Oncological Emergencies

Question 1

What are the 4 most common oncological emergencies?

Answer 1

1. neutropenic sepsis
2. hypercalcaemia
3. metastatic spinal cord compression
4. superior vena cava obstruction (SCVO)

Question 2

What is the definition of neutropenic sepsis?

Answer 2

patients having cancer treatment whose neutrophil count is less than 1 x 10^9 per litre and has either:

• a temperature higher than 38 degrees
• other signs and symptoms consistent with clinically significant sepsis

Question 3

What is the difference between septicaemia and sepsis?

Answer 3

Septicaemia:
this is the presence of a pathogen in the bloodstream, which can lead to sepsis

Sepsis:
systemic inflammatory response syndrome (SIRS) triggered by a primary localised infection

SIRS - clinical signs that occur in response to systemic inflammation

Question 4

What needs to be present for SIRS or sepsis to be diagnosed?

Answer 4

2 or more of:
1. temperature < 36o or > 38o
2. tachycardia where HR > 90bpm
3. respiratory rate > 20 per min OR PaCO2 < 4.3kPa
4. white cell count > 12 x 10^9or < 4 x 10^9

it is sepsis when there are 2 or more of these signs but they RESULT FROM INFECTION

Question 5

What is meant by severe sepsis?

Answer 5

sepsis with signs of organ hypo-perfusion

• hypoxaemia
• oliguria
• lactic acidosis
• acute alteration in mental state

Question 6

What is meant by septic shock?

Answer 6

severe sepsis with hypotension

OR the requirement for vasoactive drugs despite adequate fluid resuscitation

hypotension is systolic BP < 90 or a decrease > 40 from baseline

Question 7

Why does neutropenic sepsis occur in cancer patients?

Answer 7

• chemotherapy is given to target cancer cells, but it will also target healthy cells
• damage to the bone marrow from chemotherapy results in a drop in neutrophil count

Question 8

Which patients are at a greater risk of neutropenic sepsis?

Answer 8

it is common with intense chemotherapy regimes:
1. haematological malignancies
2. breast cancer
3. germ cell tumours

Question 9

How does someone with neutropenic sepsis typically present?

Why is it important to identify this quickly?

Answer 9

• patients will decompensate quickly
• typically, a young patient receiving chemo will present with a temperature but other parameters are normal
• they do not have the neutrophil count to mount the infection so rapidly decompensate

important to identify early as it has a 5% mortality rate

Question 10

When does neutropenic sepsis typically occur?

Answer 10

it typically occurs between 7 and 14 days post-chemotherapy

it is VITAL to ask patients when they had chemotherapy

Question 11

What is the typical presentation of someone with neutropenic sepsis?

Answer 11

• they present with being non-specifically unwell
• they may be tachycardic or hypotensive
• they may have a temperature
• they may have localising signs of infection

a temperature can depend on whether they have had paracetamol

Question 12

Why is it important to perform a head-to-toe examination of anyone presenting with non-specific signs of illness?

Answer 12

to look for localising signs of infection that could be affecting one part of the body

Question 13

What are common signs of a CNS infection?

Answer 13

• headache
• visual disturbances
• neck stiffness

Question 14

What are common signs of a respiratory tract infection?

Answer 14

• cough
• shortness of breath
• chest discomfort

Question 15

Why is it important to inspect the oral cavity in chemotherapy patients?

Answer 15

• some chemotherapy regimes can result in mucositis (sore mouth)
• if the mouth becomes ulcerated, this is a potential route for infection

Question 16

What question is particularly important to ask chemotherapy patients when it comes to a potential source of infection?

Answer 16

do they have a central venous catheter in place?

the area of the line must be assessed for signs of redness and discharge

this could be a PICC line in-situ, Hickman line, central line or portacath

Question 17

What symptoms may suggest a GI tract infection?

Answer 17

• abdominal pain
• diarrhoea

Question 18

Which patients are more likely to have stents in place and what symptoms might infection produce here?

Answer 18

Biliary stents (liver malignancy):
infection may produce RUQ pain or rigors

Ureteric stents:
infection may produce flank pain, dysuria, haematuria + frequency

Question 19

What are the 4 most important areas to cover in a neutropenic sepsis history?

Answer 19

• chemotherapy drugs and TIMING + any access / lines
• previous episodes
• presence of localising symptoms
• any allergies

Question 20

What is involved in the physical examination for suspected neutropenic sepsis?

Answer 20

• temperature + circulatory status (ABC)
• NEWS score
• full systematic examination (cardiovascular, respiratory + abdominal)
• focus on potential sites of infection (lines / catheters / perianal area)
• review previous + recent microbiology for resistant organisms

Question 21

What is meant by the A-E approach for a potential septic patient?

