Oncological Emergencies: Superior Vena Cava Obstruction, Metastatic Spinal Cord Compression, Neutropenic Sepsis, Malignant Hypercalcemia, Tumour Lysis Syndrome, Palliative Care

Question 1

Superior vena cava obstruction

• pathophysiology, presentation, associated cancers
• management

Answer 1

Compression of the SVC by a tumour/LN

• SOB
• face, neck, arm (periorbital edema)
• headache worse in morning
• visual change
• pulseless JVP congestion

SCLC, lymphoma, breast

Symptomatic - endovascular stent + GC
Definitive - address malignancy, patient dependent

Question 2

Metastatic spinal cord compression

• pathophysiology, presentation, associated cancers
• investigations
• management

Answer 2

Compression of SC by spine tumour, bony mets, myeloma, prostate

• back, spine, neck pain, worse when lying down/at night
• weak, tingling limbs
• saddle anaesthesia, urinary/fecal retention

UMN above L1- increased tone, weak legs/reduced sensation, increased reflexes, positive Babinski
LMN in cauda equina - saddle anaesthesia, reduced anal tone, urinary retention

Neurological symptoms and signs suggestive of MSCC => MRI within 24hrs
Pain suggestive of spine mets but no neuro signs or symptoms => MRI within 1wk
-DIAGNOSIS - MRI

SYMPTOMATIC - dexmeth to reduce swelling + analgesia
Definitive - address underlying cause

Question 3

Neutropenic sepsis

• pathophysiology, presentation
• investigations, diagnosis
• prophylaxis
• management

Answer 3

1-2wks post chemo - U0.5 neutrophils, 38C+, any sign of sepsis

Prophylactic if at risk - fluoroquinolone

Urgent empirical broad spec ABx - tazocin

• specialist risk stratification for OP management
• SEPSIS 6

Question 4

Malignant hypercalcemia

• pathophysiology, presentation, associated cancers
• investigations
• management

Answer 4

Primary PTH, bone mets, myeloma, PTHrp from squamous LC

• Painful bones
• Renal stones
• Abdo groans - N+V, constipation
• Psychiatric moans - fatigue, agitation, confusion

U&E, PO4, PTH, VitD
ECG
CXR, Skeletal survey

INITIAL - saline rehydration followed by bisphosphonates
-add calcitonin until bisphosphonates work

Question 5

Tumour lysis syndrome

• pathophysiology, presentation, associated cancers
• prophylaxis
• investigations
• management

Answer 5

Breakdown of tumour cells => high K, PO4, urate, low Ca

• chemotriggered breakdown of lymphoma, leukemia
• arrythmias, AKI, muscle spasm

Prophylaxis - allopurinol or rasburicase

Investigations

• U&E, creatinine - AKI?
• ECG

Initial -

• cardiac stabilisation if K 6.5+/ECG changes -Ca gluconate, insulin dextrose, Ca resonium
• fluid resus with/without loop
• rasburicase => prevent urate crystal formation
• PO4 binders if not in AKI

Question 6

Palliative care

-sedation to relieve symptoms => management of SE

Answer 6

Sedation - BZ, opioids => increased secretions that cannot be cleared
Conservative - suction and positioning
Medical - glycopyrronium/hyoscine

Question 7

Malignant ascities

• causes
• management

Answer 7

Serum ascities albumin gradient U11 - portal HTN

• liver disease (cirrhosis, ALF, liver mets)
• RHF
• portal vein thrombosis

SAAG 11+

• nephrotic
• severe malnutrition

Reduce Na, fluid restriction
Spironolactone, loop diuretics
Large volume paracentesis
Prophylactic ABx - ciprofloxacin