Acute presentations due to underlying cancer

Question 1

Hypercalcaemia:

• Definition
• Cancer causes
• Causes
• Symptoms
• Signs
• Investigations
• Management including supportive

Answer 1

Hypercalcaemia:

• Definition: outside of 2.2-2.51mmol/l and usually indicates diffuse disease / advanced stage :(. 65% blood ca bound to albumin
• Pathophysiology: low ca stims parathyroid gland to release PTH which inc ca renal absorption, vit d activation to inc ca GI tract absorption and osteoclast activity to inc ca released from bone resorption. If high calcitonin released from parafollicular/c cells dec renal resorption and dec osteoclast activity
• Causes: most common in breast, scc, renal, myeloma, lymphoma.
  80% due to humoural cause (chemical agents release by tumour which disrupts ca haemostasis, such as PTHrp, overproduction vit d).
  20% due to bone invasion (osteolytic mets with local release of cytokines cause inc bone resorption and there is local bone destruction)
• Symptoms: nausea, anorexia, thirst, polydipsia/uria, weak, constipation, confusion, drowsy, bone pain
  Stones, moans, bones, abdominal groans
• Signs: ventric arrythmias, pancreatitis, AKI
• Investigations: bloods (serum ca, seerum albumin), then PTH, PTHrp, vit D to find out cause. If 2.8-3 mild, if 3-3.5 mod, if >3.5 severe
• Management: 24 hours of saline rehydration, bisphosphonates to inhibit osteoclast bone resorption (IV pamidronate or zolendronic acid but can cause renal failure to make sure hydrated), exog calcitonin (dec clast activity + renal reabsorption) useful to bridge as works within 4 hours but tachyphylaxis usually develops within 48 hours, haemodialysis if cardiorenal disease, systemic treatment of malig
  Remember bisphosphonates can take 4 days to begin to work and max effect 4-7 days. When following up bloods every 2-4 weeks are high recurrence.

Question 2

SVCO:

• Definition
• Cancers which cause this
• Symptoms
• Investigation
• Risk factors
• Management - + complications of the definitive treatment

Answer 2

SVCO:

• Definition: obstruction of blood flow through the SVC via compression (NSCLC, SCLC, mesothelioma) or occlusion (non hodgkin lymphoma, thrombus via central venous catheter)
  SVC drains venous blood from H&N and upper limbs into right atrium
• Symptoms: causes oedema hence swelling of face/neck/limbs, distended neck/chest veins, sob/cyanosis, stridor, hoarse voice, lethargy, headache, confusion (cerebral oedema), conjunctival swelling/blurred vision
• Investigations: normally clinical, CXR, CT thorax with contrast
• Management: sit upright/elevate head, oxygen, dexmethasone 16mg (in steroid responsive maligs/laryngeal oedema although no evidence) + PPI, opioids, benzodiazepines, stent for relief, anticoags if thrombus
  Average life expectancy after is 6 months

Question 3

Malignant spinal cord compression:

• Definition
• Pathophysiology
• Common cancer causes
• Symptoms
• Signs
• Investigations
• DD (3)
• Management including supportive
• Poor prognostic signs
• Other non cancer causes of compression

Answer 3

Metastatic spinal cord compression:

• Definition: occurs when dural sac and its contents are compressed at the level of the cord or cauda equina
• Pathophysiology: 80% by collapse or compression of a vertebral body containing the metastatic disease (arterial seeding), 10% by a direct tumour (paraspinal mass) extension into epidural space (extradural) (esp lymphoma). Compression of cord causes oedema, venous congestion and demyelination which is reversible but when prolonged can cause vascular injury, cord necrosis and permanent damage
  Most common site is thoracic
• Common cancer causes: breast, prostate, lung, lymphoma, myeloma, renal, thyroid
• Symptoms: back pain worse coughing/lying down/neck flexion and can radiate to legs/chest and poor response to analgesia, motor symptoms (reduced power, difficulty standing/walking often symmetrical), sensory loss, sphincter dysfunction (urin hesitancy/freq/retention/incontinence)
• Signs: + babinski sign
  if acute then flaccid paralysis. If chronic spasticity (inc tone, clonus, hyperreflexia below MSCC level), plantar reflexes up going (not cauda equina), sensory loss in derm level, palp bladder (retention)
• Investigations: MRI within 24 hours
• DD: spinal stenosis, prolapsed disc, spinal epidural abscess
• Management: urgent to reduce risk paraplegia, dexamethasone 16mg + PPI within 24 hours, surgery to relieve compression/remove tumour/stabilise spine (if good performance status/absence visceral mets, single level spinal disease) including balloon kyphoplasty. Also radiotherapy, or chemo (if sensitive tumours like lymphoma/sclc)
  Supportive care: analgesia, laxatives, bladder care, VTE prophylaxis, physio
• Poor prognostic signs: loss of sphincter function, inability to walk, acute onset/rapid progression. Radiosensitive tumours have improved functional capacity (lymphomas, myelomas, breast, prostate)
• Other non cancer causes: fracture, TB, disc prolapse, epidural haematoma