Answer 21

A - airway
B - breathing
C - circulation
D - disability
E - exposure

if one or more red flag is present during any stage, the patient should be treated for sepsis

Question 22

What red flags may be identified during the breathing stage of assessment?

Answer 22

• RR >/= 25 breaths per minute
• O2 required to keep SpO2 > 92%

Question 23

What red flags may be identified during the circulation stage of assessment?

Answer 23

• tachycardia > 130 bpm
• systolic BP < 90 or a drop of 40 from normal
• lactate >/= 2 mmol/l

Question 24

What red flags may be identified during the disability stage of assessment?

Answer 24

• acute confusional state
• responds only to voice or pain or unresponsive

V, P and U in the AVPU scale

Question 25

What red flags may be identified during the exposure assessment?

Answer 25

* non-blanching rash * mottled, ashen or cyanotic apperance * **urine output < 0.5 ml/kg/hour**

Question 26

What should be done if any red flag symptoms are present?

Answer 26

* B - blood cultures * U - measure urine output * F - IV fluids * A - broad spectrum antibiotics * L - measure lactate * O - high-flow oxygen | SEPSIS 6 performed within 1 hour (BUFALO)

Question 27

What is an alternative way of remembering the sepsis 6?

Answer 27

* take blood cultures, give IV antibiotics * take urine output, give IV fluids * take lactate, give high-flow oxygen | the **take 3 / give 3** method

Question 28

What blood samples are useful in a patient with signs of neutropenic sepsis?

Answer 28

* **FBC** - to look at the *neutrophil count* and for signs of *anaemia* * **inflammatory markers** - CRP and lactate * LFTs to assess liver function * assessment of hepatic function to determine if patient is *dehydrated*

Question 29

What blood cultures are taken?

Answer 29

* **x2 paired blood cultures** are taken (aerobes & anaerobes) * if a **line is present** then 1 is taken from this and 1 from the periphery * if the patient does not have a line, then 2 peripheral samples are used

Question 30

What additional investigations may be performed depending on presentation?

Answer 30

* **swabs** are taken from any area that shows a **discharge** * sputum culture * urine analysis and culture * stool analysis and culture (if diarrhoea) * CXR if respiratory signs / symptoms

Question 31

What are the NICE guidelines for treatment of suspected sepsis?

Answer 31

**broad spectrum IV antibiotics** must be given **within 1 hour** of all suspected cases ## Footnote **allergy status** must be assessed and **cannula in-situ** before abx started within 1 hour of initial presentation

Question 32

Following IV abx, what other management steps are in place?

Answer 32

* give **IV fluids** if patient is hypotensive or tachycardic * **strict fluid balance** with monitoring of input and output * escalate to oncology SPR

Question 33

What is the difference in treatment for patients with suspected sepsis that are having palliative chemotherapy?

Answer 33

* often they will not want to spend a lot of time in hospital * abx are given until the patient is proven not to be neutropenic * if the patient is neutropenic, the **duration of antibiotics** depends on their **MASCC score**

Question 34

What is the MASCC score?

Answer 34

* assesses the **risk of complications** during a febrile neutropenic episode * the score works out when **abx can be de-escalated** and a palliative care patient can be sent home on **oral abx** | multinational association for supportive care in cancer patients

Question 35

What parameters does the MASCC score consider?

Answer 35

* infection burden * co-morbidities * age > 60 * blood pressure * presence of COPD * tumour type - haematological / solid * fluid status * in-patient / out-patient ## Footnote the lower the score, the lower the risk of a poor outcome

Question 36

What is G-CSF?

Answer 36

they are haematopoitic growth factors that **promote stem cell proliferation** and **shorten the duration of neutropenia** | G-CSF agents are **Filgrastim** or **Lenograstim** ## Footnote this does NOT mean that the patient will not be neutropenic it **shortens the duration** of the neutropenia, meaning it is **less likely to contract an infection** during this time

Question 37

When is G-CSF given to a patient?

