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Palliative Care + Oncology > Metastatic Disease + Emergencies > Flashcards

Metastatic Disease + Emergencies Flashcards

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1
Q

What is most common malignancy to cause spinal cord compression

What are common cancers that spread to bone in adults and in children

A 
Breast
Lung
Prostate
Myeloma
Lymphoma 
Less commonly renal, thyroid, bladder, colon, melanoma

Children

  • Ewings sarcoma
  • Medullablastoma
  • Neuroblastoma
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2
Q

Where in spine is affected / how does malignancy cause spinal cord compression

A

Usually vertebral body met causing vertebra collapse = common
Extension of extra-dural tumour into vertebral column = rare
20-30% will be at multiple level

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3
Q

What are features

A

Back pain = most common presentation

  • Usually at level of compression
  • Cervical / thoracic / night pain = worrying
  • Worse coughing / lying flat
  • Radiating round
Later signs 
LL weakness and arms if cervical 
Sensory loss and numbness
Peri-anal numbness
Autonomic - bladder/ bowel incontiennce - ALWAYS ASK 
Upgoing plantar

Remember
Neuro signs depending on level e.g. if posterior will cause dorsal column signs which is rare and loss of proprioception (off balance / +Ve Romberg)
At level of compression = LMN flaccid + radicular pain
Below lesion = UMN spastic and sensory loss
Spinal cord ends at L1/2 so if below this = LMN signs

If complete compression
Loss of all sensory
Bilateral UMN weakness
Bladder and bowel

If anterior
Partial loss of pain and temp
Bilateral UMN
Bladder and bowel

Can get cauda equine if below L1/2 as where spinal cord ends

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4
Q

What is back pain typically

A 
Thoracic = 70% 
Radicular nerve pain 
Night pain 
Usually bilateral
Sharp / shooting
Worse with cough / sneezing / movement
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5
Q

Where is most likely lesion

A

Extradural vertebral body

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6
Q

If above L1

A

LMN at level and UMN signs below as nothing can get through

Sensory loss below lesions

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7
Q

If below L1

A

LMN signs as in cauda equine and no spinal cord

Perianal numbness

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8
Q

What are reflexes

A

Increase below lesion and absent at level

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9
Q

When do you consider

A

Any patient with Hx cancer and back pain
Or red flags
Do whole spine MRI

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10
Q

How do you manage cord compression

A

Best red - flat until spine stability assess with MRI
High dose oral dexamethasone + PPI cover
Pain relief
Urgent MRI whole spine 24 hours
Urgent spinal surgical referral / oncological / RT assessment
Consider proplhyatic VTE if reduced mobility

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11
Q

What is role of spinal surgery

A

Decompression and stabilisation with laminectomy

= gold standard

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12
Q

When is spinal surgery possible

A 
Fit
Acute onset paraplegia 
Low metastatic disease
Isolated compression
Good sensory and motor prior
No Hx of cancer
Fracture dislocation 
Radioresistant tumour

Often not possible due to frailty, bone destruction, multiple sites

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13
Q

What else can be given

A

Chemo if highly sensitive e.g. germ cell or lymphoma

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14
Q

What is supportive Rx of cord comrpession

A 
Lie flat
Catheter if retention
Monitor bowel
Physio
BM monitoring 
DVT prophylaxis
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15
Q

How do you investigate

A

MRI whole spine = gold standard as 20-30% will have compression at multiple levels
Isotope bone
FBC, U+E, LFT, Ca, PSA, LDH
Myeloma screen

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16
Q

What is most common cause of SVC obstruction / SMS

A

Tumour pressing on vena cava or structures in mediastinum = 80%
Lung cancer = most common
- SCLC
- NSCLC
Non-Hodgkin’s Lymphoma
Could be the first presentation of cancer

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17
Q

What are other causes

A 
Rarer malignant 
Neuroblastoma in children 
Kapsoi sarcoma 
Metastatic breast
Germ cell 
Non-malignant 
Aortic aneurysm 
Mediastinal fibrosis - TB / post RT 
Retrosternal goitre
SVC thrombosis - polycythaemia, catheter, shunt,
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18
Q

What are features

A 
Often develops over many weeks 
Dyspneoa = most common
Orthopnoea 
Tachypnoea
Swelling of face, neck, arm - worse morning and lying flat
Headache - worse in morn due to cerebral oedema
- Papilloedema = very late sign 
Pemperton sign 
- Distended neck veins / SOB / facial swelling = worsen when raise arm 
Stridor if life threatening airway compression 
Cough
Chest pain
Facial, neck and upper thoracic plethora
Very ill / anxious 
Engorged neck and chest veins - pulseless 
Conjuncival and perioedema oedema
Visual disturbance / papilloedema 
Dysphagia due to mediastinal compression
Visual disturbance 
Peripheral cyanosis
Pulseless jugular venous distension
Increased JVP 
May have reduced GCS

