Oncological Emergencies COPY

Question 1

How are most chemo regimens delivered?

Answer 1

On a 3 weekly basis

Question 2

What is the most common side effect of chemo?

Answer 2

Neutropenia

Question 3

When does neutropenia tend to occur during chemo?

Answer 3

Around day 7-14 of each 3 weekly cycle

Question 4

What is the normal neutrophil count?

Answer 4

> 1.5x10^9

Question 5

At what neutrophil level is there an increased risk of infection?

Answer 5

<1x10^9

Question 6

Noting the risk of neutropenia that comes along with chemo, what should you advise patients?

Answer 6

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

Question 7

What are the criteria for diagnosis of neutropenic fever?

Answer 7

A. febrile
B. neutropenia <1x10^9
C. no haemodynamic compromise

Question 8

Define neutropenic sepsis

Answer 8

Evidence of sepsis (hypotension, tachycardia…) + neutrophils <1x10^9 with or without fever

Question 9

What are the most common microbes causing neutropenic sepsis?

Answer 9

85% endogenous flora (e.g. gut, biliary tract, urinary tract)
75% gram -ve bacilli
Fungal infections in prolonged neutropenia (esp. haematological malignancies)

Question 10

What symptoms might patients with neutropenic sepsis describe?

Answer 10

Anorexia
Malaise
Lethargy 
Sweats
Fevers, rigors, chills
Symptoms related to site of infection

Question 11

What should you ask in your history if you suspect neutropenic sepsis?

Answer 11

Symptoms related to chest infections, GI tract, urinary tract, CNS infections, skin infections, abscesses, sore throat, recent interventions (e.g. dental work)

Question 12

What should you do in your examination if you suspect neutropenic sepsis?

Answer 12

Temperature
Pulse
BP
O2 sats
RR
Full ex

Question 13

What investigations should you do if you suspect neutropenic sepsis?

Answer 13

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

Question 14

How do you manage neutropenic sepsis?

Answer 14

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

Question 15

What alternative antibiotic can you give for penicillin allergy for neutropenic sepsis?

Answer 15

Ceftazidime + gentamicin if mild

Vancomycin + gentamicin +/- metronidazole if severe

Question 16

What two things is tazocin?

Answer 16

Pipercillin + tazobactam

Question 17

What monitoring should be done in neutropenic sepsis?

Answer 17

Temp, pulse, BP, O2 sats
UO
Check for positive cultures, optimise antibiotic therapy
FBC, UE, CRP daily

Question 18

When should you switch to stage 2 antibiotics in neutropenic sepsis?

Answer 18

If patient remains febrile after 48h of stage 1 antibiotics

Question 19

What is stage 1 antibiotics?

Answer 19

Tazocin

Question 20

What is stage 2 antibiotics?

Answer 20

Meropenem 1g IV 8hrly

Question 21

When can you switch to oral antibiotics in neutropenic sepsis?

Answer 21

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)

Question 22

In which cancers is malignant spinal cord compression most commonly seen?

Answer 22

In cancers which typically spread to bone (breast, carcinoma of bronchus, prostate, myeloma, renal)

Question 23

What may cause MSCC?

Answer 23

Vertebral collapse

Extradural metastases

Question 24

Where is the commonest site of MSCC?

Answer 24

Thoracic spine

Question 25

What are the typical features of MSCC?

Answer 25

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

Question 26

What are the typical features of pain due to MSCC?

Answer 26

Thoracic, radicular in distribution (i.e. radiation along dermatome), worsening over weeks/months, worse with cough, sneezing, wt bearing

Question 27

Give examples of UMN findings

Answer 27

Hypertonia Hyper-reflexia Clonus Upgoing plantars

Question 28

How might sensory disturbances present in MSCC?

Answer 28

Loss of sensation below dermatomal level of compression

Question 29

What is the gold standard investigation for suspected MSCC?

Answer 29

MRI spine (allows diagnosis, confirms level of compression, allows safety assessment)

Question 30

Why might someone need a CT to diagnose MSCC?

