Oncology emergencies Flashcards by Ellen Thomas

What are the main oncology emergencies?

Hypercalcaemia

Superior Vena Cava Obstruction

Tumour lysis syndrome

Neutropenic sepsis

Spinal cord compression

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What is meant by corrected calcium?

40% of circulating calcium is bound to albumin, but labs only measured unbound calcium

Corrected calcium is calculated based on serum albumin levels

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Your patient is hypercalcaemic.

Their PTH level is also high, what could be the cause?

Hyperparathyroidism

High PTH:

Increases bone resorption
Increases calcium reabsorption in kidneys
Converts inactive vit D to active vit D which increases Ca absorption in intestine

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What does the body do to correct low calcium?

Stimulate parathyroid hormone release

Which increases bone resorption and renal calcium reabsorption.

Also stimulates renal conversion of inactive vit D to active vit D, which increases intestinal calcium absorption.

These mechanisms restore the serum calcium to normal

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Your patient is hypercalcaemic.

Their PTH level is normal, what could be the cause?

Malignancy

Drugs: thiazide diuretics, vit D

Endocrine: thyrotoxicosis, primary adrenal insufficiency

Granulomatous conditions: sarcoidosis, TB

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How does malignancy cause hypercalcaemia?

Ectopic production of PTH or PTH-related peptide by tumour cells

Osteolytic (bone mets)

Ectopic calcitriol (active vit D)

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Clinical presentation of hypercalcaemia?

Bones: pain

Stones: renal stones

Abdominal groans: nausea, constipation

Psychic moans: confusion, drowsy

Also:

prologed QT
pancreatitis
coma
muscle weakness

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What investigations would you do for hypercalcaemia?

Bedside:

Obs
BMs
ECG (Qt interval)

Routine:

Bloods: FBC, U+E, Ca, CRP, LFT (esp alk phos), Clotting, PTH, TFTs
XR
Urine Ca and P

Specialist:

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Which blood tests are particularly important for hypercalcaemia?

Albumin and urea: if raised could indicate dehydration

Alkaline Phosphatase: if raised indicates bony mets, thyrotoxicosis

Calcitonin: if raised indicates possible B cell lymphoma

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Acute management of hypercalcaemia in cancer patient?

Rehydrate: 0.9% NaCl
Bisphosphonates: pamidronate, zolendronic acid
Treat underlying cause

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How do bisphosphonates help in hypercalcaemia?

They inhibit osteoclasts so reduce bone absorption and turnover

This reduces Ca levels

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How can you manage persistent hypercalcaemia in malignancy?

Denosumab: a monoclonal antibody drug which inhibits maturation of osteoclasts

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Where does the SVC connect to at either end?

What does it do?

It runs from where R and L brachiocephalic veins join to the RA

It’s the venous drainage for the head, neck, upper limbs and upper thorax

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What causes SVC obstruction?

Inside the vessel:
- thrombus

Inside the vessel wall:
- direct tumour invasion

Outside the vessel:
- tumour (lung cancer, lymphoma)

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Clinical features of SVC obstruction?

SYMPTOMS:
Dyspnoea
Chest pain at rest
Cough
Neck and face swelling
Arm swelling
Dizzy
Headache
Visual disturbance
Syncope

SIGNS:
Dilated veins over arms, neck and chest wall
Resp distress
Cyanosis

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Investigations of SVC obstruction?

Clinical diagnosis

Usual bedside and routine

Specialist:

CXR
CT scan
Contrast venography

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Management of SVC obstruction?

Elevation of head
Oxygen therapy

High dose steroids

Endovascular stenting

Anti-coagulation if thrombosis

Treat tumour: chemo, radiotherapy

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What is tumour lysis syndrome?

What causes it?

The abrupt release of large quantities of cellular components into the bloodstream following rapid lysis of the malignant cell

Caused by treatment

Or spontaneously, this commonly occurs in haematological malignancies like ALL, Burkitt’s lymphoma

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What are the risk factors for tumour lysis syndrome?

Treatment sensitive tumours

Volume depletion (bleeding, dehydration)

Renal impairment

High pre-treatment lactate, urate, LDH levels

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Clinical features of tumour lysis syndrome?

Weakness

Paralytic ileus: constipation, vomiting, abdo pain

Arrhythmias: palpitations, chest pain, collapse

Seizures

AKI: reduced UO, lethargy, nausea

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What investigations would you do in suspected tumour lysis syndrome?

Bedside:

UO
Urinalysis

Routine:
- Bloods: FBC, U+E, serum LDH, urate, phosphate, Ca

What is LDH?

Lactate dehydrogenase

An enzyme the body uses in respiration (glucose -> energy)

Found in muscles, liver, heart, pancreas, kidneys, brain, blood cells

What would you see in bloods of someone with tumour lysis syndrome?

HypERuricaemia

HypERphosphataemia

HypERkalaemia

HypOcalcaemia

AKI: so raised creatinine, urea

Why does tumour lysis syndrome cause AKI.

Tumour lysis syndrome causes release of allsorts into the blood, including uric acid and Ca phosphate crystals

Deposition of both these in the renal tubules causes AKI

How can you prevent tumour lysis syndrome? When should you think about doing this?