Answer 37

it is **NOT** routinely prescribed * it is given to patients on chemotherapy regimes with **high risk of neutropenia** * or if they have had a **previous episode** requiring hospitalisation * or multiple **co-morbidities** / severe sepsis

Question 38

Describe normal calcium homestasis when there is a high blood calcium level

Answer 38

* the thyroid gland releases **calcitonin** when blood calcium is too high * calcitonin promotes the osteoblasts to ***deposit calcium within the bone*** * calcitonin ***reduces absorption*** of calcium in the ***kidneys*** * this results in a decline in blood calcium levels

Question 39

Describe calcium homeostasis when blood calcium is too low

Answer 39

* the parathyroid gland releases **PTH** * PTH promotes osteoclasts to release calcium from the bones * PTH stimulates the kidneys to **absorb calcium** from the urine * the kidneys convert 25-hydroxy Vitamin D to **dihydroxy Vitamin D** - this stimulates the **bowels to absorb calcium**

Question 40

In general, why does hypercalcaemia occur in malignancy?

Answer 40

due to factors produced by tumours which **increase bone resorption** and potentially **increase renal tubular calcium reabsorption** ## Footnote these are **transforming growth factor alpha** + **parathyroid hormone (PTH) related peptides**

Question 41

What is transforming growth factor alpha and how does it work?

Answer 41

* it is a polypeptide stimulator of **cell growth and replication** that is produced by **many cancer cells** * it is a powerful stimulator of **bone resorption**

Question 42

How do PTH-related peptides work?

Answer 42

* it is a tumour-associated protein that **mimics PTH** * it stimulates **bone resorption** and increases plasma calcium

Question 43

What malignancies are commonly associated with hypercalcaemia?

Answer 43

* it is common in cancers that have **bone mets** and in tumours that **secrete PTH-RPs** ## Footnote this includes: * lung cancer (NSCLC) * prostate cancer * breast cancer * renal cell carcinoma (often secretes PTH-RPs) * myeloma + lymphoma

Question 44

What are the general symptoms of hypercalcaemia?

Answer 44

* dehydration * muscle weakness * fatigue * bone pain

Question 45

What are the CNS symptoms of hypercalcaemia?

Answer 45

* confusion * seizures * proximal neuropathy * hyporeflexia * coma

Question 46

What are the GI tract symptoms of hypercalcaemia?

Answer 46

* weight loss * N & V * abdominal pain * constipation * ileus * dyspepsia * pancreatitis

Question 47

What are the cardiac symptoms of hypercalcaemia?

Answer 47

* bradycardia * arrhythmia * cardiac arrest

Question 48

What is the most common ECG finding in hypercalcaemia?

Answer 48

bradycardia with a **short QT interval** ## Footnote **wide T waves** + **prolonged PR interval** can also be seen

Question 49

What is the management for mild hypercalcaemia?

Answer 49

when Ca is **< 3.0 mm/l** then management involves **rehydration with IV fluids**

Question 50

What is the treatment for more severe hypercalcaemia?

Answer 50

when Ca **> 3.0mm/l** OR patient is **symptomatic**: * at least **3L of sodium chloride** is given BEFORE * **bisphosphonate** treatment * ***thiazide diuretics MUST be STOPPED*** and furosemide is considered

Question 51

What bisphosphonates may be given in hypercalcaemia? What else must be done?

Answer 51

* usually **Zometa 4mg IV** is given * **pamidronate 60 - 90mg** is considered if there is a *decline in renal function* * patient ***MUST be rehydrated*** with 3L sodium chloride prior to bisphosponate therapy | **renal function** MUST be monitored when patient is given bisphosphonat

Question 52

When might calcitonin be considered in hypercalcaemia?

Answer 52

* if calcium levels are VERY high, patient is considerably symptomatic and there are **concerns about tachyphylaxis** | a decrease in response to a drug after it is initially given ## Footnote would still try to initially manage with IV fluids and bisphosphonates

Question 53

What are the 10 red flag symptoms when someone presents with back pain?

Answer 53

1. age < 20 or > 50 2. trauma 3. weight loss 4. pyrexia / night sweats 5. leg weakness 6. sensory loss of LL 7. thoracic back pain 8. constant pain at night and at rest that doesn't respond to analgesia 9. urinary retention / faecal incontinence 10. saddle anaesthesia / loss of anal tone

Question 54

What is shown in this image?

Answer 54

metastatic spinal cord compression (MSCC) at T10 ## Footnote the vertebra is affected by the tumour and the CSF (white layer surrounding SC) is not evident at this level

Question 55

How common is MSCC? Which cancers does it usually occur in?

Answer 55

* it is the most common neurological complication of cancer * occurs in 5% of all cancers * most common in **breast, prostate, lung** and **haematological**

Question 56

What are the different mechanisms by which MSCC can occur?

Answer 56

* **soft tissue** can infiltrate the spinal canal * cancer can compress the vertebrae and lead to **bony prominences** compressing the spinal canal * via **drop mets** - these are metastases that enter the CSF space

Question 57

How does MSCC usually present?

