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Flashcards in ONCOLOGICAL EMERGENCIES Deck (52):
1

A 50-year-old woman with early breast cancer presented with fatigue to the accident and emergency department on day 7 of her first adjuvant chemotherapy cycle. On examination, her temperature was 38.5°C, her pulse was 110 beats per minute and her blood pressure was 110/70 mmHg. A full blood count was requested. What is the most appropriate next step?

Await FBC results

IV broad spectrum antibiotics

IV broad spectrum antibiotics and granulocyte colony-stimulating factor (G-CSF)

Oral broad spectrum antibiotics

Oral broad spectrum antibiotics and granulocyte colony-stimulating factor (G-CSF)

This person should be treated as having neutropenic sepsis until proven otherwise. The answer is IV broad spectrum antibiotics.

2

How long after chemotherapy is someone most likely to suffer from neutropenia?

7-10 days but this can be earlier or later

3

What are the first line antibiotics that you would give to a chemotherapy patient in whom you suspected neutropenic sepsis?

Piperacillin with tazobactam 4.5g QDS

4

What are the first line antibiotics that you would give to a chemotherapy patient who was hypotensive and in whom you suspected neutropenic sepsis?

Piperacillin with tazobactam 4.5g QDS

PLUS

Gentamicin 7 mg/kg OD

5

What are the first line antibiotics that you would give to a chemotherapy patient who is allergic to penicillin and in whom you suspected neutropenic sepsis?

Reaction to penicillin is rash only:

Meropenem 1g TDS or Cetazidime 2g TDS

PLUS

Gentamicin 7 mg/kg OD



Documented anaphylaxis:

Ciprofloxacin 400 mg BD

PLUS

Amikacin 7.5 mg/kg OR Gentamicin 7 mg/kg

6

What are the sepsis six?

High flow oxygen

Take blood cultures

IV antibiotics

Measure serum lactate and FBC

IV fluids

Insert catheter to measure accurate urine output

7

A 26 year old presents with a short history of facial swelling, headache and shortness of breath. What oncological emergency might this be?

Superior vena cava obstruction

8

What are the clinical features of vena cava obstruction?

Shortness of breath

Face or arm swelling or oedema

Headache

Hoarseness

Venous distention in the neck and distended veins in the upper chest and arms

Lightheadedness

Cough

Edema of the neck, called the collar of Stokes

9

What types of cancer most commonly cause superior vena cava obstruction?

Non small cell lung cancer - 50%

Small cell lung cancer - 22%

Lymphoma - 12%

Metastatic - 9%

Breast cancer

Kaposi's sarcoma

10

What are the non-cancerous causes of superior vena cava obstruction?

Aortic aneurysm

Mediastinal fibrosis

Goitre

SVC thrombosis

11

How life threatening is superior vena cava obstruction?

Often not immediately, so an attempt should be made to make a definitive diagnosis and obtain tissue samples.

12

How do you treat superior vena cava obstruction caused by malignancy?

High dose steroids results in symptomatic relief

Intravascular stenting can be good palliative treatment

Removal or shrinking of tumour is clearly best course, however, surgical removal is almost impossible in these situations.

Small cell lung cancer: chemotherapy + radiotherapy

Non-small cell: radiotherapy

13

What are the red flags for spinal cord compression?

Cauda equina:

Bladder dysfunction

Sphincter disturbance

Saddle anaesthesia

Lower limb weakness

Gait disturbance


Lying flat increases pain

Worse at night

Refractory to treatment

Thoracic or cervical back or neck pain

14

What percentage of cancer patients are affected by metastatic spinal cord compression?

5-10%

15

What are the three cancers most commonly associated with metastatic spinal cord compression?

Lung

Breast

Prostate

16

How does spinal cord compression lead to nerve damage?

Direct compression leads to oedema, venous congestion and demyelination

Prolonged compression leads to vascular injury and hence infarction of spinal cord.

17

What imaging should you order for someone with suspected spinal cord compression?

Whole spine MRI

18

How do you manage someone with spinal cord compression?

Corticosteroids (dexamethasone 16 mg loading dose and until treatment is planned) are routinely given to reduce tumour bulk or spinal cord swelling

Surgery is the initial treatment of choice for patients with spinal cord compression as radiotherapy will not treat structural failure and so decompression and/or stabilisation (with or without bone graft, instrumentation, and vertebral reconstruction) is needed to prevent further neurological damage.

Surgery not always appropriate though

19

What are the factors that would indicate a good prognosis following treatment for spinal cord compression?

Breast cancer as the primary site

Solitary or few spinal metastases

Absence of visceral metastases

Ability to walk unaided

Minimal neurological impairment

No previous radiotherapy

20

What are the factors that would indicate a poor prognosis following treatment for spinal cord compression?

Lung or melanoma as primary

Multiple spinal metastases

Visceral metastases

Unable to walk

Severe weakness

Recurrence after radiotherapy

21

What percentage of cancer patients are affected by brain metastases?

Up to 40%

22

What is the prognosis of a patient once brain metastases have been diagnosed?

1-2 months

23

What are the most common primary sites for cancers leading to brain metastases?

