Oncology Teaching Clinic - 2 Flashcards

1
Q

Pathophysiology of oncological emergencies

A
  • A space-occupying lesion causing obstruction
    or pressure effect
    , ie. ductal obstruction, fluid accumulation, perforation, fistula, ulcers, hemorrhage and ischemia
  • Metabolic or hormonal problems: e.g. SIADH, PTHrP, hormone deficiency
  • Cytopenia because of disease involvement or
    treatment side effects on bone marrow
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2
Q

Causes of sudden deterioration in cancer patient

A
  • Disease progression
  • Complications of disease
  • Complications of treatment e.g. fibrosis from RT
  • Co-morbid condition worsening
  • Organ decompensation
  • Infection
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3
Q

Presentation of mechanical oncological emergencies

A

Airway: Stridor, SOB, Hemoptysis
GI: Pain, distension, V/D, Hemorrhage
GU: Pain, low urine output, altered consciousness, hematuria
Neuro: focal neurological S/S, altered consciousness

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4
Q

General approach to oncological emergencies

A

History
—History of present illness
—Past history of disease and treatment
—Medical illness
—Drug history

Physical examination
—Local
—Regional
—Systemic
—Neurological

Investigation
—Simple and Quick
—Helps management of acute problem
—Long term management for disease control
later
—Assess fittness of patient for treatment

Treatment:
—Acute Management: life and death
—Long term Management: Disease control

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5
Q

Tumor lysis syndrome

  • Clinical sequalae
  • Diagnosis
A

Cause: Rapid lysis of tumor cells (e.g. by anti-cancer drugs) leads to release of excessive quantities of cellular contents into systemic circulation

Clinical sequalae:
- HyperK, hypoerPo4, hyperurate
- Metabolic acidosis (lactate)
- HypoCa
- ARF (uric acid nephropathy and acute nephrocalcinosis)
- Arrhythmia

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6
Q

Tumor lysis syndrome

Clinical and Lab diagnostic criteria

A

Lab diagnostic criteria: Within even days after initiation of therapy. Requires two or more of:
- Hyperuricaemia (uric acid > 8 mg/dl or 475μmol/L)
- Hyperphosphataemia (phosphate > 4.5mg/dl or 1.5 mmol/L)
- Hyperkalaemia (potassium > 6.0 mmol/L)
- Hypocalcaemia (corrected calcium < 7mg/dL or 1.75 mmol/L; or ionised Ca < 1.12)

Clinical TLS: requires criteria for laboratory TLS to be met + one of the following:
- Cardiac dysrhythmia or sudden death probably or definitely caused by hyperkalaemia
- Cardiac dysrhythmia, sudden death, seizure,
neuromuscular instability
(such as tetany, paraesthesias, muscle twitching, Trousseau’s sign, Chvostek’s sign, laryngospasm or bronchospasm), hypotension or heart failure, probably or definitely due to hypocalcaemia.
- Increase in serum creatinine by 0.3 mg/dl (or a single value over 1.5 times upper limit of normal range if no baseline test available); or oliguria (urine output < 0.5 ml/kg/hr for six hours)

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7
Q

Risk factors of tumour lysis syndrome

A
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8
Q

High risk cancers to TLS

Prevention of TLS

A

Prevention:
* Recognition of patient at risk
* Before start of chemotherapy (48 hrs): aggressive hydration (UO > 100ml/h), use rasburicase or allopurinol as prophylaxis, urine alkalinisation, use furosemide/ mannitol as needed
* Continue for 3-5 days after chemotherapy
* Monitoring: BP, heart rate and rhythm, tumor mass measurement, blood electrolytes, renal function, urine output and urinalysis.

High risk CA:
* Burkitt lymphoma
* Burkitt-type ALL
* Other ALL with WCC>=100
* AML with WCC>=50

TLS can precede chemotherapy

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9
Q

First-line investigation for TLS

A

Bloodtests
- Moderate risk patients – daily bloods
- High risk patients – every 8–12 hours
- Repeat tests over the period of highest risk for
TLS, seven days for haem. cancers

Biochemistry panel for Laboratory TLS:
- urea, creatinine, potassium, albumin and calcium
- Uric acid level
- Phosphate level

