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Oncological Emergencies Flashcards

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1
Q

What can cause a superior vena cava obstruction

A

Extrinsic
- Tumour compression

Intrinsic

  • Tumour induced thrombosis - fast onset
  • Foreign body such as line - can also trigger thrombosis
  • Tumour within the vessel itself (e.g. Renal)
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2
Q

Which cancers are most associated with superior vena cava compression

A

Lung cancer is most common
Occurs in 5% of cases

Occurs in 2% of non-Hodgkin’s lymphoma

Most often manifests in patients with a malignant disease process within the thorax

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3
Q

List some benign causes of superior vena cava obstruction

A

Aneurysm
Goitre
Fibrosis - mediastinal
Infection

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4
Q

Symptoms of superior vena cava obstruction usually appear rapidly - true or false

A

True

Usually within 6 weeks

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5
Q

List symptoms of superior vena cava obstruction

A 
Swelling of face, neck, one or both arms 
Distended veins 
Shortness of breath 
Cough 
Headache and CNS symptoms 
Lethargy
Syncope 
Pemberton's sign - face goes red/congested when both arms raised
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6
Q

If only one arm is swollen in a patient with superior vena cava obstruction what does it suggest

A

That the obstruction is more distal

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7
Q

List some of the signs of superior vena cava obstruction seen on examination

A

Early stage - puffy neck, neck veins that don’t collapse
Later stage - distended veins in neck and chest, swelling in face, neck and arms
Advanced - injected conjunctiva and sedation

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8
Q

Benign tumours are more likely to cause superior vena cava obstruction than malignant ones - true or false

A

False
Malignancy is the cause in 85% of cases
Benign tumours like teratomas or goitres are only the cause in 12%

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9
Q

How do you manage superior vena cava obstruction when caused by a clot

A

Local thrombolysis with streptokinase/alteplase

Anticoagulation - LMW heparin for 5 days whilst starting warfarin

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10
Q

How do you manage extrinsic causes of superior vena cava obstruction

A

Chemotherapy - used for responsive tumours like SCLC, lymphoma etc

Radiotherapy - used for some other malignant causes/ to treat underlying cancer

SVC stent - gives rapid relief of symptoms but doesn’t treat cause

Steroids often prescribed but no evidence they help!

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11
Q

How can tumours cause spinal cord compression

A

Usually due to extravordal compression of spinal cord or cauda equina
1- can invade through the intervertebral foramina (common in retroperitoneal tumours)
2- can invade through the vertebral body (vertebra mets) into the epidural space
3- direct mets into the cord (rare)
4 - tumour induced vascular damage or compression of blood supply can lead to cord infarction
5 - can be due to paraneoplastic syndromes

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12
Q

List the most common malignant tumours to compress the spinal cord

A

Lung - commonly via the vertebral body
Breast - commonly via the vertebral body
Prostate
Multiple myeloma

Melanoma
Lymphoma - commonly via the intervertebral foramina
Renal cell

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13
Q

List the main symptoms of spinal cord compression

A

Pain - in spine

  • severe, burning pain
  • worse on coughing/straining/lying flat
  • relieved by sitting
  • radicular pain - can spread

Bowel changes - mainly constipation, some incontinence (sphincter disturbed)
Urinary retention
Loss of sexual ability

Weakness - bi or unilateral
Often new difficulty walking or climbing stairs
Sensory changes - loss of proprioception, light touch or pin prick
Numbness and weakness

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14
Q

How quickly do symptoms of spinal cord compression present

A

Usually over a longer time period

However, some neurological deficits come on rapidly (few hours) - especially in rapidly proliferating cancers

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15
Q

What imaging technique is used to diagnose spinal cord compression

A

Urgent MRI of full spine

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16
Q

When would you do an LP on someone with suspected spinal cord compression

A

If you suspect meningeal involvement

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17
Q

List some benign causes of spinal cord compression

A 
Meningioma - benign tumour 
Haematoma 
Abscess 
Slipped disc 
Osteoporotic fracture of a vertebral body 
Spondylolithesis 
Guillain-BArre 
Plexus lesions 
Infection - spinal TB
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18
Q

