Oncological Emergencies COPY Flashcards
How are most chemo regimens delivered?
On a 3 weekly basis
What is the most common side effect of chemo?
Neutropenia
When does neutropenia tend to occur during chemo?
Around day 7-14 of each 3 weekly cycle
What is the normal neutrophil count?
> 1.5x10^9
At what neutrophil level is there an increased risk of infection?
<1x10^9
Noting the risk of neutropenia that comes along with chemo, what should you advise patients?
To monitor for symptoms of infection, e.g. flu like symptoms, fevers, or focal infections (UTI, sore throat etc.)
Advise to monitor temp, and medical assessment is req. if 1 recording >38.5/<36C or 2 recordings >38C 2 hours apart
What are the criteria for diagnosis of neutropenic fever?
A. febrile
B. neutropenia <1x10^9
C. no haemodynamic compromise
Define neutropenic sepsis
Evidence of sepsis (hypotension, tachycardia…) + neutrophils <1x10^9 with or without fever
What are the most common microbes causing neutropenic sepsis?
85% endogenous flora (e.g. gut, biliary tract, urinary tract)
75% gram -ve bacilli
Fungal infections in prolonged neutropenia (esp. haematological malignancies)
What symptoms might patients with neutropenic sepsis describe?
Anorexia Malaise Lethargy Sweats Fevers, rigors, chills Symptoms related to site of infection
What should you ask in your history if you suspect neutropenic sepsis?
Symptoms related to chest infections, GI tract, urinary tract, CNS infections, skin infections, abscesses, sore throat, recent interventions (e.g. dental work)
What should you do in your examination if you suspect neutropenic sepsis?
Temperature Pulse BP O2 sats RR Full ex
What investigations should you do if you suspect neutropenic sepsis?
FBC, UE, LFTs, bone profile, CRP Coagulation screen if DIC suspected Blood cultures MSSU Stool culture if diarrhoea Throat swab, sputum culture, skin swabs if appropriate CXR
How do you manage neutropenic sepsis?
Supportive care, e.g. fluids, O2 if indicated
Broad spectrum antibiotics - tazocin 4.5g IV 6hrly + gentamicin 7mg/kg IV
Consider G-CSF to boost neutrophil count
What alternative antibiotic can you give for penicillin allergy for neutropenic sepsis?
Ceftazidime + gentamicin if mild
Vancomycin + gentamicin +/- metronidazole if severe
What two things is tazocin?
Pipercillin + tazobactam
What monitoring should be done in neutropenic sepsis?
Temp, pulse, BP, O2 sats
UO
Check for positive cultures, optimise antibiotic therapy
FBC, UE, CRP daily
When should you switch to stage 2 antibiotics in neutropenic sepsis?
If patient remains febrile after 48h of stage 1 antibiotics
What is stage 1 antibiotics?
Tazocin
What is stage 2 antibiotics?
Meropenem 1g IV 8hrly
When can you switch to oral antibiotics in neutropenic sepsis?
After completion of antibiotic course (3d IV) if improving + no longer neutropenic can swap to oral ciprofloxacin (unless culture suggests something else may be better)
In which cancers is malignant spinal cord compression most commonly seen?
In cancers which typically spread to bone (breast, carcinoma of bronchus, prostate, myeloma, renal)
What may cause MSCC?
Vertebral collapse
Extradural metastases
Where is the commonest site of MSCC?
Thoracic spine
What are the typical features of MSCC?
Pain
Sensory/motor symptoms - e.g. weakness/sensory loss
Autonomic symptoms, e.g. urinary incontinence/retention, faecal incontinence
Spinal tenderness
UMN findings
Reduced anal tone
What are the typical features of pain due to MSCC?
Thoracic, radicular in distribution (i.e. radiation along dermatome), worsening over weeks/months, worse with cough, sneezing, wt bearing
Give examples of UMN findings
Hypertonia
Hyper-reflexia
Clonus
Upgoing plantars
How might sensory disturbances present in MSCC?