Symptoms may improve as collateral veins develop

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19
Q

How do you investigate

A

Dx = usually clinical
If not life threatening then try to obtain diagnosis
Up to 60% do not have Dx of malignancy

CXR
- Mass
- Mediastinal LN
- Other signs of lung cancer e.g. pleural effusion
CT chest with thorax
- Define anatomy of obstruction and level
- Can do opportunistic biopsy
Superior vena cava venogram
Bronchoscopy if lung suspected (most likely)

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20
Q

How do you Rx

A 
Sit patient up 
O2 sats and ABG 
Give O2 if needed 
High dose dexamethasone + PPI 
If life threatening airway compromise e.g. stridor insert stent under radiological guidance

Rx cause with chemo / RT
Balloon venoplasty or stunting for recurrent benign
Thrombolysis and anti-coagulation if due to thrombosis

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21
Q

What is most common life threatening disorder associated with malignancy
How do you work out

A

Hyperclacaemia
Bad prognostic indicator

Free Ca = measures Ca + (40-albumin x0.02) OR
For every 10g albumin is <40 add 0.2 to calcium

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22
Q

What causes

A

Bone mets increasing osteolytic activity

  • Breast
  • MM
  • Prostate
  • Also lymphoma / SCC

Or production of PTH / TNF / Il by tumour

  • SCC of the lung
  • T cell lymhpoma

Or tumour specific
- e.g. in myeloma reduced Ca excretion due to AKI by Bence Jones

Other causes of high calcium much less common and are only considered once malignancy / PTH ruled out

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23
Q

What are the features of hypercalcaemia

A

Dehydration - reduced sensitivity to ADH
Polyuria
Renal stones in chronic
AKI in acute

Bone pain
Osteoporosis in chronic
Weakness

Abdo pain - renal / pancreatitis 
Constipation 
N+V 
Anorexia 
Weight loss
Peptic ulcer due to increased gastric secretion 
Fatigue / lethargy 
Depression - chronic
Psychosis 
Altered mental status / confusion
Cognitive impairment 
Seizure
Coma

In severe>3.5
HTN due to vasoconstriction - check Ca in HTN
Prolonged QT
Cardiac arrhythmia

