Oncological emergencies Flashcards

1
Q

When should you suspect neutropenic sepsis

A

In any unwell cancer patient within 6 weeks of receiving chemotherapy

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2
Q

What are the signs of neutropenic sepsis

A

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

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3
Q

Describe the management of neutropenic sepsis

A

Refer to local guidelines or start empirical antibiotics piperacillin/tazobactam

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4
Q

Which cancers most commonly cause metastatic spinal cord compression

A
Lung
Breast
Prostate
Myeloma
Melanoma
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5
Q

What causes spinal cord compression in metastases

A

Collapse or compression of vertebral body

Direct extension of a tumour into vertebral column

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6
Q

What are the signs and symptoms of metastatic spinal cord compression

A

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

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7
Q

Describe the management of metastatic spinal cord compression

A

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

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8
Q

Describe superior vena cava syndrome

A

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

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9
Q

What are the causes of superior vena cava syndrome

A

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

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10
Q

What are the signs and symptoms of superior vena cava syndrome

A

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

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11
Q

How do you manage superior vena cava obstruction?

A

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

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12
Q

What is the most common metabolic abnormality among cancer patients?

A

Hypercalcaemia

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13
Q

What is the prognosis for someone with malignancy associated hypercalcaemia

A

75% mortality within 3 months

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14
Q

Why does calcium need correcting to the serum albumin concentration?

A

Very protein bound

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15
Q

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

A

Decrease

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16
Q

What causes malignancy associated hypercalcaemia

A

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

17
Q

What are some signa and symptoms of malignancy associated hypercalcaemia

A
Weight loss
Anorexia
Nausea
Polydipsia
Polyuria
Constipation 
Abdominal pain 
Dehydration 
Weakness
Confusion 
Seizure
Coma
18
Q

Describe the management of malignancy associated hypercalcaemia

A

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

19
Q

Which cancers commonly cause brain mets

A

Breast
Lung
Colorectal
Melanoma

20
Q

Describe the prognosis of brain mets

A

Poor prognosis 1-2 months

Better prognosis with single lesion or lesion from breast cancer

21
Q

What are the signs and symptoms of brain mets

A
Headache - worse in morning and bending forward 
Focal neurological signs
Ataxia
Fits
Nausea
Papilloedema
22
Q

Describe the management of brain mets

A

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

23
Q

Describe tumour lysis syndrome

A

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

24
Q

What is the management of tumour lysis syndrome

A

Prevent with hydration and Uricolytic (allopurinol, rasburicase)

25
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
26
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
27
Describe SIADH as a paraneoplastic syndrome and list the cancers commonly associated
Excessive ADH secretion causing hyponatraemia | Lung, pancreas, lymphoma, prostate
28
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
29
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
30
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
31
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
32
Describe acanthosis nigricans as a paraneoplastic syndrome and list the cancers commonly associated
Velvety, hyperpigmented skin (flexural) | GI
33
Describe pemphigus as a paraneoplastic syndrome and list the cancers commonly associated
Blisters to skin/mucous membranes | Lymphoma, thymus, Kaposi's sarcoma
34
Describe hypertrophic osteoarthropathy as a paraneoplastic syndrome and list the cancers commonly associated
Periosteal bone formation, arthritis and finger clubbing | Lung