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10
Q

Treatment of TLS

A
  • Discussion with a senior/consultant, or need
    ICU support
  • Aggressive hydration (3 litres/m2 per day)
  • Correction of hyperkalaemia
  • ECG monitoring
  • Rasburicase 0.2 mg/kg IV once daily (in 50 ml NS 0.9% over 30 minutes)** for 3– 7 days.**
  • Stop allopurinol (allopurinol blocks conversion of xanthine to uric acid (affect Rasburiscase efficacy)

Rasburicase:
- Recombinant form of urate oxidase, Catalyzes the oxidation of uric acid to allantoin (soluble, excrete by kidney)
- C/I in G6PD deficiency
- Common S/E: rash and urticaria

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11
Q

Neutropenic fever

  • Definition
  • Risk
  • Causes
  • Pathogens
A
  • Fever: defined as a single oral temperature
    measurement of ≥38.3°C or a temperature
    of ≥38.0°C sustained over a 1-hour period.
  • Neutropaenia: defined as an ANC of <500
    cells/mm3, or an ANC expected to decrease
    to <500 cells/mm3 during the next 48 hours

Risk: 10%–50% of patients with solid tumours

Causes:
* common sites of tissue-based infection include the intestinal tract, lung and skin
* Chemotherapy induced mucositis: esophagitis, enterocolitis, oral mucositis
* Catheter associated infections/ Air (pulmonary aspergillosis)

Pathogens:
* Fungi in haematological maligancy or
prolonged neutropenia
* Gram-positive microorganisms most common (2/3): coagulase-negative staphylococci in catheter-associated infection; viridans streptococci from oral mucositis

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12
Q

Neutropenic fever

S/S
Predisposing factors

A

Fever may be only symptom

Other S/S:
- abdominal pain, mucositis of the gastrointestinal tract, and perirectal pain.
- complications such as severe sepsis or septic shock
- Neurological or mental status changes of new onset
- Haemodynamic instability
- Evidence of hepatic insufficiency (defined as aminotransferase levels >5× normal values)
- renal insufficiency (defined as a creatinine clearance <30 ml/min)

Predisposing factors:
- severe active infections such as sepsis, hepatitis, or tuberculosis
- **bone marrow disorders **like aplastic anemia or myelofibrosis
- autoimmune diseases like systemic lupus erythematosus or rheumatoid arthritis
- cancer treatments such as chemotherapy, radiation therapy, and hematopoietic stem cell transplant (HSCT)
- Chemotherapy induced mucositis
- Indwelling vascular catheter

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13
Q

Neutropenic fever

First line investigations

A

Full Hx & P/E (daily): Focus on SKIN, GIT, RESPIRATORY tract
 Skin, perianal skin (fungal cellulitis/ abscess: pain on defecation), surgical site infections S/S
 Oral, abdomen exam (ask for mucositis, esophagitis, enterocolitis, bowel habits)
 Lung, sinus (Respiratory S/S, Sinusitis S/S e.g. fungal sinusitis from inspiration)

Ix:
 General (CBP, LFT, RFT)
 Blood cultures from central venous catheter through 2 different ports

Abdomen:
 Abdomen CT scan
 stool culture: Add-on Clostridium difficile cytotoxin & culture

Lungs:
 CXR (low risk); CT thorax (high risk)
 BAL for sampling, culture

Others:
 Urine, skin, sputum culture

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14
Q

Treatment of Neutropenic fever

A

Empirical broadspectrum antimicrobials with bactericidal activity (no WBC), minimal toxicity:

Oral out-patient treatment: Augmentin + Ciprofloxacin
– Amoxicillin-clavulanate (Augmentin) 40mg/kg/day
in 3 divided doses max. 500mg Q8H
– Ciprofloxacin 30mg/kg/day in 3 divided doses max. 750mg Q8H

IV monotherapy (standard in-patient tx)
– Piperacillin-tazobactam (Tazocin®)
– Imipenam-cilastatin (Tienam®)
– Meropenem (Meronam®)
– Cefepime (Maxipime®)
– Ceftazidime (Fortum®)

Reassess clinical status and myeloid recovery, daily examination and blood/site cultures, Consult Mibi

Modify IV antibiotics, add empirical anti-fungal therapy, re-image sites of infection if no recovery

Adjunct therapy:
- G-CSF (weak evidence)
- Vancomycin (if penicillin-resistant strep. infection/ severe mucositis)

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15
Q

Risk score for neutropenic fever

A

Multinational Association of Supportive Care in Cancer (MASCC) score

Clinical condition: Temp > 38.5 + ANC < 0.5 x 10^9/L

+ Low MASCC risk score = outpatient discharge with oral anti-bacterial therapy (Augmentin and ciprofloxacin)

