cological emergencies

Question 1

emergencies of oncological origin

Answer 1

Spinal cord compression
Superior vena cava syndrome
Brain metastasis and space occupying lesions within the brain
Cardiac tamponade
Febrile neutropenia
Hypercalcemia
SIADH (Syndrome of Inappropriate Antidiuretic Hormone)                   
Hyperviscosity syndromes
Tumor lysis syndrome

Question 2

spinal cord tumors origins

Answer 2

95% of spine tumors are metastatic.
50% of all metastatic cancer found in the spine are from one of three primary sources: breast, lung or prostate.
approximately 40% of metastatic patients will have metastases to the spine

Question 3

sign sof oncological spinal cord compression

Answer 3

Pain that worsens when the patient is lying down or with percussion of vertebral bodies is characteristic of this condition.

Question 4

Epidural spinal cord compression

Answer 4

is associated with multiple different cancers including renal, prostate and most commonly, breast and lung cancers.

caused by a tumor compressing the dural sac.

Question 5

findings of a spinal metastasis (epidural)

Answer 5

The intensity of the pain is often worsened upon valsalva maneuver.
DTR’s may be increased.
Lower extremity spasticity may develop.
Babinski’s sign may be positive

a subset can also cause more LMN sx–cauda equina syndrome

Question 6

cauda equina sx

Answer 6

Severe back pain. saddle anesthesia, i.e., anesthesia or paraesthesia involving S3 to S5

Bladder and bowel dysfunction, caused by decreased tone of the urinary and anal sphincters. Detrusor weaknesses causing urinary retention.

Sciatica-type pain on one side or both sides, Weakness of the muscles of the lower legs - often paraplegia.

Achilles (ankle) reflex absent on both sides.

Question 7

imaging of the spine

Answer 7

MRI or CT scan is indicated.

Xray misses a lot-catches lytic lesions

Question 8

tx of spinal compression

Answer 8

IV steroids

Question 9

primary and metastatic brain tumor sx

Answer 9

Altered mental status
New onset of headache or headache with a pattern of increasing intensity or frequency
Visual field changes
Focal neurologic deficits such as weakness, diminished function or sensation.
Persistent nausea and vomiting.
Stroke
Seizures

Question 10

brain mets

Answer 10

Brain metastases are the most common type of tumor found in the brain.
Metastatic brain lesions are seen in approx. 10 to 30% of all cancer patients.

The most common cancers to lead to brain metastasis include: lung cancer, breast cancer, renal cell cancer, colon cancer and melanoma.

Question 11

mc brain mets

Answer 11

lung cancer, breast cancer, renal cell cancer, colon cancer and melanoma.

Question 12

Conditions for which the Gamma knife treatment is considered to be most effective include:

Answer 12

Intracranial tumors such as acoustic neuromas, pituitary adenomas, craniopharyngiomas, meningiomas, chordomas, chondrosarcomas, glial tumors and tumors which have metastasized to the brain.
Also AV malformations

Question 13

Superior vena cava syndrome (SVCS):

Answer 13

usually the result of the direct obstruction of the superior vena cava by malignancies such as compression of the vessel wall by lung cancer, particularly right upper lobe tumors or thymoma and/or mediastinal lymphadenopathy.

Question 14

The most common malignancy causing SVCS is ___?

Answer 14

bronchogenic carcinoma

Question 15

SVCS sx?

Answer 15

Shortness of breath is the most common symptom, followed by facial or arm swelling.
The following are frequent symptoms of SVCS:
Headache
Edema of face, neck, upper extremity
Venous distention in the neck and distended veins in the upper chest and arms.
Lightheadedness
Cough

Question 16

Causes of SVC

Answer 16

Malignancy (85-95% of cases):
 Small cell (65-80% of malignancy related SVC), lymphoma, breast and testicular (each approximately 10-15% of cases of SVC)

Other causes (5-15%)
Thoracic aortic aneurysm, goiter, pericardial constriction, thrombosis, aortitis, mediastinitis, (histoplasmosis/TB), CV catheter

3-8% of lung cancer and lymphoma are noted to develop SVC.

