Oncological Malignancies Flashcards
What are the CVS oncological emergencies?
SVCO
Pericardial tamponade
What are the CNS oncological emergencies?
Inc. ICP
Spinal cord compression
What are the GIT oncological emergencies?
IO, perforated viscus
Ascites
Oesophageal obstruction/perforation
What are the haematologic oncological emergencies?
DIVC
Thrombocytopaenia
Leukostasis*, hyperviscosity syndrome
What are the metabolic oncological emergencies?
Tumour lysis syndrome Hypercalcaemia Hyperuricaemia Hypoglycaemia Lactic acidosis
What are the infectious oncological emergencies?
Neutropaenic fever
Disseminated viral infections
Fungal/parasitic dz
What are the orthopaedic oncological emergencies?
Pathological #
What are the urologic oncological emergencies?
Post-renal AKI
What are the respiratory oncological emergencies?
Airway obstruction
Pneumothorax
Pleural effusion
[SVCO] What are the causes of SVCO?
Lung CA: Most Common Cause
- Small Cell Lung Carcinoma (SCLC)
- Squamous Cell Carcinoma (SCC)
- Adenocarcinoma does NOT cause SVCO because it tends to be peripheral whereas SCC tends to be more central
Lymphoma: The second most common cause
- Any lymphoma can cause SVCO
- But most common lymphomas are DLBCL (the most common form of lymphoma) and Burkitt’s
Other mediastinal masses:
- Thymoma and Teratoma (Germ Cell Tumor)
- Recall the 5Ts (Thymus, Ectopic Thyroid, Terrible Lymphoma, Thoracic Aorta, Teratoma)
Breast cancer
Iatrogenic causes
- Lines: CVP/chemo port – SVC Thrombosis
- Benign neoplasm
- Post radiation fibrosis
- Infection / Inflammation
- Sarcoidosis
[HyperCa] What are the most common cancers that cause hyperCa?
Osteolytic: MM, Breast, RCC
Ectopic PTHrp (80%): SCC of Head & Neck & Lung
HUMORAL: Ectopic 1α-hydroxylase – lymphoma (such as HL) or non-malignant granulomatous disorder such as sarcoidosis
[MSCC] What are the most common cancers that cause metastatic spinal cord compression?
Thyroid, Breast, Lung, RCC, Ovaries, Prostate, MM
[TLS] What are the most common cancers that cause tumour lysis syndrome?
Rapid Turnover: ALL/AML, Burkitt’s/DLBCL, MM
Tumor Burden (bulky disease): Breast, Ovarian
Chemo-sensitivity of CA (aka post-chemo TLS): SCLC (small cell lung carcinoma), Lymphomas, Acute Leukemias
Where does lung CA mets to?
Brain, Bone, Liver (& Adrenals), Lung (contralateral)
Where does prostate CA mets to?
Bone, Brain (less common + pre-terminal), Liver (& adrenals), Lung
[Malignant pericardial effusion]] What are the most common cancers that cause pericardial temponade?
- Solid tumours (lung, breast) most common
- Hematologic malignancies less common
[Brain mets] What are the most common cancers that cause brain metastasis?
Secondary Metastasis
- Most Common: breast, lungs, melanoma
- Lung and Breast mets to brain v early in clinical Hx – especially important!
Less Common: RCC, Prostate
- Whereas Prostate mets to brain at pre-terminal phase only + Quite Rarely
- Haemorrhagic mets: renal cell, melanoma and choriocarcinoma
Primary brain CA – glioblastoma (v rare)
[HVS] What are the most common cancers that cause hyperviscosity syndrome?
Dysproteinaemia in monoclonal gammopathies such as Waldenstrom macroglobulinemia, MM
- Immunoglobulin binds to each other 🡪 forming clumps 🡪 hyperviscosity + thrombi
Leukostasis in CA with ↑↑WCC 🡪 ALL / AML
- If WCC > 100x109/L 🡪 causes abnormal intravascular leukocyte aggregation and clumping 🡪 hyperviscosity + thrombi 🡪 causing microcirculation occlusion local hypoxemia and haemorrhage
[SVCO] How does SVCO present?
Usually gradual, if sudden consider thrombus (e.g. lines) OR rapidly growing tumor.
- If sudden 🡪 medical emergency!
- Obstruction due to cancer is usually has insidious gradual onset
Dyspnoea the most common, earliest presentation
Head fullness
Facial swelling, Facial Plethora, Limb Swelling in very severe obstruction
- Worst in the morning, often exacerbated by bending forwards or lying down
Cough (worse on lying flat/forward)
Venous distension (of neck, chest wall) due to formation of collaterals is a sign of chronicity
Uncommon: chest pain, dysphagia, headache/confusion (if cerebral oedema – v severe)
Late / severe symptoms
- Visual disturbance
- Confusion
- Stridor, cyanosis
+ve Pemberton’s sign: bilateral arm elevation causes facial plethora
[SVCO] What are the investigations in a patient with SVCO?
Fundoscopy for papilledema (2’ to cerebral edema)
1st line = CXR
- Suspect if CXR shows mediastinal mass/widening OR abnormal shadow
- Abnormal in >80% of cases
Definitive Dx w/ CT thorax w/ contrast
- Assess level of obstruction
- Identify cause of SVCO
Followed by Histology (Fine Needle Aspirate/ CT-guided biopsy/ Bronchoscopy)
SVC Stenting is the treatment of choice for patients with severe symptoms
- Rapid palliation within 24-48h, and can be placed before tissue Dx is available
[SVCO] What is the management of SVCO?
Sit up at 30 degrees
Supplemental O2
Establish IV access (avoid UL) – will only worsen the syndrome
Observe for signs of cerebral edema / airway compromise
+/- bridging therapy of stenting will awaiting Histo Dx + Definitive Therapy
+/- IV dexamethasone if established cancer diagnosis
Definitive therapy
1) RadioTx as 1st line for radiosensitive tumors
- Non-small cell lung cancer (75-90% respond)
- Occasionally used in the absence of a histo Dx, however this does not provide immediate symptomatic benefit and will affect histology
2) Chemotherapy as 1st line for chemosensitive tumors
- Small cell lung cancer
- Lymphomas
- Germ cell tumors
Note: if aetiology is a SVC thrombosis 🡪 remove catheter and give anticoagulation
[MSCC] What is the presentation of a patient with metastatic spinal cord compression?
Back pain that may/may not be:
- Constant and Dull
- Worse with movement and weight bearing
- Worsens at night [ unexplained but somehow all pain a/w CA worsens at night! (this includes headaches etc)]
- 90% of pt with MSSC will present w back pain as 1st symptom
If compressing centrally, causes spinal cord compression, cauda equina, conus medullaris - Sensory level - LL Weakness, Numbness - Incontinence (urinary and fecal) - Saddle Anaesthesia
If compressing laterally, can cause radicular shooting pain