ONCOLOGICAL EMERGENCIES Flashcards
(52 cards)
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.
How long after chemotherapy is someone most likely to suffer from neutropenia?
7-10 days but this can be earlier or later
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
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
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
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
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
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
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
What are the non-cancerous causes of superior vena cava obstruction?
Aortic aneurysm
Mediastinal fibrosis
Goitre
SVC thrombosis
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.
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
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
What percentage of cancer patients are affected by metastatic spinal cord compression?
5-10%
What are the three cancers most commonly associated with metastatic spinal cord compression?
Lung
Breast
Prostate
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.
What imaging should you order for someone with suspected spinal cord compression?
Whole spine MRI
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
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
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
What percentage of cancer patients are affected by brain metastases?
Up to 40%
What is the prognosis of a patient once brain metastases have been diagnosed?
1-2 months
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%
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