Loss of sensation below dermatomal level of compression
What is the gold standard investigation for suspected MSCC?
MRI spine (allows diagnosis, confirms level of compression, allows safety assessment)
Why might someone need a CT to diagnose MSCC?
If MRI is CI (e.g. pacemaker)
If no prev. diagnosis of cancer, to identify a primary site
What other investigation should you do in MSCC?
Serum Ca
How do you manage MSCC?
Supportive Steroids Surgery Radiotherapy Chemotherapy
What supportive measures should be put in place for MSCC?
Keep patient lying flat until stability of spine determined
Urinary catheter if in retention
Monitor bowel function + commence bowel regimen if req. (e.g. laxatives/enemas)
Physio
Prophylactic dalteparin if bed bound
What steroid + dose should be used for MSCC?
Dexamethasone 8mg bd oral
Why are steroids used in MSCC?
To reduce swelling around lesion
What should be prescribed along with a steroid and what extra investigations should be done while a patient is on steroids for MSCC?
Gastroprotection, e.g. omeprazole
Daily BG measurements
What is the best treatment for MSCC?
Surgery followed by radiotherapy
When is surgery preferred for MSCC?
If fit, no volume met disease, life expectancy >3m
Isolated posterior cord compression
Good sensory/motor function prior to episode
No prior hx of cancer
Remainder of spine is sufficiently strong to allow stabilisation
When should surgery be avoided in MSCC?
Frailer patients with lots of mets + poor mobility
Anterior compression
What should be given to treat MSCC if the patient cannot have surgery?
Radiotherapy alone
How is radiotherapy given for MSCC?
Targeted at level of spinal cord compression
4 fractions given over 4 consecutive days
When might chemo be used for MSCC?
If primary tumour is highly chemosensitive, e.g. lymphoma/germ cell tumours
Surgery/RT CI
What are the most common malignant causes of SVCO?
Bronchogenic carcinoma (usually small cell) Lymphoma Metastatic tumours, e.g. renal cancer, germ cell
What are some rarer benign causes of SVCO?
SVC thrombosis
Mediastinal fibrosis
What is a typical history of SVCO?
Facial swelling/fullness of head
Arm swelling
Dysphagia, dyspnoea
What might you find on examination in SVCO?
Distention of neck/chest wall veins Fixed (i.e. non pulsatile), elevated JVP Facial oedema/puffiness Oedema of arms Plethora of face Peripheral cyanosis
What investigations should be done in suspected SVCO?
CXR
CT
Superior venocavogram
Bronchoscopy if lung primary suspected
What is involved in the management of SVCO?
Steroids, supportive Radiotherapy Chemo Stenting of SVC Thrombolysis + anticoagulation if SVCO due to thrombosis
What steroids should be given for SVCO and what dose?
Dexamethasone 8mg bd with gastroprotection and daily BMs
What advice should you give to patients with SVCO re. their position in bed?
Sit up - oedema worse when lying flat
What is the definitive Rx for SVCO?
Chemo/radio depending on tumour
How do you manage catheter induced SVC?
Remove catheter
Thrombolysis
Anticoagulation
What is the normal serum Ca level?
2.2-2.6mmol/L
What causes hypercalcaemia in malignancy?
Bone mets
Para-neoplastic syndrome - production of PTH-rp
What cancers most commonly produce PTH-rp?
Squamous cancers
HTLV-1 related T cell lymphomas
What are the clinical features of hypercalcaemia?
Osmotic features - dehydration (polydipsia, polyuria)
Cognitive impairment, lethargy, fatigue, psychosis
Constipation, NV
Renal failure
Cardiac arrhythmias
How should you manage hypercalcaemia in malignancy?
Check PTH (PTH suppressed if PTH-rp producing tumour)
Rehydration (saline)
Bisphosphonates (zoledronic acid)
Rarely: Calcitonin, Steroids