Answer 57

* if the lesion is **above L1** - patient presents with **UMN symptoms** * if the lesion is **below L1** - patient presents with **cauda equina** * 60% of patients will have **pain**

Question 58

What are the key features of an UMN lesion?

Answer 58

* no muscle wasting (except for disuse atrophy) * "clasp-knife spasticity" / hypertonia * clonus present * hyperreflexia * positive Babinski sign

Question 59

What are the key features of a LMN lesion?

Answer 59

* flaccid paralysis * decreased reflexes * presence of fasciculations (twitching) * decreased muscle tone * muscle atrophy * negative Babinksi sign

Question 60

What are the typical symptoms of cauda equina syndrome?

Answer 60

* severe back pain * bilateral sciatica * perianal "saddle" anaesthesia * bowel / bladder dysfunction (most commonly urinary retention) * sexual dysfunction

Question 61

If someone presents with any of the red flag back pain symptoms what must be immediately done?

Answer 61

an **urgent MRI** of the whole spine

Question 62

What is the treatment pathway for suspected MSCC?

Answer 62

* **16mg dexamethosone** with PPI cover * **urgent MRI** of whole spine within 24 hours ## Footnote dexamethasone is a steroid that can aid with **removing some oedema** and **decompressing the spinal cord** prior to intervention

Question 63

If MRI comes back as positive for MSCC, what are the next steps?

Answer 63

* **neurosurgical intervention** is considered for eligible patients * **radiotherapy** is an alternative option

Question 64

When is someone with MSCC considered for surgery?

Answer 64

* MRI shows a **single area** of vertebral collapse / SCC with **no other metastatic disease** throughout the spine * patient has good performance status * predicted survival greater than **3 months** * **not paraplegic** for more than **48 hours**

Question 65

When is radiotherapy typically used for MSCC?

Answer 65

* when **multiple areas** of the spinal canal are affected * poor performance status * poor prognosis of **< 3 months** | palliative radiotherapy can improve motor function + symptoms

Question 66

What are the side effects associated with radiotherapy for MSCC?

Answer 66

* pain flare * nausea * vomiting * diarrhoea * tiredness

Question 67

Why is it important to perform radiotherapy quickly when suspecting MSCC?

Answer 67

57% of patients will **regain the ability to walk again** if treated **within 24 hours** ## Footnote if all motor function is lost for 48 hours, then recovery is unlikely

Question 68

What is meant by superior vena cava obstruction (SVO)?

Answer 68

obstruction to the superior vena cava blood flow by **external compression**, **thrombosis** or **direct invasion** of the SVC | this restricts blood return to the heart from the head, neck and UL

Question 69

What are the characteristic symptoms of SVCO?

Answer 69

* **swelling** of the face / neck / arms * **distended veins** across the neck + chest * breathlessness * headache (worse on coughing) * cyanosis * visual disturbances

Question 70

What is the first-line investigation for suspected SVCO?

Answer 70

**CXR** this gives the ability to identify **mediastinal widening** and may show the primary cause of SVCO | CXR is normal in 16% patients with SVCO ## Footnote mediastinal widening = **width > 8cm** on PA view

Question 71

Following CXR, what investigation would be performed for SVCO?

Answer 71

**high-resolution CT / CT with contrast** ## Footnote this allows you to identify the **underlying cause** and the extent to which the **disease has progressed**

Question 72

Why is it important to perform both a CXR and CT in SVCO?

Answer 72

* this allows you to identify whether obstruction is from an **external cause** or **internal (thrombus)** * management depends on the cause

Question 73

What are the most common malignant causes of SVCO?

Answer 73

1. lung cancer 2. lymphoma 3. mediastinal lymphadenopathy 4. germ cell tumours 5. thymomas 6. oesophageal cancer 7. tumour associated thrombus (as a result of hypercoaguability) | these are all cancers affecting the mediastinum / central chest

Question 74

What are the most common benign causes of SVCO?

Answer 74

1. non-malignant tumours (goitre) 2. mediastinal fibrosis - idiopathic / post-radiotherapy 3. infection - TB 4. aortic aneurysm 5. thrombus associated with indwelling catheters

Question 75

What is the first step in treatment for SVCO?

Answer 75

**16mg dexamethasone** with PPI cover | this is performed whilst awaiting CT results

Question 76

After CT results, what are the potential treatment options for SVCO?

Answer 76

* **vascular stent** if cause is external compression + patient decompensated * **radiotherapy / chemotherapy** - if cancer would respond quickly to these * **anticoagulation with LMWH** if thrombus is confirmed