How do you treat malignant spinal cord compression

A

Steroids - immediate dexa dose as holding measure (even if just suspected)
followed by oral bd
Aims to reduce oedema
Give with PPI or H2 antagonist

Analgesia - pain often severe so needs aggressive treatment

Surgery - resection of isolated mets

Radiotherapy - mainstay of treatment (with or without surgery)

Chemo - used for very sensitive tumours, usually used after RT due to rapid effects

Treat the cancer too!

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19
Q

What is the definition of neutropenic sepsis

A

Fever in patient with neutropenia
Fever (>38°C) for ≥2h when neutrophil count < 0.5 x 10^9/L
Or other clinical signs of infection

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20
Q

Neutropenia is most common immediately after chemo - true or false

A

False

It is most common 10-14 days post chemotherapy (but can occur within 7 days for taxanes)

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21
Q

How does neutropenic sepsis present

A

Symptoms may be minimal - low threshold for diagnosis

OR chills, fevers, rigors, sore throat, aches

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22
Q

How do you treat neutropenic sepsis

A

Septic screen and sepsis 6 to start - emergency
Treatment with tazocin and gentamicin
Consider penicillin allergy and renal function
Can tailor antibiotics once the cultures come back

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23
Q

How does chemo cause neutropenic sepsis

A

Suppression of the bone marrow = leads to decreased white cell (inc. neutrophils) production and therefore increased infection risk

Cells in the GI tract mucosa are affected by chemo as they are rapidly dividing - this can allow some gut flora to cross into the blood (due to comprimised mucosal layer) and cause an infection

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24
Q

List sources of infection in neutropenic sepsis

A

In most cases the cause is not found - positive blood culture is the only sign
Lungs, GI tract, urinary tract are common sites
Central venous access devices such as PIC lines are another potential source

