Oncological Emergencies

Question 1

What are the 3 main criteria for diagnosing neutropenic sepsis?

Answer 1

Patient undergoing anticancer treatment
Neutrophils <0.5x10˄9/L
Temperature >38

Question 2

How many days after chemotherapy does neutropenic sepsis tend to occur?

Answer 2

7-14 days

Question 3

Give 4 risk factors for neutropenic sepsis

Answer 3

Active chemotherapy
Extensive field radiotherapy 
Haematological malignancy
Infection risk increased ie. increased exposure to pathogens 
Autoimmune predisposition

Question 4

Give 3 examples of pathogens that commonly are the cause of neutropenic sepsis

Answer 4

80% are endogenous flora
Staph. aureus
Staph. epidermidis
Enterococcus
Streptococcus
MRSA

Question 5

How does neutropenic sepsis present?

Answer 5

Tachycardia
Hypotension 
Tachypnoea
Fever
Drowsy
Confused
Sx related to site of infection eg. cough, painful line

Question 6

What scoring system is used to score neutropenic sepsis?

Answer 6

MASCC

Score out of 26, if >21 then low risk

Question 7

What investigations will be done for a patient with neutropenic sepsis?

Answer 7

FBC
U+Es
LFTs
Lactate
CRP
Blood culture
Urine culture
Sputum culture
Line/wound swab
ABG
Imaging --> CXr, AXr, CAP CT

Question 8

How is neutropenic sepsis managed?

Answer 8

Empirical IV broad spectrum Abx within the hour –> Tazocin or Meropenem
IV fluids –> 0.9% saline 500ml over 1 hour
Catheterise
Escalate to senior

Question 9

What other longer term management can be given to patients with neutropenic sepsis?

Answer 9

Granulocyte Colony Stimulating Factor (GCSF) makes bone marrow produce WBCs

Question 10

How can neutropenic sepsis be prevented?

Answer 10

Patient education
Antibiotic prophylaxis
Decrease dose of further chemotherapy cycles

Question 11

Describe the pathophysiology of metastatic spinal cord compression

Answer 11

Caused by the collapse or compression of a vertebral body that contains metastatic disease or the growth of a primary tumour. This results in compression of the spinal cord.

Over time this leads to vascular injury, cord necrosis and permanent damage .

Question 12

Which cancers commonly metastasise to bone?

Answer 12

Breast
Prostate
Lung 
Myeloma 
Lymphoma

Question 13

What are the clinical features of metastatic spinal cord compression?

Answer 13

Back pain --> radicular, prolonged, exacerbated by straight leg raise, coughing, sneezing or straining. 
 Limb weakness
Sensory loss (dermatomal) 
Bladder and anal sphincter dysfunction

Question 14

Describe the features of cauda equina

Answer 14

Bilateral sciatica 
Impotence
Bladder dysfunction 
Saddle anaesthesia 
Loss of anal tone
Weakness of gluteal muscles

Question 15

What is the main investigation needed in metastatic spinal cord compression?

Answer 15

MRI Spine within 24 hours

Question 16

How is metastatic spinal cord compression managed conservatively?

Answer 16

Bed rest with log-rolling 
Bladder care 
Physiotherapy 
OT 
VTE prophylaxis

Question 17

How is metastatic spinal cord compression managed medically?

Answer 17

Dexamethasone 16mg + PPI protection
Analgesia
Laxatives

Question 18

How is metastatic spinal cord compression managed surgically?

Answer 18

Surgery –> relieves compression, removes tumour, stabilises spine

Question 19

How is metastatic spinal cord compression managed palliatively?

Answer 19

Radiotherapy

Question 20

What is the pathophysiology of superior vena cava obstruction?

Answer 20

Obstruction of blood through the SVC causing occlusion which leads to reduced venous return to the heart.

Question 21

Give 2 causes of extrinsic superior vena cava obstruction?

