Oncological Emergencies

Question 1

When is neutropenic sepsis most likely to occur?

Answer 1

7-14 days post-chemo

Question 2

What is neutropenic sepsis defined as?

Answer 2

Patients undergoing treatment whose neutrophil count is <1x10^9, with either:

1. Temperature >38
2. Other signs consistent with sepsis

Question 3

What is febrile neutropenia?

Answer 3

60-70% of fevers during neutropenia have no identifiable ateology

Question 4

How is neutropenic sepsis managed?

Answer 4

Broad spectrum antibiotics within 1 hour

Question 5

What is a MASCC score?

Answer 5

Assessment of the risk of complications during a febrile neutropenic episode

Question 6

What tumours is hypercalcaemia most common in?

Answer 6

Breast, lung, prostate, SCC, myeloma

Question 7

What is normal calcium homeostasis when there is an increase in blood calcium?

Answer 7

Thyroid releases calcitonin

Promotes osteoblasts to deposit calcium in bones & reduces absorption in the kidneys

Calcium blood level falls

Question 8

What is normal calcium homeostasis when there is a decrease in blood calcium?

Answer 8

Parathyroid releases PTH

Promotes osteoclasts to release calcium from bones (resorption)

Stimulates absorption by the kidney

Activates vitamin D (stimulates bowel to absorb calcium)

Question 9

What is transforming growth factor alpha?

What does it do?

Answer 9

Stimulator of cell growth, produced by many tumour cells

Stimulates bone resorption

Question 10

What is PTH related peptide

Answer 10

Mimics PTH

Stimulates bone resporption & increases plasma calcium

Question 11

Hypercalcaemia presentation:

CNS

Answer 11

Confusion
Seizures
Proximal neuropathy
Hyporeflexia
Coma

Question 12

Hypercalcaemia presentation: GI

Answer 12

Nausea & vomiting
Constipation
Dyspepsia
Abdo pain

Question 13

Hypercalcaemia presentation: Cardiac

Answer 13

Bradycardia
ECG changes
Arrhythmia
Hypertension

Question 14

Hypercalcaemia presentation: other

Answer 14

Dehydration
Weakness
Fatigue
polyuria
Bone pain

Question 15

What ECG changes may you see in hypercalcaemia?

Answer 15

Short QT interval

Wide T wave

Prolonged PR

Question 16

How is hypercalcaemia managed?

Answer 16

1. Normal saline quarter hourly for 24 hours (then 6 hourly for 48-72 hours with adequate K+)
2. IV Bisphosphonates

Question 17

Give 2 examples of bisphosphonates

Answer 17

Pamindronate

Zolendronic acid

Question 18

Side effects of bisphosphonates

Answer 18

Oesophagitis

Osteonecrosis of the jaw

Question 19

How do bisphosphonates work?

Answer 19

Inhibit osteoclastic bone resorption, reducing amount of calcium from bones released into blood

Question 20

How are seizures/ arrhythmias from hypercalcaemia managed?

How are they given?

Answer 20

Calcitonin & corticosteroids

S/C calcitonin with oral prednisolone

Question 21

What is the pathophysiology of MSCC?

Answer 21

Direct compression by vertebral collapse

Or direct extension of malignancy

Question 22

Which part of the spine is MSCC most common in?

Answer 22

Thoracic

Question 23

Which cancers is MSCC most common in?

Answer 23

Prostate, breast, lung, myeloma, lymphoma

Question 24

What % of people with MSCC have no pain?

Answer 24

40% painless

Question 25

How is the pain from MSCC usually described?

Answer 25

'Band-like' pain

Question 26

What is the initial management for suspected MSCC?

Answer 26

16 mg dexamethasone (+ PPI) Urgent MRI (within 24 hours)

Question 27

How does dex help in MSCC?

Answer 27

Reduces swelling & oedema around the tumour & reduces pressure on the spinal cord

Question 28

What are the 3 definitive treatment options for MSCC?

Answer 28

Spinal surgery Radiotherapy Chemotherapy

Question 29

when is surgery indicated for MSCC?

Answer 29

Single site & good prognosis, few co-morbidities

Question 30

How is radiotherapy given for MSCC?

Answer 30

Single fraction of radiotherapy Mainstay of treatment for MSCC

Question 31

When would you give chemo for MSCC?

Answer 31

In a very chemosensitive cancer e.g. SCLC, germ cell tumour, lymphoma

Question 32

If patients are treated in <24 hours, how many are able to walk again?

Answer 32

60%

Question 33

What is the pathophysiology of SVC obstruction? | 3

Answer 33

Extrinsic compression, thrombosis or invasion of the wall of the SVC

Question 34

What is the most common cause of SVC obstruction?

Answer 34

Extensive lymphadenopathy in the upper mediastinum

Question 35

What cancers most commonly cause SVC obstruction? | 2

Answer 35

Lung cancer & lymphoma

Question 36

How does SVC obstruction present?

Answer 36

Breathlessness, headache, swelling in the face, neck or arm Distented neck & chest veins Cyanosis Visual disturbance

Question 37

What are the features of headache in SVC obstruction

Answer 37

Worse on coughing & worse in the morning

Question 38

What is the immediate management of SVC obstruction?

Answer 38

16mg dexamethasone daily

Question 39

What procedure is needed urgently in SVC obstruction?

Answer 39

Urgent vascular stenting

Question 40

What treatment is needed following stenting?

Answer 40

Radiotherapy or chemotherapy

Question 41

What should be done if SVC obstruction is the initial presentation of a cancer?

Answer 41

Biopsy (N.B. tumour likely to progress rapidly)

Question 42

Give two alternative causes of SVC obstruction

Answer 42

Goitre | Aortic aneurysm