Oncological emergencies

Question 1

When should you suspect neutropenic sepsis

Answer 1

In any unwell cancer patient within 6 weeks of receiving chemotherapy

Question 2

What are the signs of neutropenic sepsis

Answer 2

Localizing signs may be absent
T >38 degrees C
Neutrophils <0.5X10^9/L

Question 3

Describe the management of neutropenic sepsis

Answer 3

Refer to local guidelines or start empirical antibiotics piperacillin/tazobactam

Question 4

Which cancers most commonly cause metastatic spinal cord compression

Answer 4

Lung
Breast
Prostate
Myeloma
Melanoma

Question 5

What causes spinal cord compression in metastases

Answer 5

Collapse or compression of vertebral body

Direct extension of a tumour into vertebral column

Question 6

What are the signs and symptoms of metastatic spinal cord compression

Answer 6

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

Question 7

Describe the management of metastatic spinal cord compression

Answer 7

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

Question 8

Describe superior vena cava syndrome

Answer 8

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

Question 9

What are the causes of superior vena cava syndrome

Answer 9

Mostly common cancers - lung, lymphoma, thyoma, germ cell, breast metastases

Question 10

What are the signs and symptoms of superior vena cava syndrome

Answer 10

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

Question 11

How do you manage superior vena cava obstruction?

Answer 11

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

Question 12

What is the most common metabolic abnormality among cancer patients?

Answer 12

Hypercalcaemia

Question 13

What is the prognosis for someone with malignancy associated hypercalcaemia

Answer 13

75% mortality within 3 months

Question 14

Why does calcium need correcting to the serum albumin concentration?

Answer 14

Very protein bound

Question 15

What happens to the PTH levels when serum calcium is high due to malignancy

Answer 15

Decrease

Question 16

What causes malignancy associated hypercalcaemia

Answer 16

PTH related protein produced by the tumour
Tumour production of calcitriol
Local osteolysis

Question 17

What are some signa and symptoms of malignancy associated hypercalcaemia

Answer 17

Weight loss
Anorexia
Nausea
Polydipsia
Polyuria
Constipation 
Abdominal pain 
Dehydration 
Weakness
Confusion 
Seizure
Coma

Question 18

Describe the management of malignancy associated hypercalcaemia

Answer 18

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

Question 19

Which cancers commonly cause brain mets

Answer 19

Breast
Lung
Colorectal
Melanoma

Question 20

Describe the prognosis of brain mets

Answer 20

Poor prognosis 1-2 months

Better prognosis with single lesion or lesion from breast cancer

Question 21

What are the signs and symptoms of brain mets

Answer 21

Headache - worse in morning and bending forward 
Focal neurological signs
Ataxia
Fits
Nausea
Papilloedema

Question 22

Describe the management of brain mets

Answer 22

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

Question 23

Describe tumour lysis syndrome

Answer 23

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

Question 24

What is the management of tumour lysis syndrome

Answer 24

Prevent with hydration and Uricolytic (allopurinol, rasburicase)

Question 25

What are paraneoplastic syndromes

Answer 25

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

Question 26

Describe hypercalcaemia as a paraneoplastic syndrome and list the cancers commonly associated

Answer 26

PTH related protein secreted by the tumour

Lung, oesophagus, skin, cervix, kidney and breast

Question 27

Describe SIADH as a paraneoplastic syndrome and list the cancers commonly associated

Answer 27

Excessive ADH secretion causing hyponatraemia

Lung, pancreas, lymphoma, prostate

Question 28

Describe Cushing’s syndrome as a paraneoplastic syndrome and list the cancers commonly associated

Answer 28

Tumour secretes ACTH or CRF, causing adrenal to produce high levels of corticosteroid
Lung, pancreas, thymus, carcinoid

Question 29

Describe neuropathy as a paraneoplastic syndrome and list the cancers commonly associated

Answer 29

Antibody mediated neuronal degeneration: Peripheral, autonomic, cerebellar
Lung, breast, myeloma, Hodgkin’s, GI

Question 30

Describe lambert-eaton myasthenic syndrome as a paraneoplastic syndrome and list the cancers commonly associated

Answer 30

Antibody to voltage gated ion channel on pre-synaptic membrane causes weakness (proximal leg most common)
Mostly lung, also GI, breast, thymus

Question 31

Describe dermatomyositis and polymyositis as a paraneoplastic syndrome and list the cancers commonly associated

Answer 31

Inflammation of the muscles with a heliotrope rash

Lung, breast, ovary, GI

Question 32

Describe acanthosis nigricans as a paraneoplastic syndrome and list the cancers commonly associated

Answer 32

Velvety, hyperpigmented skin (flexural)

GI

Question 33

Describe pemphigus as a paraneoplastic syndrome and list the cancers commonly associated

Answer 33

Blisters to skin/mucous membranes

Lymphoma, thymus, Kaposi’s sarcoma

Question 34

Describe hypertrophic osteoarthropathy as a paraneoplastic syndrome and list the cancers commonly associated

Answer 34

Periosteal bone formation, arthritis and finger clubbing

Lung