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25
How long should it take for bacterial infection to respond to antibiotics in neutropenic sepsis
2-7 days | If patient has fevers past this point then consider fungal infection or maybe viral
26
Which surgical technique is used for malignant cord compression
Anterior laminectomy – allows better removal of tumour and re-construction of vertebral body
27
When is radiotherapy used alone for treatment of cord compression
Majority of cases - In patients unfit for surgery - Those with multi-level disease - With disease elsewhere that may or may not be controlled - In those with some residual neurological function
28
How is radiotherapy given for malignant cord compression
20Gy in 5 # over 1 week May use higher dose if post op or if only site of metastasis Direct field, single posterior Prescribed to the depth of the cord
29
Radiotherapy for cord compression has an immediate benefit - true or false
False No immediate effect Some neurological improvement over following weeks; improved pain control; or halting of further deterioration
30
What is radicular pain
Band like burning pain sometimes with hypersensitivity | Seen in cord compression
31
Which patients get surgery for malignant cord compression
If fit for surgery If only one vertebral level/region involved No widespread mets Radio-resistant primary e.g. renal, sarcoma. Previous RT to site. Unknown primary - take tissue sample
32
Chemotherapy is used to treat malignant cord compression in which cases
In theory can be used for the very sensitive tumours: - Lymphoma. - Teratoma. - SCLC (maybe) Not usually used alone
33
What are the initial investigations for SVC obstruction
CXR – is there a mass? Venogram – is there a clot? CT Chest
34
What can cause malignant hypercalcaemia
Humoural - often mediated by PTH related protein (paraneoplastic seen in lung cancer) Local bone destruction/invasion - especially in lung, breast and myeloma Tumour production of vitamin D analogues (calcitriol) -especially lymphomas.
35
How do cancer patients with hypercalcaemia present
``` Nauseated, anorexic Weight loss Thirsty - dehydration Pass lots urine (polydypsia and polyuria). Constipated Abdominal pain Depression Confused. Poor concentration, drowsy, lethargy Bone pain ```
36
How do you investigate hypercalcaemia
Calcium level - symptoms usually start over 2.6 Albumin to correct calcium Urea and electrolytes – looking for dehydration. Phosphate - low in hyperparathyroidism If no known malignancy – myeloma screen
37
How do you treat malignant hypercalcaemia
Rehydration first - need several litres of normal saline (careful if risk of heart failure) Bisphosphonates - usually zoledronic acid Systemic management of malignancy
38
Why must you make sure a hypercalcaemic patient is hydrated before treating with bisphosphonates
Can cause renal failure so must make sure properly rehydrated first.
39
What is pericardial tamponade
Pericardial effusion develops and compresses ventricle | This reduces cardiac output and collapses the right atrium increasing venous back pressure.
40
What can cause a pericardial effusion
Malignant. Trauma – injury, post-op, iatrogenic e.g. pacing line. Infection – TB, viral. Post MI. Connective tissue disease e.g. SLE, Rheumatoid. Drugs e.g. hydralazine, isoniazid. Uraemia.
41
How does malignant pericardial tamponade present
``` Primarily shortness of breath. Cough Fatigue. Palpitations. Symptoms of pericarditis (chest pain improved by sitting forward). Symptoms of advanced cancer. ``` Jugular venous distension. Pulsus paradoxus -venous return drops when intra-thoracic pressure raised (breathing in) Soft heart sounds or pericardial rub. Poor cardiac output – tachycardia with low BP and poor peripheral perfusion
42
How do you investigate a malignant pericardial tamponade
CXR - enlargement of cardiac silhouette (globular) ECG - reduced complex size (low QRS voltage) Echocardiogram – rim of pericardial fluid. Cytology of pericardial fluid
43
How do you treat a malignant pericardial tamponade
Pericardiocentesis – drain pericardium. Pericardial window – operation to allow pericardial fluid to drain into pleural cavity. Systemic management of malignancy.
44
Why are PEs common in malignancy
Malignancy is a pro-thrombotic state
45
How does PE present
``` Acute deterioration in SOB Tachypnoea Tachycardia Cough Haemoptysis Low pa CO2 - blowing it off Pleuritic chest pain Unilaterla leg swelling ```
46
How do you manage a PE
Support patient – O2, IV fluids, resuscitation if necessary Anticoagulation For most cancer patients this is LMWH for 6 months Also treatment dose fragmin Consider Rivoroxaban if recurrent DVTs / PE
47
List some metabolic oncological emergencies
Hypercalcaemia - most common Tumour lysis syndrome SIADH
48
List some neurological oncological emergencies
Spinal cord compression | Brain mets leading to raised ICP
49
List some cardiovascular oncological emergencies
Malignant pericardial effusion | SVC obstruction
50
List some haematological oncological emergencies
Hyperviscosity due to dysproteinaemia Hyperleukocytosis DIC
