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Oncological emergencies and complications of underlying cancer Flashcards

1
Q

What are the oncological emergencies?

A

Cord compression
SVCO
Neutropenic sepsis
Tumour lysis syndrome
Malignant hypercalcaemia

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2
Q

What cancers are associated w cord compression?

A

Lung, breast, kidney, prostate, - drain in to para vertebral LN
thyroid metastatic cancer
Primary bone tumours or CNS malignancies

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3
Q

What are the CF of cauda equina?

A

Is just a differential to cord compression??
LMN and normally unilateral
Saddle anaesthesia
Reduced anal tone
Painless urinary retention
Lower back pain
Impotence
Can have mixed picture w cord compression

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4
Q

What are the CF of cord compression?

A

UMN and normally symmetrical
Pain first, few weeks before, is severe and progressive
Weakness next, is progressive
Thoracic spine mainly
Can have sensory dysfunc
Can have mixed picture w cauda equina
UMN signs below level, LMN signs at level?

Vertebral body collapses = explanation for sudden severe sx

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5
Q

What are the ix into cord compression?

A

MRI spine within 24 hour of presentation

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6
Q

What is the immediate management of cord compression?

A

Analgesia
VTE prophylaxis - TEDS and LMWH prophylaxis
Catheterise if urinary retention
Dex - 16mg (high dose)

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7
Q

What is the definitive management of cord compression?

A

RT adjuvant to surgery or on its own if can’t have surgery, esp if myeloma eg. if there is compression in multiple places
Surgical decompression and recon - if don’t know the type of cancer, good time to get a biopsy
Within 24 hours of diagnosis

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8
Q

What is malignant hypercalcaemia?

A

Serum calcium >2.6 mmol/L, most common cause of hypercalcaemia

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9
Q

What malignancies are associated w hypercalcaemia?

A

Breast
Multiple myeloma
Lymphoma
SqCC lung cancer

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10
Q

What mechanisms cause malignant hypercalaemia?

A
  1. Osteolytic mets
  2. PTHrP secretion - 80%
  3. Increased Vit D production (= increased absorption of Ca)
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11
Q

What are the CF of hypercalcaemia?

A

Mild - asymptomatic, polyuria, polydipsia, mild cog impair, dyspepsia
Mod - all mild, constipation, weak, fatigue, N, dehydration
Severe - all mild and mod, abdo pain, vom, cardiac arrhythmia, pancreatitis, coma

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12
Q

What is an easy way to remember hypercalcaemia affects?

A

Stones - renal calculi
Bones - fragilty fracture, bone pain
Thrones - polyuria and constipation
Psychiatric moans - mood disturb
Groans - abdo pain, pancreatitis

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13
Q

What is the management of malignant hypercalcaemia?

A

Mild <3mmol/l = oral fluids
Mod 3-3.5 and severe >3.5 = IV fluids to rehydrate and admit
Treat underlying malignancy, if can’t treat will likely recur in 2w
Calcitonin - promotes urinary Ca excretion and inhibits bone resorption
IV bisphosphonates - pamidronate, zolendronic acid (easier to dose)
Normally give 3L of IV fluid before you give IV bisphosphonates

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14
Q

What are the most common organisms involved in neutropenic sepsis?

A

Gram -ve - E.coli, Klebsiella, Pseudomonas
Gram +ve - STAPH EPIDERMIDIS, S.aureus, S.pneumoniae
Viruses - HSV, VZV, EBV, CMV
Fungal - Candida, Aspergillus

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15
Q

What are the CF of neutropenic sepsis?

A

Sx of specific infection eg. purulent cough or dysuria
Fever >38, <36 and non specific sx eg. malaise and fatigue
Acute confusion
>90 BPM
Reduced urine output
BP <90
RR >20
Day 7-10 of treatment, lowest blood count therefore lowest neutrophils

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16
Q

What are the ix into a pt presenting with fever?

A

Bloods - VBG/ABG, FBC, CRP, U+E, LFT, bone profile, clotting, fungal assays, BBV screen
Cultures - blood, line, sputum, urine, stool, wound swabs
Imaging - CXR, LP, echo

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17
Q

What is the sepsis 6 bundle?

A
  1. Oxygen
  2. Abx - empirical - tazocin - piperacillin w tazobactam
  3. IV fluids
  4. Blood cultures
  5. Urine output
  6. Lactate
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18
Q

How can pt be risk assessed if suspect neutropenic sepsis?