Question 4

VTE:

• Pathophysiology
• Which cancers in particular
• Risk factors - patient, treatment, cancer related
• Symptoms
• Investigations
• Management
• Prophylaxis

Answer 4

VTE:

• Pathophysiology: 2nd leading cause cancer death. Virchows triad is venous stasis, endothelial damage, hypercoag state. In cancer inc immobility + cancers compress vasculature so inc venous stasis, plus cancer cells + healthy cells become hypercoag via expressing adhesion molecules which inc procoag particles expression.
• Which cancers in particular
• Risk factors:
  Patient related: previous VTE, obesity, <3 months since diagnosis
  Treatment related: surgery, chemo, hospitalisation
  Cancer related: high stage/grade, primary site
• Symptoms: unilat leg swelling/erythema, red/warm. If PE SOB, tachyc, pleuritic chest pain, cough, haemoptysis, fever
  Wells: for DVT if >1 likely, for PE if >4 likely
• Investigations: D dimer (>500ng/ml), CT angiogram, if DVT doppler uss
• Management: subcut LMWH dalteparin or DOAC for min 6 months
• Prophylaxis: aspirin, LMWH if high risk. Khorana risk model is screening for risk of VTE to decide to give prophylaxis and is risk VTE in 2.5 months and if >2 then need it (platelet count >350, leucocytes >11, bmi >35, hb <100

Question 5

Bowel obstruction:

• Definition
• Types of cancer causes
• Symptoms
• Signs
• Causes (5)
• Investigations
• Management
• Complications

Answer 5

Bowel obstruction:

• Definition: mechanical blockage in GI tract which leads to dilatation and electrolyte secretion into bowel hence oedema, ischaemia and perforation
• Types of cancer: colorectal, ovarian, esophageal, stomach, pancreatic
• Symptoms: gradual onset N+ bilious V, abdo pain, abdo distension, visible peristalsis, not passing stool/wind
• Signs: dehydration, distended, guarding, tinkling bowels (tympanic high pitch)
• Causes: radiation therapy, tumour inside GI tract/pressing it from outside (this is mechanical), scar tissue, hard stool, functional (infiltration of myenteric plexus)
• Investigations: obs, urinalysis, bloods (fbc, crp, lactate, U+Es/urea, creatinine), axr (in small >3cm, conniventes valvulae, central. In large >6cm, haustra, peripheral. If perforated pneumoperitoneum means perforation), ct abdo + pelvis identifies level + cause
• Management: IV fluids, NG tube, nbm, enema if hard stool, analgesia, iv abx, adhesiolysis, surgery stenting via endoscope, gastrostomy to decompress, antiemetics. Surgery if single level but may not be helpful/ well enough. If palliative syringe driver, control pain + nausea
• Complications: dehydration, peritonitis, necrosis, renal impairment

Question 6

Pleural effusion:

• Definition
• Causes
• Cancer causes
• Symptoms
• Signs
• Investigations
• Lights criteria
• Management
• Other non malignant causes of effusions
• Safe triangle borders

Answer 6

Pleural effusion:

• Definition: too much fluid in the pleural cavity
• Causes: PE, pneumonia, malignant where cancer cells spread to this space
• Cancer causes: lung, breast, mesothelioma, ovarian, non hodgkins lymphoma, kidney, stomach, colon
• Symptoms: gradual sob worse when lying down, dry cough, pleuritic chest pain, fever
• Signs: tachypnoea, stony dull percussion, decreased breath sounds, decreased vocal resonance
• Investigations: ecg, bloods (fbc (infection?), u+es, lfts, crp, bone profile, ldh, clotting, d dimer), cxr, uss guided pleural fluid aspiration sent for biochem, cytology, microbiology (if cancer will be exudate fluid which is thick + cloudy and pleural protein >30g/l)
• Light’s criteria: use this is pleural fluid protein is between 25-35. Exudative if any of these:
  Pleural fluid / serum protein >0.5
  Pleural fluid / serum LDH > 0.6
  Pleural fluid LDH > 2/3 upper limit of normal
• Management: sit up, drain thoracocentesis (pleural aspiration), if keeps recurring tunnel catheter, chest drain (never insert unless diagnosis fully established as need pleural biopsies unless v urgent PH <7.2 or pus) , pleurodesis if keeps recurring (pain, bleeding, infection, injury to lungs)
• Other causes:
  Exudative due to leaky caps: TB/other infections, inflammatory RA/pancreatitis
  Transudative due to dec albumin/inc hydrostatic pressure: HF, cirrhosis, PE
• Safe triangle borders for chest drain:
  Sup = base axilla
  Inf = 5th ics
  Ant = lat edge pect major
  Post = lat edge lat dorsi