Lung cancer - 42%

Breast cancer - 19%

Colorectal - 9%

Melanoma - 7%

Unknown primary - 7%

24

What are the most common presenting symptoms of brain mets?

Headache

Focal weakness

Ataxia

Seizures

Nausea and vomiting

Drowsiness

Confusion

Altered personality

Cranial nerve palsies

25

What investigations would you want to do for someone in whom you suspected brain metastases?

CT head with IV contrast

MRI may help with resectability

26

How do we manage confirmed brain metastases?

High dose steroids

Treat seizures with anticonvulsants

MDT - neurosurgeons, radiotherapists, palliative care

Whole brain radiotherapy - standard palliative treatment

Neurosurgery

Stereotactic radiosurgery

27

What are the side effects of whole brain radiotherapy in the treatment of brain metastases?

Fatigue

Alopecia

Scalp erythema

Impaired cognitive function

28

What are the indications for performing neurosurgery on someone with brain metastases rather than palliation with whole brain radiotherapy?

Resection of solitary or 3 or less accessible metastases

Palliation of hydrocephalus / debulking of large metastases

Biopsy for histological diagnosis

29

What is stereotactic radiosurgery?

Gamma-knife and linear particle accelerator-based systems that deliver high dose RT with mm accuracy to a sharply defined target, sparing surrounding normal tissue

30

What are the primary cancers most commonly responsible for bowel obstruction?

Colorectal

Gynaecological

31

What are the clinical features of bowel obstruction?

Abdominal pain

Vomiting

Constipation

32

What investigations should be done to confirm bowel obstruction?

Plan X-ray

CT

33

What are the factors that would indicate a poor prognosis following treatment for malignant bowel obstruction?

Chemoresistance

Large volume ascites

Multiple site disease

Albumin of less than 25g/L

34

What are the factors that would indicate a good prognosis following treatment for malignant bowel obstruction?

Chemosensitivity

No/small volume ascites

Single-site disease

Albumin of more than 25g/L

35

How do we manage someone with malignant bowel obstruction?

Drip and suck - NG tube and IV fluids

Enema if faecal impaction is thought to be contributing

Steroids - reduce bowel wall oedema

Anti-emetics

Motility agents (if sub-acute) - metoclopramide

Antisecretory agents (octreotide) to reduce GI secretion

Surgery

36

When would we decide to take a patient with bowel obstruction to surgery?

If symptoms fail to resolve after 48 hours of conservative management

37

What are the surgical options for management of malignant bowel obstruction?

Resection of tumour

Bypass

Formation of stoma

Stenting

38

What percentage of cancer patients will develop a VTE?

20%

39

Why are cancer patients more at risk of VTE?

Hypercoagulable state - tumour cells release factors that activate the coagulation system

Sick patients in bed leads to venous stasis

More likely to have surgery

40

What are the cancer related risk factors for developing a VTE?

Extensive disease

Chemotherapy

Hormonal treatment

Central venous catheter

Recent surgery

41

What is the long term treatment for VTE associated with malignancy?

NOT warfarin

LMWH

42

Why do we not give cancer patients warfarin to prevent recurrent VTEs?

Unstable INRs as a result of changeable nutrition, liver function and drug interactions.

43

What proportion of cancer patient will develop hypercalcaemia?

10-30%

44

What are the cancers most commonly associated with hypercalcaemia?

Breast

Lung

Melanoma

45

What are the clinical features of hypercalcaemia?

Lethargy

Confusion

Anorexia

Nausea

Constipation

Polyruria and polydipsia - severely volume deplete

Hypotensive

Tachycardia

46

How do we treat hypercalcaemia in a cancer patient?

Address volume depletion with IV fluids - may require large amounts

Bisphosphonates (pamidronate or zoledronic acid) - block osteoclastic bone reabsorption

Steroids

SC calcitonin - short lived effect

Treat underlying disease

47

What are the cancers most commonly associated with tumour lysis syndrome?

Leukaemia

Lymphoma

48

What are the characteristic electrolyte imbalances of tumour lysis syndrome?

Hyperkalaemia

Hyperphosphataemia

Hypocalcaemia

Hyperuricaemia

49

What are the clinical features of tumour lysis syndrome?

Nausea and vomiting

AKI

Seizures

Cardiac arrhythmias

50

Why does tumour lysis cause hypocalcaemia?

Because the sudden rise in phosphate causes high levels of calcium phosphate to be made and calcium is therefore used up.

51

What is the name of the classification system for tumour lysis syndrome?

Cairo-Bishop definition

52

How does the Cairo-Bishop system classify tumour lysis syndrome?

Laboratory tumour lysis syndrome is an abnormality in two or more of the following:

Uric acid of more than 475umol/l or 25% increase

Potassium of more than 6 mmol/l or 25% increase

Phosphate of more than 1.125mmol/l or 25% increase

Calcium of less than 1.75mmol/l or 25% decrease


Clinical tumour lysis syndrome is lab tumour lysis syndrome factors plus one or more of:

Increased serum creatinine (1.5 times upper limit of normal)

Cardiac arrhythmia or sudden death

Seizure