A

MASCC risk index <21 = high risk, >21 = low risk
Disease burden - none, mod, severe
Co morbidities - HTN, COPD, prev fungal infection, dehydration
Status of onset - inpt or outpt
Age - <60 or >60

also .. no organ failure, soft tissue infection or indwelling line, not AL

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19
Q

What is the microbial management of neutropenic sepsis?

A

Sepsis 6
Abx - tazocin
Indwelling venous cath = vancomycin
Still febrile and unwell after 48 hours = meropenem or vancomycin
No response w/i 4-6 days = ix for fungal infections eg. HRCT
Sometimes use prophylactic fluoroquinolone

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20
Q

What are the RF of neutropenic sepsis?

A

Neutropenia that is significant, sustained and expected to last >7 days
Clinically unstable
Underlying malignancy and treated w high intensity chemo
Co morbidities

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21
Q

What is the ongoing management of neutropenic sepsis?

A

Measure temp and baseline bloods until apyrexial and neutropenia gone

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22
Q

What is tumour lysis syndrome?

A

Metabolic disturbances from the breakdown of malignant cells after starting treatment for the cancer

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23
Q

What are the biochemical abnormalities of tumour lysis syndrome?

A

Hyperkalaemia
Hyperphosphataemia
Hypocalcaemia (because of raised phosphate)
Hyperuricaemia - breakdown of nucleic acids
25% increase/decrease - Cairo Bishop scoring

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24
Q

What increases the risk of TLS?

A

High proliferation rate
Chemosensitivity
Large tumour burden
Haem malignancies
Pre existing met abnormalities
Renal impairment