Answer 21

Right sided lung tumour

Superior mediastinal lymphadenopathy –> lymphoma, thymoma, germ cell tumour

Question 22

Give 2 causes of intrinsic superior vena cava obstruction?

Answer 22

Thrombosis
Foreign body (central venous catheter)
Tumour

Question 23

Give 4 features of superior vena cava obstruction

Answer 23

Shortness of breath 
Swelling of face, neck and arm 
Choking sensation 
Headache 
Lethargy 
Cough 
Chest pain 
Dysphagia 
Distended neck and chest wall veins

Question 24

What investigations are required in superior vena cava obstruction?

Answer 24

Chest x-ray
CT chest with contrast (urgent)
Angiography

Question 25

How is acute superior vena cava obstruction managed?

Answer 25

Sit patient up IV access 100% O2 Dexamethasone 8mg BD

Question 26

How is stable superior vena cava obstruction managed?

Answer 26

Chemotherapy Radiotherapy Stent

Question 27

What cancers are commonly associated with malignant hypercalcaemia?

Answer 27

``` Breast Squamous cell lung cancer Prostate Lymphoma Myeloma Leukaemias ```

Question 28

What are the 3 main pathological mechanisms of malignant hypercalcaemia?

Answer 28

Tumour secretion of parathyroid hormone related peptide Osteolytic metastases with local cytokine release Tumour production of vitamin D metabolites

Question 29

Give some clinical features of malignant hypercalcaemia

Answer 29

``` *Very non-specific* Fatigue Drowsiness Anorexia Dehydration Weakness Depression Seizures Nausea Vomiting Polyuria Postural hypotension Constipation ```

Question 30

What investigations are required in diagnosing malignant hypercalcaemia?

Answer 30

``` FBC U+Es Ca2+ (corrected) PTH/PTHrP Phosphate Myeloma screen ECG ```

Question 31

How is malignant hypercalcaemia managed?

Answer 31

Rehydration --> 0.9% saline 3-6L in 24 hours Monitor U+Es Bisphosphonates --> 30-60 mg Pamidronate IV over 24 hours Treat underlying malignancy

Question 32

Describe the pathophysiology of Tumour Lysis Syndrome

Answer 32

Massive lysis of rapidly proliferating tumour cells resulting in the release of intracellular contents into the circulation. Occurs 3-7 days after chemotherapy

Question 33

What cancers are commonly associated with Tumour Lysis Syndrome?

Answer 33

``` High grade lymphoma ALL Myeloma Germ cell tumour Breast cancer ```

Question 34

Give 5 metabolic abnormalities associated with Tumour Lysis Syndrome

Answer 34

``` Hyperuricemia Hyperkalemia Hyperphosphatemia Hypocalcaemia Hypomagnesaemia ``` Leads to metabolic acidosis

Question 35

What 3 characteristics of a tumour are most likely to predispose to Tumour Lysis Syndrome?

Answer 35

Large tumour Large tumour burden High proliferation rate

Question 36

Give 5 clinical features of Tumour Lysis Syndrome

Answer 36

``` N+V Diarrohea Flank pain Arrythmias Lethargy Confusion Haematuria Syncope Hallucinations Seizures Oedema Oliguria Coma Muscle cramps Heart failure Anorexia ```

Question 37

What investigations will be carried out to diagnose Tumour Lysis Syndrome?

Answer 37

``` FBC U+Es Ca2+ Phosphate Magnesium Urate ABG ECG LDH --> tumour burden assessment ```

Question 38

How is Tumour Lysis Syndrome managed?

Answer 38

Urgent correction of hyperkalaemia (with calcium gluconate, insulin) Monitor fluid balance via U+Es Need for haemodyalysis

Question 39

How is Tumour Lysis Syndrome prevented?

Answer 39

Identify high risk patients early Keep well hydrated Low risk --> allopurinol 300mg PO od High risk --> rasburicase 200 micrograms/kg OD