+ High MASCC risk score = hospital admission with IV anti-biotics

High risk: : MASCC score is less than 21, with Profound neutropaenia (ANC≤100 cells/mm3) expected to last >7 days

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16
Q

Examples of multidrug resistant pathogens

A
  • MRSA,
  • VRE,
  • ESBL-producing gram-negative bacteria
  • Carbapenemase-producing enterobacteriaceae
17
Q

Adrenal crisis
- Cause
- Presenting S/S
- First line investigations

A

Cause:
- Primary adrenal insufficiency: Sepsis, acute metabolic stress, abrupt glucocorticoid withrawal, bilateral adrenal metastasis
- Bilateral adrenal infarct/ hemorrhage
- Pituitary or hypothalamic adrenal insufficiency (rare)

S/S:
- Hyperpigmentation of skin
- Hypoglycaemia and HyperK: Lethargy and fatigue, confusion
- Fever, rigour
- Diffuse bone pain, abdominal pain
- Shock
- Dehydration: Postural Hypotension +/- reflex tachycardia, Cold peripheries
- Renal failure: HypoNa, HyperK

Ix:
- Electrolytes and renal function test
- ACTH deficiency: Low 9am serum cortisol, Short synacthen test, Insulin tolerance test, serum ACTH
- Check RAAS function: Basal aldosterone, Basal plasma renin activity
- Ddx: CT abdomen, Cranial MRI, Septic workup, Autoimmune diseases

18
Q

Approach to HypoNa (e.g. due to adrenal crisis)

A
19
Q

Adrenal crisis

Treatment

A

Treat hypotension: IV fluid resuscitation, monitor CVP via central line, monitor fluid status and UO

Treat cortisol deficiency:
- Dexamethasone 4mg stat then 4-8 mg over 24 hours (divded dose) if continuously measuring serum cortisol level
- Hydrocortisone 100mg stat then 100-200mg
over 24 hours (divided dose) if no repeating biochemical tests frequently
- Fludocortisone for chronic adrenal deficiency

  • Correct low Na (12mmol/day change max), glucose level and hyperkalemia
20
Q

Anaphylaxis and hypersensitivity

  • Presenting S/S
  • Ix
  • High risk drugs
A

S/S: Mild symptoms (no respiratory distress) or Severe shock
- Atopy: periorbital edema, bronchospasm/ laryngeal edema/ SOB/ wheezing, uritcaria/ angioedema, allergic conjuntivitis, facial flushing
- Anaphylatic shock: distributive shock, warm peripheries with tachycardia, chest pain…etc

Ix: Plasma mast cell tryptase, CBC with WBC differential count, pulse oximetry, BP/P, ABG ± UO, CVP if severe hypotension

High risk drugs:
- Platinum based chemo (e.g. cisplatin, carboplatin, oxaliplatin)
- Taxane chemo (e.g. paclitaxel, docetaxel)
- Monoclonal Ab (e.g. rituximab)
- Analgesics: morphine, NSAIDs
- Contrasts, vaccines
- Skin prep (e.g. alcohol, chlorhexidine), latex

21
Q

Anaphylaxis and hypersensitivity

  • Treatment
A

Stop inciting drug, call for help

0.5mg (0.01mg/kg) IM epinephrine every 5 minutes, IV epinephrine ( 50 mcg, 0.5 ml, 1:10,000 dilution in boluses) if refractory

Airway: Immeidate intubation vs angioedema/ bronchospasm

Breathing: 100% O2, 15L/ min via non-rebreathing mask

Circulation:
- Place pt in recumbent position and elevate the feet to restore intravascular volume
- Secure IV access and give rapid fluid challenge (1-2L IV NS)

Drug therapy:
Antihistamines: chlorphenamine 10-20mg slowly IV or IM
Steroids: hydrocortisone 200mg slowly IV or IM
Bronchodilators: salbutamol 2.5-5.0mg nebulized or 0.25mg IV
IV glucagon for those on β-blocker
Atropine for bradycardia

22
Q

SVCO

  • Presenting S/S
  • Ix
  • Most common causes
A

Common causes: Lung cancer (SCC or SCLC usu), Lymphoma, metastatic breast cancer, germ-cell tumours, thymoma and mesothelioma

