > plasma osmolaltiy

32
Q

Mx of SIADH

A

Anti-cancer treatment
Fluid restrictions
Demeclocycline

33
Q

Prevention of tumour lysis syndrome

A

Allopurinol - 2 days prior
IV fluids - 1 day prior
K+ levels monitored every 2 hours for the first 8-12 hours of treatment

34
Q

Mx of tumour lysis syndrome

A

Rasburicase - recombinant urate oxidase

35
Q

Causes of MSCC

A

Collapse of a vertebral body containing metastatic disease
Direct tumour expansion causing pressure on the spinal cord
Metastatic lesions in the vertebral bodies causing compression

36
Q

Mx of neutropenic sepsis

A

IV TAZOCIN - within 1 hour
- if still febrile after 48 hours switch to meropenem + vancomycin
Fluid resuscitation
Consider catheterisation for urine monitoring
Consider G-CSF in patients with extreme sepsis/neutropenia

Yr4 - Cancer Care (12 decks)

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