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Cancer care > Oncological emergencies and complications of underlying cancer > Flashcards

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
Q

What are the consequences of the electrolyte imbalance in TLS?

A

Hyperkalaemia = arrhythmia
Hyperuricaemia = AKI
Hyperphorphataemia = Ca phosphate dysreg
Seizures, cardiac arrest, death

26
Q

What are the CF of TLS?

A

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
Q

What are the ix into TLS?

A

U+E - eGFR, electrolytes, urate = essential ix
Additional ix = urine dip + microscopy, serum lactate and LDH, ECG

28
Q

What is given as prophylaxis to prevent TLS?

A

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
Q

What is the management of TLS?

A

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
Q

What are the indications for haemofiltration/dialysis in TLS?

A

Untreatable fluid overload
Resistant hyperkalaemia
Hyperphosphataemia induced sx hypocalcaemia

31
Q

What is SVCO? What causes it?

A

Malignant sup vena cava obstruction, normally drains the upper limbs, head and neck
Lung cancer is the most common cause, NSCLC

32
Q

What are the CF of SVCO?

A

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
Q

What is Pemberton’s sign?

A

Pt raised both arms above head for 1-2 mins:
+ve = this causes congestion, cyanosis and resp distress

34
Q

What are the ix into SVCO?

A

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
Q

When should you be worried that SVCO is becoming an emergency?

A

Airway obstruction eg. stridor
Neuro sx that indicate cerebral oedema eg. confusion, coma, reduced conc

36
Q

What is the emergency management of SVCO?

A

Endovascular stent, shunt or thrombolysis

37
Q

What is the general management of SVCO?

A

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
Q

What is the prognosis of SVCO?

A

~6 months - is a poor indicator of survival, it indicates that tumour is extensive
Symptom relief is easy and 100% achieve

39
Q

What is the presentation of pleural effusion?

A

SOB
Pleuritic chest pain
Non productive cough
Stony dull percussion
Reduced breath sounds
± tracheal deviation only if vv big

40
Q

What are the ix into pleural effusion?

A

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
Q

What is the management of pleural effusion?

A

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
Q

What are some malignant causes of ascites?

A

Stomach, colon, pancreas, liver, ovarian
Lymphoma
Mets in abdo cavity

43
Q

What is the presentation of ascites?

A

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
Q

What are the ix into ascites?

A

Bloods - FBC, U+E, LFT
Abdo US, CT abdo ?
Diagnostic paracentesis

45
Q

What is the management of ascites?

A

Na restriction
Spironolactone
Therapeutic paracentesis

46
Q

What are some malignant causes of upper GI bleed?

A

Haematemesis and malaena - gastric and oesophageal cancer

47
Q

What are the ix into upper GI bleed?

A

G+S and crossmatch, coag
OGD

48
Q

What is the management of haematemesis?

A

AtoE - resus and blood products
Biopsy during OGD to guide treatment

49
Q

What are the CF of raised ICP?

A

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
Q

What are the ix into raised ICP?

A

GCS, fundoscopy
CT head
Bloods - BM esp

51
Q

What is the management of raised ICP?

A

Elevate head, analgesia, cyclizine
Dex
IV mannitol or hypertonic saline to reduce ICP
Palliative RT

52
Q

What are the CF of radiation mucositis?

A

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
Q

What is the management of radiation mucositis?

A

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
Q

What is immune related colitis? What causes it?

A

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
Q

What is the management of immune related colitis?

A

Oral/IV steroids
Infliximab second line

56
Q

What cancers commonly cause malignant bowel obstruction?

A

Ovarian
Colon
Or infiltration of the myenteric plexus or muscle of colon

57
Q

What is the management of malignant bowel obstruction when pt fit for surgery?

A

Endoscopic stenting
Cancer treatments

58
Q

What is the management of inoperable malignant bowel obstruction (pt not fit for surgery)?

A

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
Q

What is DIC?

A

Disseminated Intravascular Coagulation - formation of lots of micro thrombi in the circulation which uses up plt = haemorrhage

60
Q

What is the FBC in DIC?

A

Thrombocytopenia
Anaemia - clots shear RBC
coag - prolonged INR, APTT, fibrinogen depleted

61
Q

What is the management of DIC?

A

Treat underlying cause
Blood products

62
Q

What is the RT management of MSCC?

A

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)

Cancer care (6 decks)

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