Oncological Emergencies (know best for exams) Flashcards
List the main oncological emergencies
- Spinal cord compression
- Superior vena caca obstruction
- Raised intracranial pressure
- Hypercalcaemia
- Pulmonary embolism
- Neutropenic sepsis
- Thrombocytopenia
What are the symptoms and signs of spinal cord compression?
Localised back pain and tenderness:
• Most common early symptom
• Exacerbated by coughing, sneezing, straining or lying flat
• Uncontrolled by analgesia
• Pain may travel along the nerve root distributing (radicular pain)
Neurological problems develop as disease advances:
• Bladder dysfunction -retention, dribbling, incontinence of urine
• Bowel dysfunction -faecal incontinence, constipation
• Weakness in arms or legs
• Hypoesthesia
Tumours below L1/2 may cause cauda equine compression:
• Sciatic pain -often bilateral
• Bladder dysfunction with retention and overflow incontinence
• Impotence
• Sacral aesthesia
• Loss of sphincter tone
• Weakness and wasting of gluteal muscles
Bilateral motor neurone signs → assumed to be SCC until proven otherwise.
• A swelling or lump may be visible over the area of SCC on the back (Gibbus: swelling due to spinal angulation caused by vertebral collapse)
What are the investigations of spinal cord compression?
- Full neurological examination
- MRI whole spine (1st line)
What is the management of spinal cord compression?
MEDICAL EMERGENCY DO NOT DELAY!!
Immediate Actions:
• Dexamethasone 8mg PO/IV BD and proton pump inhibitor
• Analgesia
• Log roll if unstable (seek orthopaedic advice)
Surgical decompression
• treatment of choice if feasible
• Radioresistant tumours e.g. melanoma, clear cell carcinoma
Radiotherapy:
radiosensitive tumours
• 8Gy in 1# or 20Gy in 5# or 30Gy in 10#
What are clinical outcomes of spinal cord compression?
- Outcome is strongly dependent on the level of neurological dysfunction the patient had before treatment as well as the pathology.
- 80% of patients ambulatory before treatment will remain able to walk.
- If the diagnosis is made late or left untreated they are at risk of irreversible paraplegia, quadriplegia and loss of bowel or bladder function. Functional recovery is poor in general
- ~30% of patients with SCC will survive for 1 year.
What are the symptoms of superior vena cava obstruction (SVCO)?
Gradual onset over several weeks as the tumour grows. • Dyspnoea • Swelling of neck, face and arms. • Cough • Headache • Visual disturbance • Dizziness • Syncope • Chest pain • Hoarseness • Nasal congestion • Epistaxis • Haemoptysis • Dysphagia *Symptoms exacerbated by lying down or bending over (ask in history)
What are the signs of SVCO?
SVCO causes increased intravenous pressure:
• Jugular veins become engorged with absent waveforms
• Collateral veins become prominent over the neck and chest wall.
• Dusky skin
• Facial oedema and plethora
• Arm oedema
• Proptosis, stridor
• Papilloedema (late)
What are the causes of SVCO?
- Most commonly malignancy
- SCLC (usually right upper lobe)
- Non-Hodgkin’s Lymphoma
- Other mediastinal tumours
- Metastases
- Rarely sarcoidosis/TB
Recall the investigations for SVCO
Chest X-Ray:
• Right para-tracheal mass
• Mediastinal lymphadenopathy
• Other signs of lung cancer e.g. pleural effusion
CT Chest:
• Investigation of choice
• Define the level and degree of venous blockage
• Identify cause and help staging
• Plan biopsy (CT guided or bronchoscopy)
How is SVCO managed?
- ABCDE
- Sit patient upright
- High flow O2
- Dexamethasone 8mg BD w/ PPI
- Get a tissue diagnosis (determine radio and chemosensitivity)
- Stenting (interventional radiology)
- Chemotherapy (for chemosensitive tumours e.g. SCLC/germ cell)
- Radiotherapy
What is the clinical outcome of SVCO?