51
List some infectious oncological emergencies
Neutropenic fever and sepsis
52
What is a paraneoplastic syndrome
A consequence of cancer that is not due to the local presence of cancer cells Mediated by hormones or cytokines excreted by tumour cells or by an immune response against the tumour
53
Which cancers most commonly cause a paraneiplastic syndrome
Lung Breast Ovaries Lymphoma
54
Which cancers most commonly cause malignant hypercalcaemia
``` Myeloma Squamous Cell Lung Cancer Renal Cancer Breast Cancer Prostate Cancer (NB: Very rarely) Squamous Cell Head and Neck Cancer Leukemia ```
55
How can hypercalcaemia affect an ECG
``` Bradycardia Short QT interval Prolonged PR interval Wide T wave Atrial or ventricular arrythmias ```
56
Which cancer is associated with SIADH
Small cell lung cancer
57
How do you treat SIADH
Treatment of cancer Fluid restriction (1 – 1.5 L daily) Demeclocycline
58
How can brain mets present
``` New onset headaches Cognitive, personality, and behavioral changes Nausea and vomiting Memory loss Increased intracranial pressure Paraesthesias Vision disorder Bells palsy Ataxia Seizures ```
59
Which cancers often cause a malignant pericardial effusion
``` Lung cancer Breast cancer Lymphoma Leukemia Melanoma ```
60
List common pathogens which cause neutropenic sepsis
``` Escherichia coli Pseudomonas aeruginosa Acinetobacter baumannii Klebsiella pneumoniae Coagulase positive/negative staphylococci ```
61
What is the definition of an oncological emergency
Broad term | Typically a pathology that will be irreversible and harmful if not treated within minutes- days
62
When does tumour lysis occur
Any time after the introduction of anti-cancer therapy
63
What causes tumour lysis syndrome
Chemo or other treatment causes rapid breakdown of tumours/cancer cells They release their intracellular matierials including K+ etc. This disturbs the electrolyte balance and upsets the kidneys
64
Tumour lysis syndrome is associated with which cancers
Lymphomas Germ cell tumours Those that respond well to treatment
65
List risk factors for tumour lysis syndrome
Specific tumour types - AML, ALL, Burkitt's lymphoma are all high risk Nephrotoxic drugs Dehydration History of renal disease Those that are high risk can be given prohlyaxis
66
What prophylaxis is available for tumour lysis syndrome
Low risk - hydration (3L a day) +/- allopurinol Intermediate risk - hydration (3L a day) and allopurinol High risk - Hydration for up to 7 days post-chemo and rasburicase IV
67
How does tumour lysis syndrome present
``` High K+, phosphate, urate Low calcium Oliguria AKI Nausea and vomiting Cardiac arrhythmia Seizure Confusion ```
68
How do you manage tumour lysis syndrome
Urgent treatment of any arrhythmia and hyperkaelamia Fluid resuscitation Close monitoring of input/output Correct electrolyte abnormalities
69
How do you differentiate between hyperparathyroidism and hypercalcaemia of malignancy
Check PTH level Will be high in hyperparathyroidism and low in cancer Also check calcium and phosphate
70
How does raised ICP present
``` Headache - chronic/daily - Worse on coughing, leaning forward etc Often associated with nauses Weakness, sensory changes Personality change Seizures ```
71
What can cause raised ICP in cancer patients
Brain mets - lung, breast, prostate etc. | Bleeds from the tumour - may have been asymptomatic on its own
72
How do you treat intracranial mets
Steroids started immediately - reduces oedema and symptoms Surgery - role in limited disease With large lesions,, debulking can prolong survival Radiotherapy
73
How do you innvestigate SVCO
CXR - may see widened mediastinum or the mass lesion | CT chest - shows location, severity and associated pathology (e.g. mass or thrombus)
74
Which organisms are the main cause of neutropenic sepsis
Gram negatives
75
What can trigger opiate toxicity
Over medication Renal failure Frailty and intercurrent illness
76
How does opiate toxicity present
Pinpoint pupils SLow, shallow breathing Falling asleep or loss of conscioussness Blue fingers etc
77
How can you severe opiate toxicity
Administer naloxone - if in respiratory depression If mild toxicity just withdraw opiate and monitor
78
Which cancers can lead to malignant bowel obstruction
Disseminated intraabdominal cancers e.g. ovarian, peritoneal Others include, colon, gastric, breast with mets
79
How does malignant bowel obstruction present
``` Abdominal pain Distension No bowel sounds present No bowel movement - absolute constipation Vomiting Bloating ```
80
How do you diagnose malignant bowel obstruction
AXR - dilated bowel loops and air/fluid level | CT abdo/pelvis to assess the cause
81
How do you manage malignant bowel obstruction
Usually palliative at this point Make them NBM Give IV fluids and electrolytes Decompression and bowel rest - NG tube Analgesia Can give subcut steroids to reduce oedema Prokinetcics to stimulate peristalsis - e.g. metoclopramide May do debulking, resection etc to relieve symptoms

Oncology (7 decks)

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