Answer 30

If MRI is CI (e.g. pacemaker) | If no prev. diagnosis of cancer, to identify a primary site

Question 31

What other investigation should you do in MSCC?

Answer 31

Serum Ca

Question 32

How do you manage MSCC?

Answer 32

``` Supportive Steroids Surgery Radiotherapy Chemotherapy ```

Question 33

What supportive measures should be put in place for MSCC?

Answer 33

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

Question 34

What steroid + dose should be used for MSCC?

Answer 34

Dexamethasone 8mg bd oral

Question 35

Why are steroids used in MSCC?

Answer 35

To reduce swelling around lesion

Question 36

What should be prescribed along with a steroid and what extra investigations should be done while a patient is on steroids for MSCC?

Answer 36

Gastroprotection, e.g. omeprazole Daily BG measurements

Question 37

What is the best treatment for MSCC?

Answer 37

Surgery followed by radiotherapy

Question 38

When is surgery preferred for MSCC?

Answer 38

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

Question 39

When should surgery be avoided in MSCC?

Answer 39

Frailer patients with lots of mets + poor mobility | Anterior compression

Question 40

What should be given to treat MSCC if the patient cannot have surgery?

Answer 40

Radiotherapy alone

Question 41

How is radiotherapy given for MSCC?

Answer 41

Targeted at level of spinal cord compression | 4 fractions given over 4 consecutive days

Question 42

When might chemo be used for MSCC?

Answer 42

If primary tumour is highly chemosensitive, e.g. lymphoma/germ cell tumours Surgery/RT CI

Question 43

What are the most common malignant causes of SVCO?

Answer 43

``` Bronchogenic carcinoma (usually small cell) Lymphoma Metastatic tumours, e.g. renal cancer, germ cell ```

Question 44

What are some rarer benign causes of SVCO?

Answer 44

SVC thrombosis | Mediastinal fibrosis

Question 45

What is a typical history of SVCO?

Answer 45

Facial swelling/fullness of head Arm swelling Dysphagia, dyspnoea

Question 46

What might you find on examination in SVCO?

Answer 46

``` Distention of neck/chest wall veins Fixed (i.e. non pulsatile), elevated JVP Facial oedema/puffiness Oedema of arms Plethora of face Peripheral cyanosis ```

Question 47

What investigations should be done in suspected SVCO?

Answer 47

CXR CT Superior venocavogram Bronchoscopy if lung primary suspected

Question 48

What is involved in the management of SVCO?

Answer 48

``` Steroids, supportive Radiotherapy Chemo Stenting of SVC Thrombolysis + anticoagulation if SVCO due to thrombosis ```

Question 49

What steroids should be given for SVCO and what dose?

Answer 49

Dexamethasone 8mg bd with gastroprotection and daily BMs

Question 50

What advice should you give to patients with SVCO re. their position in bed?

Answer 50

Sit up - oedema worse when lying flat

Question 51

What is the definitive Rx for SVCO?

Answer 51

Chemo/radio depending on tumour

Question 52

How do you manage catheter induced SVC?

Answer 52

Remove catheter Thrombolysis Anticoagulation

Question 53

What is the normal serum Ca level?

Answer 53

2.2-2.6mmol/L

Question 54

What causes hypercalcaemia in malignancy?

Answer 54

Bone mets | Para-neoplastic syndrome - production of PTH-rp

Question 55

What cancers most commonly produce PTH-rp?

Answer 55

Squamous cancers | HTLV-1 related T cell lymphomas

Question 56

What are the clinical features of hypercalcaemia?

Answer 56

Osmotic features - dehydration (polydipsia, polyuria) Cognitive impairment, lethargy, fatigue, psychosis Constipation, NV Renal failure Cardiac arrhythmias

Question 57

How should you manage hypercalcaemia in malignancy?

Answer 57

Check PTH (PTH suppressed if PTH-rp producing tumour) Rehydration (saline) Bisphosphonates (zoledronic acid) Rarely: Calcitonin, Steroids