Oncological emergencies and complications of underlying cancer Flashcards
What are the oncological emergencies?
Cord compression
SVCO
Neutropenic sepsis
Tumour lysis syndrome
Malignant hypercalcaemia
What cancers are associated w cord compression?
Lung, breast, kidney, prostate, - drain in to para vertebral LN
thyroid metastatic cancer
Primary bone tumours or CNS malignancies
What are the CF of cauda equina?
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
What are the CF of cord compression?
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
What are the ix into cord compression?
MRI spine within 24 hour of presentation
What is the immediate management of cord compression?
Analgesia
VTE prophylaxis - TEDS and LMWH prophylaxis
Catheterise if urinary retention
Dex - 16mg (high dose)
What is the definitive management of cord compression?
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
What is malignant hypercalcaemia?
Serum calcium >2.6 mmol/L, most common cause of hypercalcaemia
What malignancies are associated w hypercalcaemia?
Breast
Multiple myeloma
Lymphoma
SqCC lung cancer
What mechanisms cause malignant hypercalaemia?
- Osteolytic mets
- PTHrP secretion - 80%
- Increased Vit D production (= increased absorption of Ca)
What are the CF of hypercalcaemia?
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
What is an easy way to remember hypercalcaemia affects?
Stones - renal calculi
Bones - fragilty fracture, bone pain
Thrones - polyuria and constipation
Psychiatric moans - mood disturb
Groans - abdo pain, pancreatitis
What is the management of malignant hypercalcaemia?
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
What are the most common organisms involved in neutropenic sepsis?
Gram -ve - E.coli, Klebsiella, Pseudomonas
Gram +ve - STAPH EPIDERMIDIS, S.aureus, S.pneumoniae
Viruses - HSV, VZV, EBV, CMV
Fungal - Candida, Aspergillus
What are the CF of neutropenic sepsis?
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
What are the ix into a pt presenting with fever?
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
What is the sepsis 6 bundle?
- Oxygen
- Abx - empirical - tazocin - piperacillin w tazobactam
- IV fluids
- Blood cultures
- Urine output
- Lactate
How can pt be risk assessed if suspect neutropenic sepsis?
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
What is the microbial management of neutropenic sepsis?
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
What are the RF of neutropenic sepsis?
Neutropenia that is significant, sustained and expected to last >7 days
Clinically unstable
Underlying malignancy and treated w high intensity chemo
Co morbidities
What is the ongoing management of neutropenic sepsis?
Measure temp and baseline bloods until apyrexial and neutropenia gone
What is tumour lysis syndrome?
Metabolic disturbances from the breakdown of malignant cells after starting treatment for the cancer
What are the biochemical abnormalities of tumour lysis syndrome?
Hyperkalaemia
Hyperphosphataemia
Hypocalcaemia (because of raised phosphate)
Hyperuricaemia - breakdown of nucleic acids
25% increase/decrease - Cairo Bishop scoring
What increases the risk of TLS?
High proliferation rate
Chemosensitivity
Large tumour burden
Haem malignancies
Pre existing met abnormalities
Renal impairment
What are the consequences of the electrolyte imbalance in TLS?
Hyperkalaemia = arrhythmia
Hyperuricaemia = AKI
Hyperphorphataemia = Ca phosphate dysreg
Seizures, cardiac arrest, death
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
What are the ix into TLS?
U+E - eGFR, electrolytes, urate = essential ix
Additional ix = urine dip + microscopy, serum lactate and LDH, ECG
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
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
What are the indications for haemofiltration/dialysis in TLS?
Untreatable fluid overload
Resistant hyperkalaemia
Hyperphosphataemia induced sx hypocalcaemia
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
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
What is Pemberton’s sign?
Pt raised both arms above head for 1-2 mins:
+ve = this causes congestion, cyanosis and resp distress
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
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
What is the emergency management of SVCO?
Endovascular stent, shunt or thrombolysis
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
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
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
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
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
What are some malignant causes of ascites?
Stomach, colon, pancreas, liver, ovarian
Lymphoma
Mets in abdo cavity
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
What are the ix into ascites?
Bloods - FBC, U+E, LFT
Abdo US, CT abdo ?
Diagnostic paracentesis
What is the management of ascites?
Na restriction
Spironolactone
Therapeutic paracentesis
What are some malignant causes of upper GI bleed?
Haematemesis and malaena - gastric and oesophageal cancer
What are the ix into upper GI bleed?
G+S and crossmatch, coag
OGD
What is the management of haematemesis?
AtoE - resus and blood products
Biopsy during OGD to guide treatment
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
What are the ix into raised ICP?
GCS, fundoscopy
CT head
Bloods - BM esp
What is the management of raised ICP?
Elevate head, analgesia, cyclizine
Dex
IV mannitol or hypertonic saline to reduce ICP
Palliative RT
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
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
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
What is the management of immune related colitis?
Oral/IV steroids
Infliximab second line
What cancers commonly cause malignant bowel obstruction?
Ovarian
Colon
Or infiltration of the myenteric plexus or muscle of colon
What is the management of malignant bowel obstruction when pt fit for surgery?
Endoscopic stenting
Cancer treatments
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
What is DIC?
Disseminated Intravascular Coagulation - formation of lots of micro thrombi in the circulation which uses up plt = haemorrhage
What is the FBC in DIC?
Thrombocytopenia
Anaemia - clots shear RBC
coag - prolonged INR, APTT, fibrinogen depleted
What is the management of DIC?
Treat underlying cause
Blood products
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)