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24
Q

What can hypercalcaemia be mistaken for

A

Terminal feature of cancer

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25
How do you manage
Monitor Ca, phosphate and check PTH Treat malignancy + liase with oncology Supportive - Avoid drugs that increase - thiazide / vit D - Avoid sedatives as confuse patient - Remove Ca from any parenteral - Encouraging mobilisation IV access Rehydration with 4-6l of 0.9% saline = most important to improve flow through kidney - Monitor U+E closely as Mg and K may fall - may need to add IV biphosphonate if renal function normal but risk of hypoCa if on denosumab Loop diuretic to increase excretion (only if overloaded as high complication) Prophylactic VTE
26
What is rare management What do you do if severe >3.5, coma, arrhythmia
Calcitnonin - IM or SC - Increases excretion and bone resorption - Very rarely used, works better for other causes Octeroide - Somatostatin analogue which reduced PTH - Very rare Steroids Consider ITU with cardiac monitoring Consider haemofiltration if severe renal failure and can't use rehydration and biphosphonates
27
What does chemo result in
Neutropenia | Often day 7-14 days but can be 6 weeks
28
What causes increase risk
``` <1 x10 ^9 but extreme = -0.5 Long duration Catheter / central line Mucosal inflammation High dose chemo Stem cell transplant ```
29
What do you advise patients to do
Monitor for signs of infection Seek medical help if temp >38.5 or <36 Two readings >38
30
What is febrile neutropenia and how do they present
``` Patient febrile - may have low temp Neutrophils <1 No harm-dynamic compromise Rigors Drowsy ```
31
What is neutropenic sepsis
Evidence of sepsis - hypo / tachy / prolonged CRT / reduced UO Metabolic acidosis Neutrophil <1 With or without fever
32
What are common causes
``` 85% from gut / biliary / urine tract Gram -ve E.coli Klebsiella S.pneumonia Enterococci Staph Fungal in prolonged haem - candida / aspergillus ```
33
How do you take Hx and exam
``` Systematic - chest / GI / UTI / CNS / headache / skin / ENT Recent intervention Vital signs Full exam Try to determine source of infection ```
34
How do you investigate
``` FBC - risk of neutropenia / thrombocytopenia from chemo U+E - need for gentamicin LFT - sepsis / chemo affecting CRP - for response ABG - Lactate / acidosis Bone bloods if risk of hypercalcaemia Coag screen if DIC suspected due to sepsis Blood culture MSSU ECG ``` ``` Depending on suspected infection CXR if resp Stool culture if diarrhoea Throat swab Sputum culture Skin swab LP CT if fungal suspected ```
35
How do you manage
``` ABCDE Keep patient in a side room LIase with oncology - may need dose adjustment - may consider G-CSF As emergency - SEPSIS 6 - Take cultures, measure lactate and UO - IV access - Fluid resus if dehydrated / tachycardia / low BP - O2 if indicated Broad spec Ax as per guidelines Cathterise and monitor UO and vital signs Inotropes / platelet transfusion etc SENIOR HELP May need ICU ```
36
What Ax in stage 1
``` As guidelines Piperacillin Tazobactum Gentamicin Consider vanc / metronidazole if penicillin allergy ```
37
When to you switch to stage 2
If febrile after 48 hours or deteriorating
38
What is stage 2
Meropenum unless culture suggest divergent
39
When do you change to oral
3 days IV Ax and improving | Oral ciprofloaxicin
40
What can you consider
G-CSF to boost neutrophil
41
What else do you give
Paracetamol Anti-emetic Catheter if hypotensive
42
How do you monitor response
Vital signs Urine output Daily FBC, U+E, CRP
43
How do you review treatment
``` Fluid input and output Vital signs Clinical exam U+E Temp, NP, pulse CRP + neutrphil ```
44
What may you need to do
Change chemo regimen
45
Who is at great risk of falling ill suddenly
Leukaemia patients esp AML
46
What are they at risk of
Infection Bleeding Hyperviscosity
47
What should you do
FBC, U+E, LFT, Ca, glucose, clotting | Consider CT if suspect CNS bleed
48
Hyperviscosity
If WCC. >100 thrombi may form in heart, brain and lung
49
When is G-CSF used
``` High risk of neutopenia Elderly Specific malignancy - NHL / ALL Previous neutropenia Combination chemo and RT ```
50
What is the issue with with cancer patients + fever
No neutrophils so typical symptoms of infection may not be present Treat any acutely unwell child for infection until proven otherwise
51
What are early symptoms of raised ICP
Early morning headache Vomiting - worse in morning Tense fontanelle Increased OFC
52
What are late signs of raised ICP
``` Constant headache Papilloedema Diplopia (VI palsy) Loss of upgaze - Parinaud Neck stiffness Status epilepticus Reduced GCS Cushings - Low HR - High BP - Irregular breathing / low RR ```
53
How do you investigate
CT = 1st line MRI Only do if safe
54
What do you do for raised ICP to palliate
Dexamethasone to reduce oedema and increase CSF flo
55
What are other options
Neurosurgery - Ventriculostomy - EVD - VP shunt
56
What is tumour lysis
Cancer cells grow rapidly so after chemo / dexamethasone get rapid death and release of intracellular contents into plasma Increased K, urate, phosphate Low calcium AKI - suspect in AKI and chemo regime Risk of arrhythmia
57
When does it occur
Shortly after Dx if fast growing tumour or after Rx e.g. chemo Can occur after RT / dexamethasone but more rare Common in leukaemia and lymphoma and germ cell
58
What does it result in
``` Hyperkalaemia Hyper-phosphate Hyper-Mg Hyper-urate High LDH / AFP Hypo- calcium AKI due to increased CK / deposition of CaPO4 in tubules ```
59
What is required for Dx
``` Lab values +1 of Increased CK Seizure Arrythmia Sudden death As well as biochemical abnormality ```
60
How do you prevent and Rx
Prevent IV fluid IV allopurinol / urate aoxidase to decrease uric before chemo and a few days after Monitor electrolytes in fast growing tumour ECG FLUIDS = mainstay Diuresis NEVER give potassium Can give Rasburicase to decrease uric acid (enzyme that binds) Treat hyperkalaemia Renal replacement therapy
61
How do you treat hyperkalaemia
Ca Resonium in long term Salbutamol Insulin dextrose RRT
62
If someone presents with features of hypercaclaemia how do you investigate
``` Hx - drugs + FH Bloods - Bone profile - Ca, phosphate, PTH - U+E - Myeloma - ALP - Amylase for pancreatitis - Glucose for polyuria etc. ECG Imaging for cause ```
63
How does hypercalcaemia cause AKI
Renal tubular damage | Leads to hypokalaemia, dehydration, increased Na excretion which causes renal vasoconstriction and AKI
64
Where are brain mets most common from
``` Lung = 50% Breast = 15% Melanoma Unknown primary Others = renal / colon ```
65
What is most common type of brain tumour
Brain mets
66
How can it present
Seizure Focal neuro - dysphasia, UMN weakness, visual field, ataxia Confusion Personality chane
67
How do you investigate
MRI brain with contrast
68
What will MRI show
``` Multiple discrete well demarcated lesion Hypointense on T1 Hyperintense on T2 Marked gadolinium enhancement Considerable vaosgenic oedema ```
69
How do you manage
High dose dexamethasone with PPI cover Symptom control e.g. seizure Liase with oncology to Dx primary
70
What should be considered for Rx
Whole brain RT Consider chemo if chemo-sensitive tumour - SCLC / breast Consider neurosurgery - biopsy useful if unknown primary

Palliative Care + Oncology (6 decks)

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