Presenting S/S:
Symptoms
* Dyspnoea, cough
* Facial swelling, dysphagia
* Head ‘fullness’
* Symptoms exacerbated by bending forwards / lying down

Signs
* Facial swelling and plethora, cyanosis
* Distended neck and chest wall veins
* Upper limb oedema
* Cognitive dysfunction, coma
* Pemberton sign

Ix:
- CXR, CT thorax, Venogram
- Cancer: Sputum/ pleural/ FNAC LN cytology; CT guided biopsy, Bronchoscopy and Mediastinoscopy

23
Q

SVCO

Management

A

Acute Management:
- Dexamethasone 16mg daily divided dose (4mg Qid) with Pantoloc (PPI)
- Endovascular stenting + LMWH coverage +/- systemic thrombolysis: relief in 2-3 days, subject to availability
- Surgical resection of obstruction

Treating underlying cancer:
- Chemotherapy: for chemo-sensitive CA such as SCLC and lymphoma
- Radiotherapy: for non severe symptoms (e.g. established collaterals), slow effect onset

24
Q

Malignant spinal cord compression

  • Presenting S/S
  • Ix
  • Red flag signs
A

S/S:
- Chronic back pain
- Sensory symptoms (negative or positive), Motor symptoms (weakness, reflexes, incoordination…), Autonomic symptoms (sympathetic, urinary, bowel, sexual)

Ix:
- Clinical exam: Straight leg raise test for herniated disc/ sciatica, Full neurological exam, Pelvic and abdominal exams for autonomic function, Log-roll test for spinal stability
- Spine imaging: X-ray, MRI, CT myelogram, PET-CT (met.)
- Blood tests: tumour markers, electrolytes (Calcium, phosphate esp.), PTHrP, Vitamin D

Red flag signs:
- Pain in C or T or L spine, severe and unremitting, affects sleep
- Spinal pain exacerbated by straining (e.g. cough, sneeze)
- Local bony tenderness

25
Q

Malignant spinal cord compression

Treatment
Scoring systems for choice of surgery

A

Acute management:
- Dexamethasone 16mg in divided dose with PPI cover
- Analgesia: Weak opioids or higher for neurological pain
- Consult orthopaedics for surgical decompression ad stabilisation, Vertobroplasty or Kphoplasty for vertebral body collapse
- Radiotherapy: alone or post-op
- Prophylactic LWMH

Long-term management:
- Rehabilitation
- Systemic treatment for CA

Scoring systems: Tokuhashi scoring system/ SINS score (Spinal Instability Neoplastic Score)

26
Q

Hypercalcemia of malignancy

  • Presenting S/S
  • Causes
  • ## Ix
A

Causes:
- PTHrP/ Ectopic PTH production
- Bone metastasis and osteolysis
- Lymphokine production that activate osteoclasts (e.g. MM)
- Extra-renal production of dihydroxy-VitD (e.g. T-cell lymphoma)

S/S:
- Typical hyperCa S/S: “moans, groans, thrones, stones, psychiatric overtones…”

Ix:
- Corrected total serum calcium/ Ionized Ca
- Phosphate, hydroxy-Vit D and dihydroxy Vit D level
- PTH level, PTHrP assay
- CBC with WBC differential, SPEP/ UPEP, Serum free light chain assay, urinalysis, serum albumin/globulin ratio
- Imaging: as indicated by localizing signs of different CA

27
Q

Hypercalcemia of malignancy

Treatment

A

Acute treatment:
- Aggressive Hydration to increase Ca excretion: NS 200 500ml/hour (unless cardiac/renal disease), with potassium maintenance
- Forced diuresis once euvolaemic: use Furosemide, NOT thiazide (increase distal tubular reabsorption of calcium, causes hypocalcuiric hypercalcaemia)
- Calcitonin: inhibit bone resorption and increase renal excretion, rapid onset, short duration

Second-line:
- Denosumab: Anti-RANKL mAb
- Bisphosphonate: slow onset
- Corticosteroids

Last line:
- Mithramycin: highly toxic
- Dialysis

28
Q

Seizure

causes of seizure / altered
conscious state in cancer patients?

