Oncological Emergencies

Question 1

What is an oncological emergency?

Answer 1

A situation arising in a cancer patient, related either to the cancer itself or its treatment, for which early diagnosis and treatment is necessary to prevent major morbidity or mortality

Question 2

What are the common cancer related oncological emergencies?

Answer 2

Hypercalcaemia
Spinal cord compression
Superior vena cava obstruction
Large airway obstruction
Pleural effusion
Haemoptysis
Ureteric obstruction
GI obstruction
Gut perforation
Hyperviscosity syndrome

Question 3

What are the treatment related oncological emergencies?

Answer 3

Neutropenic sepsis
Extravasation
Tumour lysis syndrome
Thrombocytopenia

Question 4

What is normal serum calcium?

Answer 4

2.2-2.7 mmol/L

Question 5

What levels of serum calcium require treatment to avoid renal damage?

Answer 5

2.7 and 3.7 mmol/L

Question 6

What may happen if serum calcium is >3.7mmol/L?

Answer 6

Emergency, may cause cardiac arrhythmias/arrest

Question 7

What cancers does hypercalcaemia particularly occur in?

Answer 7

Lung, breast, prostate and myeloma

Question 8

Why does hypercalcaemia occur in cancer?

Answer 8

Tumour cells intefere with the normal balance between osteoclasts and osteoblasts

Question 9

What do tumour cells secrete which then cause activation of osteoclasts, osteolytic bone lesions and hypercalcaemia?

Answer 9

Cytokines (IL-1, IL-6, TNF, PTHrP)

Question 10

What is the clinical presentation of hypercalcaemia?

Answer 10

Increased calcium impairs reabsorption function of kidney tubules (reduces sensitivity to ADH)--> salt losing diuresis--?polyuria and polydipsia
Abdo pain
Nausea and vomiting
Drowsiness, confusion
Impaired consciousness
Cardiac arrhythmias

Question 11

What can happen if hypercalcaemia is untreated?

Answer 11

Dehydration, renal failure and coma

Question 12

What is the management of hypercalcaemia?

Answer 12

Attempt to rid body of calcium
Protect/improve renal function
Reduce bone breakdown

Question 13

What are the main treatments for hypercalcaemia?

Answer 13

Rehydration

Bisphosphonates

Question 14

How much fluid should be given in hypercalcaemia?

Answer 14

If renal and cardiac function OK, give 3L IV fluids over 24 hours

Question 15

How do bisphosphonates work to treat hypercalcaemia?

Answer 15

Interfere with osteoclast activity therefore inhibiting calcium release from bone and inhibit bone resorption

Question 16

How long do bisphosphonates take to have maximal effect on calcium levels?

Answer 16

3-5 days

Question 17

What does of Disodium pamidronate should be given if serum calcium is less than 3.5?

Answer 17

60mg

Question 18

What does of Disodium pamidronate should be given if serum calcium is 3.5 or more?

Answer 18

90mg

Question 19

Neutrophils make up what percentage of white blood cells?

Answer 19

40-75%

Question 20

What is neutropenia?

Answer 20

Neuts <1.5 x 10^9/L

Question 21

What can cause neuropenia?

Answer 21

Chemo
Radio
Disease with bone involvement

Question 22

People with neutropenia are at increased risk of what?

Answer 22

Infection

Question 23

What fungal infections are people with neutropenic sepsis at risk of?

Answer 23

Candida spp.

Aspergillus spp.

Question 24

What viral infections are people with neutropenic sepsis at risk of?

Answer 24

Herpes simplex

Varicella zoster

Question 25

Prolonged neutropenia increases risk of what?

Answer 25

Fungal infections

Question 26

What are the risk factors for neutropenic sepsis?

Answer 26

Neutrophil count <0.5 x 10^9/L Neutropenia lasting > 7 days Patients with mucositis (high risk of infection via mouth), concurrent illness, poor performance status

Question 27

What is the clincial presentation of neutropenic sepsis?

Answer 27

Often only pyrexia

Question 28

Fever may be absent in what patients with neutropenic sepsis?

Answer 28

Dehydrated, severely shocked or taking steroids

Question 29

What are the common sites of infection?

Answer 29

GI/resp tract, skin

Question 30

What should be treated as neutropenic sepsis?

Answer 30

2 x temps of above 38 degrees C | 1 x temp of above 39 degrees C

Question 31

Should you wait for culture results or start empirical antibiotics when treating neutropenic sepsis?

Answer 31

Start empirical straight away

Question 32

What investigations should be done for neutropenic sepsis?

Answer 32

``` Blood cultures MSU Throat swab Swab form Hickman line Swab form any skin lesion ```

Question 33

What is the first line antibiotic for treatment of neutropenic sepsis?

Answer 33

anti-pseudomonal penicillin (Tazocin) + aminoglycoside (gentamicin) if haemodynamically unstable

Question 34

When should metronidazole be added in for treatment of neutropenic sepsis?

Answer 34

If colonic symptoms e.g. diarrhoea or dental symptoms

Question 35

What should happen if the patient is still pyrexial after 48 hours?

Answer 35

Change antibiotics--> ceftaidime + vancomycin

Question 36

What should happen if the patient is still pyrexial after 96 hours?

Answer 36

May add antifungal-->Amphotericin B

Question 37

What is used first line in the RUH to treat fungal infections?

Answer 37

Caspofungin IV then PO voriconazole if patient is improving and suitable for oral treatment

Question 38

Why is granulocyte-colony stimulating factor e.g. lenograstim sometimes given?

Answer 38

May shorten period of neutropenia after chemo and therefore reduce risk of infection

Question 39

Why are growth factors not routinely given?

Answer 39

Due to cost (£40 per dose, 5-7 doses needed per chemo course)