Oncology emergencies

Question 1

Patient on chemotherapy with fever - what should you do?

Answer 1

admit urgently to hospital
IV antibiotic within 1 hour of getting to hospital
(treat as neutropenic sepsis until proven otherwise)

Question 2

Neutropenic sepsis management

Answer 2

urgent hospital assessment
IV antibiotic within 1h of arrival
bloods and full septic screen - sepsis 6
admission for further IV antibiotic therapy and close monitoring if confirmed neutropenia
if proven neutropenic, treat even if patient seems relatively well

Question 3

What neutrophil count is considered definitely neutropenic?

Answer 3

<1

Question 4

What platelet counts are acceptable in patients on chemotherapy?

Answer 4

not septic, accept >10
septic, accept >20

Question 5

What haemoglobin is acceptable in chemotherapy patients?

Answer 5

> 80 generally fine as long as not symptomatic

Question 6

What antibiotics are used for neutropenic sepsis?

Answer 6

Tazocin (tazobactam + piperacillin) or Meropenem

+/- gentamicin (good for gram -ve = gut/urine)
+/- vancomycin (skin/soft tissue/MRSA/line infection)

anti-fungal prophylaxis - fluconazole

pneumocystis jirovecii prophylacis if lymphopenic - co-trimoxazole (eg. in HIV patients)

Question 7

What is G-CSF and what is it used for?

Answer 7

granulocyte colony-stimulating factor

recombinant human haematopoietic growth factor:
- stimulates maturation of existing immature neutrophils
- does not stimulate production of new neutrophils per se

SC injection

recommended in neutropenic sepsis in some patients

Question 8

Which patients with neutropenic sepsis might be given G-CSF?

Answer 8

generally considered in critical care patients

higher risk features:
- prolonged neutropenia >7 days
- hypotension
- fungal infection
- pneumonia
- enterocolitis

Question 9

What will happen to a patient’s next dose of chemotherapy if they’ve had neutropenic sepsis?

Answer 9

do not give patient chemo if actively neutropenic - delay until recovered

reduce next dose
add prophylactic G-CSF +/- antibiotics with next chemo (generally done if chemo has curative intent)
discontinue chemo (generally palliative patients)

Question 10

Spinal cord compression presentation

Answer 10

back pain
altered sensation in legs
difficulty walking
urine retention

Question 11

Which investigation must be done for suspected spinal cord compression?

Answer 11

urgent MRI whole spine within 24h

Question 12

Spinal cord compression management

Answer 12

‘time is spine’
high dose steroid until definitive treatment
- reduces oedema surrounding tumour
- dexamethasone 16mg per day (16mg stat, then 8mg BD at morning + lunch)
- PPI for gastroprotection

urgent MRI whole spine

Question 13

Why is whole spine MRI done in suspected spinal cord compression?

Answer 13

symptoms cannot accurately predict level of compression
may be more than one level of compression

Question 14

What does a spinal cord compression look like on MRI?

Answer 14

no CSF visible around spinal cord at level of compression

Question 15

Spinal cord compression management

Answer 15

fit patient + some or all neurological function preserved:
- decompression surgery (single level) or radiotherapy (multiple levels)

frail patient/complete paralysis/poor prognosis:
- radiotherapy or supportive care

Question 16

What does a urea that is relatively higher than creatinine suggest?

Answer 16

dehydration

Question 17

Hypercalcaemia of malignancy management

Answer 17

IV fluid - 3L normal saline over 24h
bisphosphonate - zoledronic acid (dose reduce in mild-moderate renal impairment)
RANKL inhibitor - denosumab (can be used in severe renal impairment)

monitor renal function, calcium and phosphate

Question 18

Investigation of cancer-associated venous thromboembolism

Answer 18

D-dimer = not helpful in cancer pts as often raised due to malignancy

ultrasound = limb deep vein thromboses

CTPA = look for pulmonary emboli

Question 19

Which anticoagulant is used in cancer patients with a DVT?

Answer 19

dalteparin
(or DOACs, just not dabigatran as not studied)

Question 20

SVCO presentation

Answer 20

noisy and laboured breathing
facial swelling and redness
prominent veins over upper chest wall

Question 21

SVCO and upper airway obstruction management

Answer 21

ABCDE
- secure airway (ENT/anaesthetics)
- oxygen

steroids? (not in lymphoma as can make biopsies inconclusive)

SVC stenting (relives symptoms)

need urgent biopsy if tumour

Question 22

Tumour lysis syndrome prophylaxis

Answer 22

IV fluid
allopurinol - prevents uric acid formation
rasburicase - clears uric acid already formed

Question 23

Patient with small cell lung cancer presents with generalised seizure and hx of headache and weakness - what test should be done?

Answer 23

CT head - looking for cerebral metastasis

Question 24

Brain metastasis management

Answer 24

high dose steroid - dexamethasone 8mg BD with PPI cover

levetiracetam is anti-epileptic of choice in brain metastases

neurological observations

surgery?
stereotactic radiosurgery?
supportive care/whole brain radiotherapy?

Question 25

Can patients with brain metastasis drive?

Answer 25

no
must inform DVLA

Question 26

Large bowel obstruction management

Answer 26

nil by mouth

drip + suck until definitive treatment:
- large bore NG to decompress GI tract
- IV fluids

definitive:
- surgery
- endoscopic stenting

Question 27

Which anti-emetic should be avoided in bowel obstruction?

Answer 27

metoclopramide (as pro-kinetic)