Oncological emergencies Flashcards
When should you suspect neutropenic sepsis
In any unwell cancer patient within 6 weeks of receiving chemotherapy
What are the signs of neutropenic sepsis
Localizing signs may be absent
T >38 degrees C
Neutrophils <0.5X10^9/L
Describe the management of neutropenic sepsis
Refer to local guidelines or start empirical antibiotics piperacillin/tazobactam
Which cancers most commonly cause metastatic spinal cord compression
Lung Breast Prostate Myeloma Melanoma
What causes spinal cord compression in metastases
Collapse or compression of vertebral body
Direct extension of a tumour into vertebral column
What are the signs and symptoms of metastatic spinal cord compression
Back pain in 95%
Ask about nocturnal pain and pain with straining
Worry if there is cervical/thoracic pain
Also limb weakness, difficulty walking, sensory loss and bowel/bladder dysfunction
Maintain a high index of suspicion
Describe the management of metastatic spinal cord compression
Admit for bed rest and arrange urgent MRI of the whole spine
Give dexamethasone 16mg/24h PO with prophylactic gastroprotection
If reduced mobility consider thromboprophylaxis
Refer urgently to clinical oncology/cancer MDT
Radiotherapy is the commonest treatment and should be given within 24hrs
Decompressive surgery and radiotherapy may be given depending on the prognosis
Patients who lose motor function after >48hrs are unlikely to regain function
Describe superior vena cava syndrome
Reduced venous return from the head, neck and upper limbs
Due to extrinsic compression or venous thrombosis
SVC syndrome with airway compromise requires urgent treatment
What are the causes of superior vena cava syndrome
Mostly common cancers - lung, lymphoma, thyoma, germ cell, breast metastases
What are the signs and symptoms of superior vena cava syndrome
SOB, orthopnoea, stridor, plethora/cyanosis, oedema of the face and arm, cough, headache, engorged neck veins (non pulsatile, increased JVP), engorged chest wall veins. Pembertons test - Elevation of the arms to the side of the head causes facial plethora or cyanosis
How do you manage superior vena cava obstruction?
Prop up
Assess for hypoxia - pulse oximetry and blood gas - give O2 if needed
Dexamethasone 16mg/24h
CT used to define the anatomy of the obstruction
Balloon venoplasty and SVC stenting provide most rapid relief
Treat with radiotherapy or chemotherapy depending on the underlying sensitivity of the cancer
What is the most common metabolic abnormality among cancer patients?
Hypercalcaemia
What is the prognosis for someone with malignancy associated hypercalcaemia
75% mortality within 3 months
Why does calcium need correcting to the serum albumin concentration?
Very protein bound
What happens to the PTH levels when serum calcium is high due to malignancy
Decrease
What causes malignancy associated hypercalcaemia
PTH related protein produced by the tumour
Tumour production of calcitriol
Local osteolysis
What are some signa and symptoms of malignancy associated hypercalcaemia
Weight loss Anorexia Nausea Polydipsia Polyuria Constipation Abdominal pain Dehydration Weakness Confusion Seizure Coma
Describe the management of malignancy associated hypercalcaemia
Aggressive rehydration
Bisphosphonates if eGFR>30 (zoledronic acid)
Calcitonin (more rapid but tolerance can develop and is only short term effect)
Long term treatment is by control of the underlying malignancy
Which cancers commonly cause brain mets
Breast
Lung
Colorectal
Melanoma
Describe the prognosis of brain mets
Poor prognosis 1-2 months
Better prognosis with single lesion or lesion from breast cancer
What are the signs and symptoms of brain mets
Headache - worse in morning and bending forward Focal neurological signs Ataxia Fits Nausea Papilloedema
Describe the management of brain mets
Urgent CT/MRI depending on the underlying diagnosis, disease stage and performance status
Dexamethasone 16mg/24h to reduce cerebral oedema
Stereotactic radiotherapy
Discuss with neurosurgery especially if large lesion or associated hydrocephalus
Describe tumour lysis syndrome
Chemotherapy for rapidly proliferating tumours (leukaemia, lymphoma and myeloma) leads to cell death and increases urate, potassium, phosphate and decreases calcium. Risk or arrhythmias and renal failure
What is the management of tumour lysis syndrome
Prevent with hydration and Uricolytic (allopurinol, rasburicase)
What are paraneoplastic syndromes
Consist of symptoms attributable to malignancy mediated by hormones, cytokines or the cross-reaction of tumour antibodies. They do not correlate with stage/prognosis and may pre-date other cancer symptoms
Describe hypercalcaemia as a paraneoplastic syndrome and list the cancers commonly associated
PTH related protein secreted by the tumour
Lung, oesophagus, skin, cervix, kidney and breast
Describe SIADH as a paraneoplastic syndrome and list the cancers commonly associated
Excessive ADH secretion causing hyponatraemia
Lung, pancreas, lymphoma, prostate
Describe Cushing’s syndrome as a paraneoplastic syndrome and list the cancers commonly associated
Tumour secretes ACTH or CRF, causing adrenal to produce high levels of corticosteroid
Lung, pancreas, thymus, carcinoid
Describe neuropathy as a paraneoplastic syndrome and list the cancers commonly associated
Antibody mediated neuronal degeneration: Peripheral, autonomic, cerebellar
Lung, breast, myeloma, Hodgkin’s, GI
Describe lambert-eaton myasthenic syndrome as a paraneoplastic syndrome and list the cancers commonly associated
Antibody to voltage gated ion channel on pre-synaptic membrane causes weakness (proximal leg most common)
Mostly lung, also GI, breast, thymus
Describe dermatomyositis and polymyositis as a paraneoplastic syndrome and list the cancers commonly associated
Inflammation of the muscles with a heliotrope rash
Lung, breast, ovary, GI
Describe acanthosis nigricans as a paraneoplastic syndrome and list the cancers commonly associated
Velvety, hyperpigmented skin (flexural)
GI
Describe pemphigus as a paraneoplastic syndrome and list the cancers commonly associated
Blisters to skin/mucous membranes
Lymphoma, thymus, Kaposi’s sarcoma
Describe hypertrophic osteoarthropathy as a paraneoplastic syndrome and list the cancers commonly associated
Periosteal bone formation, arthritis and finger clubbing
Lung