Prognosis is dependent on:
• Underlying condition causing the obstruction
• Extent to which the SVC is obstructed.
When treated with XRT the average survival is at least 30 months in:
• 45% of lymphomas patients
• 10% of lung cancer patients
Untreated or no response: survival time is 30 days
What are the causes of increased intracranial pressure (ICP)?
- Space occupying lesions • primary brain tumour, brain metastases, abscess, haematoma
- Hydrocephalus• CSF obstruction
- Benign intracranial hypertension
Which tumours typically metastasise to the brain?
- Lung cancer
- Breast cancer
- Melanoma
What are the signs and symptoms of increased intracranial pressure/brain metastases?
- Headache (early symptom, worse in morning and when coughing or sneezing)
- Nausea and vomiting (in morning)
- Cognitive Impairment
- Drowsiness
- Seizures (10% of these patients, often focal)
- Behavioural changes
- Focal neurological changes
- Altered gait
*Papilloedema is present in 50% of cases and is usually associated with neurological deficit.
Recall the appropriate investigations in increased ICP
- Full clinical examination
- FBC, U&Es, LFTs and Tumour Markers (especially if primary unknown)
- Contrast enhanced CT
- MRI where in doubt from CT or for further characterisation
How are brain metastases managed?
Immediate:
• Steroids (Dexamethasone 8mg PO/IV b.d. and proton pump inhibitor)
• Reduced the tumour associated oedema
Further:
• Surgery or SRS
• Possible for small numbers and volume of metastases with controlled extracranial disease
• Whole brain radiotherapy (20Gy in 5# most common)
• Tissue diagnosis may be required
*CANNOT DRIVE AND MUST BE ADVISED TO INFORM DVA
Discuss brain metastases outcomes
- Prognosis is dependent on the type of primary tumour, e.g. breast cancer brain metastases have better prognosis than those due to colorectal cancer.
- Median survival without treatment is 1 month
- XRT has not always shown to be of benefit over steroids and best supportive care
What are the causes of hypercalcaemia?
- Bone metastases
- ↑ parathyroid hormone-related protein production (PTH-rp)
- Calcitriol secretion
- Hyperparathyroidism
- 20% of cases in patients with cancer are due to bone resorption by osteoclasts in areas of bone invaded by malignancy.
- 80% of cases are due to PTH-related protein production by tumour cells
What are the symptoms of hypercalcaemia?
Non specific and depend on severity (bones, stones, moans, and abdominal groans). • Fatigue, malaise and weakness • Anorexia • Polyuria and polydipsia (common in malignant aetiology) • Nausea and vomiting • Confusion • Constipation • Bone pain
*Symptoms not common when cCa <3.0mmolL-1`
*Neurological symptoms present above 3.5mmol/L:
• Confusion
• Drowsiness
• Lethargy
• Coma and eventually death
What are the signs of hypercalcaemia?
DEHYDRATION! • Dry mucous membranes • Reduced skin turgor • Tachycardia • Postural hypotension
How is hypercalcaemia investigated?
•Bloods: FBC, U&Es, LFTs CRP, Glucose, PTH, Alkphos
•12-lead ECG
shortened QT interval
severe hypercalcaemia(> 3.75 mmol/L) → widened T waves, may mimic
myocardial infarction
•Chest X-ray –If underlying cause unknown
Recall the management of hypercalcaemia
- Immediate rehydration:
IV 0.9% NaCl to promote high volume urine output.
4-6 L in 24 hours if not contraindicated (heart failure) - IV bisphosphonate:
- zolendronic acid 4 mg IV given after 24 hours - Discontinue medications which elevate calcium e.g. thiazide diuretics, calcium or vitamin D supplements
Discuss clinical outcomes of hypercalcaemia
•IV fluids and bisphosphonates can achieve normalisation of serum
calcium in 80% but can take up to 3 days
•Hypercalcaemia is an indicator of poor prognosis
•When severe it is associated with short survival weeks to a few
months
What are the symptoms of pulmonary embolism?