A

—Tumor manifestation
—Drug overdose
—Infection
—Metabolic disturbance
—Cerebral vascular accidents
—Treatment complications
—Major organ failure

29
Q

Immune related Adverse Events associated with immunotherapies

Treatment of immune-related adverse events

A

Endocrine: Thyroiditis, hypophysitis
Lung: Pneumonitis, Lung fibrosis
Kidney: Nephritis
Neuro: Meningitis, MG
Opthal: Anterior uveitis
Skin: Dermatitis, Lichen planus, Psoriasis, SJS/TEN, Vitiligo
GI: Colitis, Hepatitis

Treatment:
* Cease checkpoint inhibitor, consult sub-specialty and
consider hospitalisation

Immunosuppression:
* Systemic corticosteroids
* Infliximab (anti-TNFα)
* Mycophenolate mofetil
* Tacrolimus

Other: plasmapheresis, anti-thymocyte globulin, IVIG

30
Q

Patient developed shock, loss of
consciousness and diffuse rash 15 min after
starting carboplatin infusion. You decided to
give adrenaline. Best dosage is?

A

0.5mg (0.01mg/kg) IM epinephrine every 5 minutes, IV epinephrine ( 50 mcg, 0.5 ml, 1:10,000 dilution in boluses) if refractory

31
Q

Which of the following drug has highest risk of causing allergy/anaphylaxis?
* 1, Rituximab
* 2, Panitumumab
* 3, cyclophosphamide
* 4, Trustuzumab (herceptin)
* 5, 5-fluorouridine

A

Rituximab

High risk drugs:
- Platinum based chemo (e.g. cisplatin, carboplatin, oxaliplatin)
- Taxane chemo (e.g. paclitaxel, docetaxel)
- Monoclonal Ab (e.g. rituximab)

32
Q

55/M good past health, heavy smoker with newly diagnosed small cell lung CA developed SVCO. He presented with severe SOB and facial swelling. CT
scan shows right paratracheal LN compressing on SVC. Best drug to give to relieve symptoms
1. Furosemide
2. Mannitol
3. Hydrocortisone
4. Prednisolone
5. dexamethasone

A

Ans: dexamethasone

SVCO acute Management:
- Dexamethasone 16mg daily divided dose (4mg Qid) with Pantoloc (PPI)
- Endovascular stenting + LMWH coverage +/- systemic thrombolysis: relief in 2-3 days, subject to availability
- Surgical resection of obstruction
- RT: slow onset, not for symptomatic case

33
Q

SVCO symptoms are only partially relieved after medication. You decided to give more definite treatment to this patient. Unfortunately SVC stent is not available at your hospital. What will you do next?
1. Radiotherapy
2. Surgical resection
3. IV Pulse dose steroid
4. Chemotherapy
5. Best Supportive Care

A

Ans: Surgical resection

SVCO acute Management:
- Dexamethasone 16mg daily divided dose (4mg Qid) with Pantoloc (PPI)
- Endovascular stenting + LMWH coverage +/- systemic thrombolysis: relief in 2-3 days, subject to availability
- Surgical resection of obstruction
- RT: slow onset, not for symptomatic case

34
Q

70/M with metatstatic prostatic cancer
developed sudden onset of LL weakness, constipation and urinary incontinence. You highly suspect spinal cord compression (SCC). What is the most common presentation at initial diagnosis of SCC

  1. Back pain
  2. Limb weakness
  3. Sensory deficit
  4. Dermatomal level
    5.Bladder or bowel dysfunction
A

Ans: Back Pain

back pain is present at 95% in cord compression and can precede other symptoms by two months!

35
Q

A 25 years gentleman had newly diagnosed stage IV lymphoblastic lymphoma with bulky abdominal lymph nodes. He was started on chemotherapy. He tolerated chemotherapy well but 3 days after start of chemotherapy, he developed oligouria and become confused

You ordered some blood tests. Which of following parameter is most likely to be low?
1. Urate
2. Calcium
3. Potassium
4. Phosphate
5. Haemoglobin

A

Ans: Hypocalcemia

TLS Lab diagnosis:
- Hyperuricaemia (uric acid > 8 mg/dl or 475μmol/L)
- Hyperphosphataemia (phosphate > 4.5mg/dl or 1.5 mmol/L)
- Hyperkalaemia (potassium > 6.0 mmol/L)
- Hypocalcaemia (corrected calcium < 7mg/dL or 1.75 mmol/L; or ionised Ca < 1.12)

36
Q

cause of deranged RFT in myeloma patient?

A

—Infection
—Hypercalcemia
—Hyperuricemia
—Myeloma kidney: cast nephropathy, tubulointerstitial nephritis, glomerular deposition diseases/ glomerulonephritis