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25
What are the consequences of the electrolyte imbalance in TLS?
Hyperkalaemia = arrhythmia Hyperuricaemia = AKI Hyperphorphataemia = Ca phosphate dysreg Seizures, cardiac arrest, death
26
What are the CF of TLS?
Develop in the 1st 72 hours following treatment initiation Sx - lethargy, N+V, diarrhoea, anorexia, muscle cramps, syncope, pruritis, arthritis Signs - fluid overload, haematuria, tetany and paraesthesia, bronchospasm
27
What are the ix into TLS?
U+E - eGFR, electrolytes, urate = essential ix Additional ix = urine dip + microscopy, serum lactate and LDH, ECG
28
What is given as prophylaxis to prevent TLS?
Hypouricaemic agents = prevent hyperuricaemia and production of uric acid eg. allopurinol, rasburicase, IV normally Low risk - oral hydration and monitor Intermediate risk - IV fluids, allopurinol (7 days after initiation of therapy), TLS screen High risk - IV fluids, rasburicase (one off dose), TLS screen
29
What is the management of TLS?
Hyperphosphataemia - hydration and dietary restriction, +/- phosphate binders Hyperkalaemia - IV Ca gluconate, insulin/dextrose infusion, NEB salbutamol - ECG monitor Hypocalcaemia - don't treat asymptomatic hypocalcaemia, only treat if arrhythmia Hyperuricaemia - hypouricaemic agents All = IV fluids
30
What are the indications for haemofiltration/dialysis in TLS?
Untreatable fluid overload Resistant hyperkalaemia Hyperphosphataemia induced sx hypocalcaemia
31
What is SVCO? What causes it?
Malignant sup vena cava obstruction, normally drains the upper limbs, head and neck Lung cancer is the most common cause, NSCLC
32
What are the CF of SVCO?
Sx - SOB, facial swelling and head fullness, sx worse lying down and leaning forward, cough, dysphagia Signs - facial swelling, distended neck and chest wall veins, upper limb oedema, facial plethora, cyanosis
33
What is Pemberton's sign?
Pt raised both arms above head for 1-2 mins: +ve = this causes congestion, cyanosis and resp distress
34
What are the ix into SVCO?
80% of pt w SVCO have abnormal CXR = mediastinal widening and malignant pleural effusion CT thorax is diagnostic = where the obstruction is and the likely underlying cause Sputum cytology, LN biopsy, BM biopsy or bronchoscopy - histology
35
When should you be worried that SVCO is becoming an emergency?
Airway obstruction eg. stridor Neuro sx that indicate cerebral oedema eg. confusion, coma, reduced conc
36
What is the emergency management of SVCO?
Endovascular stent, shunt or thrombolysis
37
What is the general management of SVCO?
Elevate head and neck Histology to understand what cancer is causing the obstruction, then treat it ... Stenting, RT and chemo Steroids can be used to reduced swelling and improve sx
38
What is the prognosis of SVCO?
~6 months - is a poor indicator of survival, it indicates that tumour is extensive Symptom relief is easy and 100% achieve
39
What is the presentation of pleural effusion?
SOB Pleuritic chest pain Non productive cough Stony dull percussion Reduced breath sounds ± tracheal deviation only if vv big
40
What are the ix into pleural effusion?
CXR - meniscus, loss of costophrenic angle, fluid in lung fissures Pleural aspiration - microbiology, protein and LGH Light's criteria = exudate: >30g/L protein, >0.6 LDH CT AP w contract or pleural biopsy if aspirate didn't diagnose
41
What is the management of pleural effusion?
Small and asymptomatic = leave Large: Short term chest drain Indwelling pleural cath Pleurodesis = injection to adhere two layers of the pleura eg. tetracycline or bleomycin
42
What are some malignant causes of ascites?
Stomach, colon, pancreas, liver, ovarian Lymphoma Mets in abdo cavity
43
What is the presentation of ascites?
Sx - abdo distension, discomfort, weight gain, early satiety/anorexia, dyspnoea O/E - jaundice, muscle wasting, gynaecomastia, spider naevi, palmar erythemea, fluid thrill and shifting dullness
44
What are the ix into ascites?
Bloods - FBC, U+E, LFT Abdo US, CT abdo ? Diagnostic paracentesis
45
What is the management of ascites?
Na restriction Spironolactone Therapeutic paracentesis
46
What are some malignant causes of upper GI bleed?
Haematemesis and malaena - gastric and oesophageal cancer
47
What are the ix into upper GI bleed?
G+S and crossmatch, coag OGD
48
What is the management of haematemesis?
AtoE - resus and blood products Biopsy during OGD to guide treatment
49
What are the CF of raised ICP?
Headache - worse on cough, leaning forward N+V Lethargy, confusion, reduced conc Pupil dilation and ptosis Syncope Cushing reflex - Bradycardia, HTN and irreg breathing
50
What are the ix into raised ICP?
GCS, fundoscopy CT head Bloods - BM esp
51
What is the management of raised ICP?
Elevate head, analgesia, cyclizine Dex IV mannitol or hypertonic saline to reduce ICP Palliative RT
52
What are the CF of radiation mucositis?
Soreness, erythema of the mucous membranes Ulcers Odynophagia - can be life threatening if patient can't eat or drink Also a sepsis RF as barrier protection lost when mucous membranes broken down Is a common SE of radiation
53
What is the management of radiation mucositis?
Dental check before and treat all oral thrush w fluconazole Mouth care - brush teeth w soft brush, warm salt water rinses, ice lollies, sot moist foods and stay hydrated Analgesia No smoke Benzydamine hydrochloride mouthwash - NSAID mouthwash
54
What is immune related colitis? What causes it?
Inflam of GI tract = diarrhoea, blood, mucus, abdo pain Causes - immune checkpoint inhibitor drugs eg. pembrolizumab, nivolumab (don't need to know?) -> melanoma, HL, NSCC
55
What is the management of immune related colitis?
Oral/IV steroids Infliximab second line
56
What cancers commonly cause malignant bowel obstruction?
Ovarian Colon Or infiltration of the myenteric plexus or muscle of colon
57
What is the management of malignant bowel obstruction when pt fit for surgery?
Endoscopic stenting Cancer treatments
58
What is the management of inoperable malignant bowel obstruction (pt not fit for surgery)?
Bowel rest Sips and IV fluids NGT if lots and lots of vom Correct electrolyte imbalance Analgesia and dex If doesn't resolve cont w palliative treatment
59
What is DIC?
Disseminated Intravascular Coagulation - formation of lots of micro thrombi in the circulation which uses up plt = haemorrhage
60
What is the FBC in DIC?
Thrombocytopenia Anaemia - clots shear RBC coag - prolonged INR, APTT, fibrinogen depleted
61
What is the management of DIC?
Treat underlying cause Blood products
62
What is the RT management of MSCC?
IF think there is a possibility to regain func = x5 fractions over 5 days If don't think function preservation is possible = x1 dose (can't walk already)

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