Oncology core presentations

Question 1

SUPERIOR VENA CAVA OBSTRUCTION
i) what cancer is it most commonly associated with? how quickly does it need to be treated?
ii) what is the most common symptom? name four other features seen
iii) name two most common malignancies to cause it? name two others
iv) name three other causes
v) what does management depend on? what is the usual treatment of choice?
vi) what cancers may radical chemo or chemo RT be given? what drugs are often given but there is weak evidence

Answer 1

i) most commonly associated with lung cancer - caused be compression of the SVC
onc emergency
ii) dyspnoea is most common symptom
also see - swelling of face/neck/arms, conjunctival/periorbital oedema, headache (worse in AM), visual disturbance, puseless jugular venous distention
iii) small cell lung cancer and lymphoma
also caused by metastatic seminoma, kaposi sarcoma, breast cancer
iv) can also be caused by aortic aneurysm, medaistinal fibrosis, goitre, SVC thrombosis
v) management dep on the pt and the malignancy
usual tx of choice is endovascular stenting - symptom relief
vi) may give radical chemo or chemo RT for spec malignancies eg lymphoma, SCLC
may also give glucocorticoids

Question 2

NEOPLASTIC SPINAL CORD COMPRESSION
i) what type of compression accounts for the majority of cases? what is this usually due to? name three cancers its more common in
ii) what is the earliest and most common symptom? when may it be worse?
iii) name two other features?
iv) what neurological signs do lesions above L1 usually result in? what signs fo lesions below L1 cause?
v) are tendon reflexes increased above or below level of the lesion? what will reflexes be at the level of the lesion?

Answer 2

i) extradural compression due to vertebral body metastases
common in lung, breast and prostate cancer
ii) earliest is back pain - may be worse on laying down and coughing
iii) lower limb weakness, sensory changes (sensory loss and numbness)
iv) above L1 > UMN signs in the legs and a sensory level
below L1 > LMN symptoms in legs and perianal numbbness
v) tendon reflexes increased below level of lesion and absent at lesion level

Question 3

INVESTIGATIONS AND MANAGEMENT FOR NEOPLASTIC CORD COMPRESSION
i) what should be done within 24hrs of px?
ii) what is first line management?
iii) what should also be done urgently?

Answer 3

i) urgent MRI - whole MRI spine
ii) high dose oral dex
iii) urgent onc assessment for consideration of RT or surgery

Question 4

NEUTROPENIC SEPSIS
i) what is it? what is it usually due to?
ii) what temp should be treated as NS until proven otherwise in cancer patients?
iii) how is it treated? should investigation results be waited for before startinga abx?
iv) what three symptoms may be seen?

Answer 4

i) sepsis in a patient with low neuts - less than 1 x10 9/L
usually due to anti cancer or immunosupp treatment
ii) any temp over 38
iii) treat with broad spec abx - piperacillin with tazocin
dont delay abx
iii) signs of infection eg dysuria, diarrhoea, productive cough, chills/shivers/rigors

Question 5

HYPERCALCAEMIA - CAUSES
i) what is the most common cause in non hospitalised pts? most common cause in hospitalised pts?
ii) name three processes that may lead to HC in malignancy?
iii) how does myeloma cause HC
iv) name four other causes

Answer 5

i) primary hyperparathyroidism in non hosp
malignancy in hosp
ii) PTHrP from the tumour (SCC)
bone mets
myeloma
iii) myeloma - due to osteoclastic bone reabs caused by local cytokines eg IL-1 and TNF released by myeloma cells
iv) other causes - sarcoidosis, vitamin D intox, acromegaly, thyrotoxicosis, drugs eg thiazides

Question 6

HYPERCALCAEMIA FEATURES
i) name four features? (mnemonic)
ii) what is seen in the eyes? what is seen on ECG? what happens to BP?

Answer 6

i) bones (inc fracture), stones (renal colic and hypercalc stones), abdo groans (anorexia, N+V, constipation) and psychic moans (confusion, apathy, decreased memory)
ii) eyes - corneal calcification
shortened QT on ECG
BP - hypertension

Question 7

HYPERCALCAEMIA MX
i) what is the initial management? how much?
ii) what drug may be used following this? how long do these take to work? when it max effect seen?
iii) name two other treatment options
iv) when may loop diuretics be used?

Answer 7

i) initial mx - rehydrate with normal saline 3-4L per day
ii) give bisphosphonates post rehydration
take 2-3 days to work and max effect seen in 7 days
iii) may also give calcitonin (quicker effect than bisphos)
steroids if sarcoidosis is the cause
iv) loop di eg furosemide if patients cant tolerate aggressive fluid rehydration (use with caution due to worsening of electrolyte derange and vol deplete)