Question 7

Ascites:

• Definition
• Cancer causes
• Non cancer causes
• Symptoms
• Investigations
• Management
• DD

Answer 7

Ascites:

• Definition: accummulation of fluid in the peritoneal cavity
• Cancer causes: cancer cells irritate lining so it produces too much fluid. Or lymph glands in abdomen get blocked so they can’t drain fluid. Or cancer cells spread to liver raising pressure in nearby bv forcing fluid out
  Ovarian, breast, bowel, stomach, pancreatic, mesothelioma of peritoneum, lung, liver
• Non-cancer causes: liver disease causing portal htn, heart disease
• Symptoms: bloating/distension, abdo pain, back pain, loss appetite, indigestion, constipation, inc freq urination, sob, fatigue, weight gain
• Investigations: bloods (u+es, lfts), uss abdo, CT, ascitic tap - serum ascites albumin gradient SAAG (albumin conc in fluid - serum alb)
  If SAAG high: cirrhosis, HF, budd chiari syndrome. Due to inc hydrostatic p forcing water into cavity whilst albumin remains in vessels
  If SAAG low (<1.1g/dl): cancer, infections, pancreatitis
• Management: less salt, fluid restriction, spironolactone, ascitic drainage, if keeps recurring peritoneo venous shunt, treat cancer

Question 8

Raised intracranial pressure:

• Causes
• Cancers causing mets
• Symptoms
• Signs
• Investigations
• Management

Answer 8

Raised intracranial pressure:

• Causes: primary tumours in brain, mets to brain, infection, bleeding, swelling, blocking of csf (obstructive hydrocephalus), radiation therapy which causes cerebral oedema, abscess
• Cancers causing brain mets: melanoma, lung, breast, kidney
• Symptoms: headache worse in morning/leaning forward/straining, N+V, dizzy, behaviour changes, poor memory, restless, vision problems, weakness, numbness, cushings triad (htn, bradycardia, irreg breathing), depression of consciousness
• Signs: htn, altered level consciousness, papilloedema
• Investigations: neurolog exam, fundoscopy, CT head, MRI head, LP
• Management:

If due to tumour compression: elevate head, dexamethasone IV 8mg 4 hourly (if not working mannitol), omeprazole, analgesia, cyclizine, abx if infection, surgery to remove tumour/radiation/intrathecal chemo (LP)

If due to hydrocephalus: surgery for cerebral shunt

Question 9

Seizures:

• Causes
• Investigations
• Management

Answer 9

Seizures:

• Causes: chemo esp if given spinal, tumour growth in spine/brain or due to mets, surgery to head, swelling in brain, high fever, blood clots, infection, electrolyte changes, paraneoplastic syndromes
• Investigations: neurlog exam, bloods (u+es, fbc), contrast MRI/CT to see if parenchymal involvement, EEG, LP
• Management: if unprovoked then anticonvulsants (levetiracetam (less interactions with chemo), sodium valproate, lamotrigine). Also treat underlying cancer to reduce seizures. Benzodiazepines for provoked seizures and epileptic seizures

Question 10

GI bleeding:

• Cancer causes
• Non cancer causes
• Symptoms
• Investigations
• Management

Answer 10

GI bleeding:

• Cancer causes
  Upper: gastric
  Lower: radiation induced colitis, colorectal, small bowel
• Non cancer causes:
  Upper: oesophagitis, mallory weis tear, variceal bleed, PUD
  Lower: diverticula, IBD, anorectal disease, meckels diverticulum
• Symptoms: haematemesis, haematochezia, melena
• Investigations: DRE, bloods (fbc (anaemia?), u+es (urea?), lfts, crp, clotting, g&s, vbg for fast hb). If upper bleed OGD/CT abdo with contrast. If lower stool culture, flexible sigmoidoscopy or CT angiogram if unstable
  For upper GI bleed rockall score predicts rebleeding/mortality risk and then Glasgow blatchford score shows risk assessment hence need for admission
• Management:
  Admit if unstable or comorb
  Lower: resus, iv access, iv fluids, reverse anticoags, diluted adren + endoscopic ligation but if fails then endoscopic angiography
  Upper: platelet transfusion or FFP if needed, if non variceal PPI. If variceal terlipressn + abx + endosc band ligation, if PUD adren injection + cauterisation