Before starting chemotherapy in an at-risk patient - IV fluids - Rasburicase: catalyses uric acid -> allantoin which is more soluble - Allopurinol: blocks conversion of xanthines to uric acid

Management of tumour lysis syndrome?

Vigorous hydration Correct high potassium: - calcium gluconate - IV insulin + dextrose - salbutamol Rasburicase: uric acid -> soluble allantoin Acetazolamide: alkalinise urine b/c uric acid more soluble at higher pH Phosphate binders Dialysis in severe cases

What's the treatment for raised potassium?

Fluids Calcium gluconate IV insulin + dextrose Salbutamol nebs

Where does the spinal cord terminate and the cauda equina start? Which important nerves does the cauda equina contain?

L1 Lumbar, sacral and coccygeal nerves

Which nerve roots control these reflexes? Knee jerk Ankle jerk Which nerve roots control anal sphinchter?

L3, 4 keeps foot off the floor (knee jerk) S1 (ankle jerk) S2,3,4 keeps poo off the floor

What things can cause spinal cord compression?

Malignancy, more commonly secondary Trauma Disc prolapse Inflammatory arthritis Spinal infection Haematoma

Clinical features of spinal cord compression?

Depends on where the lesion is Radicular pain Sensory loss below level UMN signs: - hypertonia - weakness - brisk reflexes Only LMN signs if compression on the spinal nerves, so they're often present at the level of the lesion only

What are UMN and LMN signs? Which are UMN and LMN?

UMN (spinal cord) - hypertonia - brisk reflexes - weakness - no wasting or fasciculations LMN (spinal nerves, all other nerves) - hypotonia - weakness - absent reflexes - wasting - fasciculations

Signs of cauda equina?

Lower back pain Perineal numbness Loss of anal sphincter tone Urinary retention

Where are the spinal nerves?

The nerves that come out of the spinal cord at each level, C1-L1

Investigations of possible spinal cord compression?

Urgent MRI of whole spine (within 24hrs) Bloods: FBC, U+E, LFTs (could indicate liver and bone mets)

What are the red flag signs of cord compression?

Insidious onset Gait disturbance Clumsy, weak hands Loss of sexual, bladder or bowel function UMN signs in lower limbs LMN signs in upper limbs Sensory changes Lhermitte's sign: electric shocks

Management of spinal cord compression?

Analgesia High dose corticosteroids: dexamethasone Surgery, radiotherapy, chemo Bisphosphonate for bone pain caused by mets VTE prophylaxis Manage bladder and bowel, catheterise Refer to spinal rehab

Which cancer causes sclerotic bone mets? What do these look like on XR?

Prostate They look white and bright

Which cancers commonly metastasise to bone?

BLT + KP ``` Breast Lung Thyroid Kidney Prostate ```

A patient has is 9 days into their chemotherapy for breast cancer. They present with a fever and feeling generally unwell. What do you think?

Neutropenic sepsis!

What is neutropenic sepsis?

Chemotherapy can cause myelosupression - leukopenia - thrombocytopenia - low red cell count Neutropenia is low neutrophil count Makes patients susceptible to serious infections

On what day of chemo is neutropenia most likely to happen?

Day 7-14

At what neutrophil count does a patient become susceptible to sepsis?

Below 1x10^9/L

Patients should be treated for neutropenic sepsis if they meet criteria, what criteria?

They have a temperature over 38 OR A temp over 37.5 for two consecutive readings for two hours AND A neutrophil count below 1x10^9 or expected to fall below

Clinical features of neutropenic sepsis?

Fever Any infective signs Can have no symptoms except fever Suspect it in all patients with new deterioration within 6 weeks of cytotoxic chemo

What infections can patients get when they're neutropenic?

``` Meningitis Encephalitis Chest: pneumonia, empyema Liver abscess Gastroenteritis Pyelonephritis UTI Skin: cellulitis etc. ``` LINE INFECTION

Investigations of neutropenic sepsis?

Bedside: - BM - Obs - Urinalysis - ABG, VBG Routine: - Bloods: FBC, LFTs, U+E, lactate, CRP, ESR, Coag - Cultures: blood, urine, faecal, sputum, swab - CXR Do a full septic screen

Management of neutropenic sepsis?

ANTIBIOTICS, do not wait until confirmed Start within an hour of arrival at hosp Empirical abx: tazocin +/- gentamicin Low risk patients: oral abx, observe for 24hrs as inpatient High risk: IV abx and review daily as inpatient, can switch to oral after 24-48hrs if improvement Monitor for complications: AKI, DIC, organ failure Supportive tx

How long should you give abx for in neutropenic sepsis?

When neutrophils have normalised, patient has been afebrile for 24 hours and cultures are negative If patient is still neutropenic but they've been asymptomatic for 5-7 days abx can be stopped

How can you prevent neutropenic sepsis?

Prophylactic abx: a fluroquinolone (like cipro) G-CSF: stimulate bone marrow to produce WBCs Reduce chemo if palliative setting

What is the name of the drug which stimulates bone marrow to produce WBCs?

G-CSF Granulocyte colony-stimulating factor