Question 17

SVCS sequelae

Answer 17

May develop cerebral edema
Altered state of consciousness
Seizures
Airway obstruction

Question 18

dx and tx of SVCS

Answer 18

MRI with or without contrast
Steroids
Diuretics
Bed rest with elevation of head
Chemotherapy with or without radiation therapy to tumor mass.
Treatment with intravenous stents is becoming increasingly common

Question 19

Beck’s triad:

Answer 19

hypotension, JVD and muffled heart sounds.

in TAMPONADE

Question 20

“water-bottle heart”

Answer 20

seen in tamponade.

cardiomegaly, most often with with clear lung fields, (pericardial sack often containing > 250 cc fluid).

Question 21

most common cause of pericardial effusion?

Answer 21

Malignancy! Any neoplasm (breast, lymphoma, leukemia, melanoma, GI, sarcoma most common)

Question 22

EKG of tamponade

Answer 22

EKG classically shows electrical aternans as well as low voltage (diminished height) of T waves.

Question 23

Febrile neutropenia ?

Answer 23

is one of the most common complications related to cancer treatment/ chemotherapy.
contributes to 50 percent of deaths associated with leukemia, lymphomas, and solid tumors.
Bacterial infections are common in patients with febrile neutropenia, but fungal sources of sepsis are increasingly prevalent.

Question 24

febrile neutropenia neutrophil count?

Answer 24

absolute neutrophil count (ANC) less than 500 per mm3

Question 25

Tx of Tamponade

Answer 25

``` Removal of fluid from pericardial space Pericardiocentesis Sclerotic therapy Surgical placement of a pleuropericardial window or pericardiectomy Low dose radiation therapy ```

Question 26

HYpercalcemia causes

Answer 26

Bone lysis and resorption – most commonly due to metastatic breast or prostate cancer. Cytokine production – most commonly due to multiple myeloma. Tumor production of Parathyroid hormone-related protein (PTH-rP).

Question 27

Effects of hypercalcemia

Answer 27

The normal range of serum calcium is 9–10.5 mg/dL. The effects of hypercalcemia: stones (renal or biliary), bones (bone pain), groans (abdominal pain, nausea and vomiting, thrones (constipation and polyuria) and psychiatric overtones (depression 30-40%, anxiety, cognitive dysfunction, coma

Question 28

Parathyroid hormone related protein

Answer 28

PTHrP can be produced by a variety of different tumor cells. PTHrP is most commonly associated with cancer of the lung, breast, and kidney. PTHrP functions in the same way as PTH by interaction with PTH receptors.

Question 29

Hypercalcemia of malignancy dx

Answer 29

bad! 1-2 mo surivival Symptoms include increased lethargy, anorexia, nausea and vomiting, confusion, obtundation and coma. IV Lasix to promote renal excretion of calcium. Bisphosphonates i.e. Alendronate that serve to blunt osteoclast production and function which serves to block bone resorption.

Question 30

Syndrome of Inappropriate Anti-diuretic Hormone (SIADH

Answer 30

Due to ectopic production of anti-diuretic hormone ADH aka vasopressin. Most commonly due to small cell carcinoma of the lung. Other lung cancers or other solid tumors can also produce ADH. The hallmark electrolyte finding of SIADH is hyponatremia.

Question 31

tx of SIADH

Answer 31

Fluid intake restriction Demeclocycline, an ADH antagonist Treat the underlying cancer. Many cancer patients exhibit mild hyponatremia, unrelated to ectopic ADH. May be due to liver or renal dysfunction. Theory of tumor induced “reset osmostat”.

Question 32

tumor lysis syndrome

Answer 32

Occurs in cancer patients with large tumor burden that is very sensitive to chemotherapy. Pre-existing renal dysfunction is a major risk factor. Circulating lysed tumor cells may result in: hyperuricemia, hyperkalemia, and hyperphosphatemia.

Question 33

tx/prevention of TLS

Answer 33

Patient may become oliguric or anuric. Can be life threatening. Risks can be minimized by: vigorous hydration before chemotherapy. Urine alkalinization before chemotherapy. Treatment with allopurinol before chemotherapy.

Question 34

Virchow's triad

Answer 34

: a decreased blood flow rate (venous stasis), increased tendency to clot (hypercoagulability), and changes to the blood vessel wall.

Question 35

presentation of a PE

Answer 35

Shortness of breath and chest pain are the common presenting symptoms. The chest pain is usually pleuritic in nature, that is, it is made worse with deep inspiration or cough. Patients are often apprehensive. Tachypnea and tachycardia are usually present. A pleural rub may be found. With a large PE the patient may become profoundly hypotensive to the point of shock and loss of consciousness