- Pleuritic chest pain
- Haemoptysis
- Dyspnoea
- Tachypnoea
- Cough
What are the signs of pulmonary embolism?
•Tachycardia •Cyanosis •Raised JVP •Low grade fever •Pleural friction rub on auscultation over infarcted area
How is PE investigated?
- FBC, Electrolyte profile
- ABG –hypoxia, alkalosis
- Coagulation
- D-dimer
- ECG S1Q3T3
- CXR
- CT Pulmonary Angiogram
How is PE managed?
•Oxygen if hypoxic
•Analgesia
•Anticoagulate
- LMWH - Enoxaparin (If on chemotherapy) or
- DOAC –Apixaban/Rivaroxaban or related
•Thrombolysis is indicated if systolic BP <90mmHg and no contraindications
What are the clinical outcomes of PE?
- If left untreated the prognosis is poor.
- Even if treated the patient can develop chronic thromboembolic pulmonary hypertension which can lead to right heart failure.
- Mortality is lower in patients who are haemodynamically stable.
- Poor prognostic factors include:
- ↑age
- congestive heart failure
- COPD
- Tachypnoea
- Systolic arterial hypotension.
What is neutropenic sepsis?
•Sepsis with an absolute neutrophil count (ANC) of <1.0 x 109L-1
•Sepsis is ≥2 SIRS criteria and a source of infection
- Temp >38oC or <36oC
- HR > 90bpm
- RR > 20
•Fever must be assumed to be due to infection until proven otherwise
•Infection can quickly become fatal due to low ANC
What are the symptoms of neutropenic sepsis?
- Confusion
- Headache
- Malaise
- Lethargy
Local symptoms of infection: • Sore throat • Dysuria • Cough • Sputum • Skin inflammation • Abdominal tenderness
What are the signs of neutropenic sepsis?
•Crackles in chest •Inflammation around vascular access sites •Tachycardia •Hypotension •Confusion
How is neutropenic sepsis investigated?
- Full physical examination for source of infection and signs
- FBC, CRP, U&E, LFTs, serum glucose, serum lactate
Infection screen: • Blood cultures (central line and peripheral) • Urinalysis and culture • Chest X-Ray • Swab lines, throat • Atypical respiratory viral screen • LP if meningism • ECHO and CT if persistent sepsis and source unclear (?vegetation or collections)
What is the immediate management of neutropenic sepsis?
SEPSIS SIX:
- Give O2 to maintain Sats >94%
- Take blood cultures
- Give IV antibiotics
- Give IV fluid challenge
- Measure lactate
- Measure urine output
What is the extended management of neutropenic sepsis?
- Modify antibiotics depending on results.
- Consider second line antibiotic, if fever does not resolve after 48 hours or patient is deteriorating.
- Consult with microbiologist, if there is failure to respond after 5 days
- fungi or parasitic
- abscess or endocarditis
- Granulocyte Colony Stimulating Factor (GCSF)• can help ↑neutrophil count in prolonged neutropenia in context of severe sepsis
- used as prophylactic for further treatment.
What are the clinical outcomes of neutropenic sepsis?
- Prognosis depends on the severity of neutropenia and how long it takes until the patient receives treatment.
- Mortality from neutropenic sepsis has been reduced due to improvements in care and use of broad-spectrum antibiotics but remains a significant problem.
What are the symptoms of thrombocytopaenia?
•Malaise •Fatigue •General weakness •Unexplained bleeding or brushing
What are the signs of thrombocytopaenia?
- Bruising: purpura, petechial
- Epistaxis
- Bleeding mucosa
- Major life threatening bleeds
Recall the the investigations for thrombocytopaenia
- FBC, LFTs, U&Es
- Coagulation screen
- D-dimer
- Vit B12 and Folic acid levels
- Bone marrow biopsy if clinically indicated
How is thrombocytopaenia managed?
•Group and crossmatch
•Arrange platelet transfusion if:
- PLT <10 x 109L-1 or
- PLT <20 x 109L-1 with active sepsis or bleeding
