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Oncological Emergencies Flashcards

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1
Q

What is neutropenic sepsis?

A

Neutrophil count of 0.5 x 109 per litre or lower (check guidelines), plus:

Temp > 38oC

Other signs consisent with significant sepsis

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2
Q

What are some other terms for neutropenic sepsis?

A

Febrile neutropenia

Neutropenic fever

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3
Q

How does neutropenia predispose to infection?

A

Neutrophils are key component of the innate immune system

Lack of signs / symptoms causing isolated pyrexia

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4
Q

What are some causes of neutropenia?

A

Recent chemo (within 7-10 days) due to BM suppression

Malignant bone marrow infiltration

Extensive radiotherapy

Bone marror failure secondary to non-malignant disease (e.g. aplastic anaemia)

Hypersplenism

Megaloblastic anaemia

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5
Q

What increases the risk of developing neutropenic sepsis?

A

> 60

Advanced malignancy

Previous neutropenic sepsis

Mucositis (entry for bacteria)

Poor performance status

Co-morbidities

Indwelling central venous catheters

Corticosteroids (causing immunosuppression)

Prolonged hospital admission

Severe neutropenia

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6
Q

What are some non-specific symptoms of neutropenic sepsis?

A

Fatigue

Feeling warm / cold

Rigors / shaking

Sweaty / clammy

Palpitations

Dizziness

Confusion / disorientation

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7
Q

What symptoms may reflect a specific infective source in neutropenic sepsis?

A

Chest: SoB, cough, chest pain, sore throat

Urine source: dysuria, increased frequency, urgency, LUTS

Skin: rashes, blisters, pain

GI: diarrhoea, nausea, vomiting, rectal bleeding, abdo oain, sore mouth (mucositis)

Indwelling line source: pain around the line

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8
Q

What may the clinical findings in neutropenic sepsis be?

A

Haemodynamic instability (hypotension, tachycardia, tachypnoea, hypoxia)

Fever

Reduced urine output

Mottled / ashen appearance

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9
Q

What may be the examination findings of an identifiable source in neutropenic sepsis?

A

Chest: increased work of breathing, crepitations, dullness to percuss, reduced air entry

Urine: suprapubic / flank pain, cloudy urine in catheter bag

Skin: rashes, blistering, tenderness

GI: abdo tenderness, dehydration, evidence of oral mucositis, jaundice

Indwelling line source: surrounding erythema, tenderness on palpation

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10
Q

What else may cause a fever in cancer?

A

Underlying malignancy (both solid and haematological)

Immunotherapy toxicities

Inflammatory disorders (e.g. SLE, vasculitis, RA)

Drug induced

Hypothalamic dysfunction

Thyroiditis

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11
Q

What are the common gram-negative bacilli that cause neutropenic sepsis?

A

E. Coli

Klebsiella spp.

Pseudomonas aeruginosa

Enterobacter spp.

Proteus spp.

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12
Q

What are the most common gram-positive bacilli in neutropenic sepsis?

A

Staphylococcus aureus

Corynebacterium

Staphylococcus epidermidis

Streptococcus pneumoniae

Viridans streptococci

Enterococci

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13
Q

What are some common fungal causes of neutropenic sepsis?

A

Candida spp.

Aspergillus spp.

Mucorales

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14
Q

How may an infective cause be investigated in neutropenic sepsis?

A

Bedside = Urinalysis (UTI), ECG (all acutely unwell patients), Capillary blood glucose (exclude hypoglycaemia)

Lab investigations = Blood tests (FBC, U&E, coagulation, CRP, LFTs = WCC low / raised, CRP raised), Serum lactate, G&S (for transfusion), Blood cultures (two sets from peripheral vein, plus from indwelling line), ABG (extent and severity), cultures (wounds, urine, stool, sputum line tip), Viral resp swab

Imaging = CXR (pneumonia), chest CT (fungal pneumonia suspected), abdo ultrasound (biliary / abdo infection suspected)

Other = Bronchoalverlar lavage (atypical chest source = penumocystis jirovecii)

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15
Q

What is the management of neutropenic sepsis?

A

Empirical abx within one hour of arrival at hospital

Sepsis 6

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16
Q

Give example of empirical antibiotic therapy for neutropenic sepsis?

A

First-line = IV piperacillin with tazaobactam (tazocin)

Second-line (penicillin allergy) = IV meropenem

Additional anti-microbial cover = teicoplanin for gram positive organisms (e.g. for indwelling central venous catheters)

Antifungal = if fever persists beyond 4-6 days

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17
Q

What may be used for both prophylaxis and treatment of neutropenia to reduce the risk of sepsis?

A

Granulocyte-colony stimulating factor

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18
Q

How does G-CSF work?

A

Stimulates bone marrow to produce neutrophils (may form part of specific chemo regimens) e.g. filgrastim

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19
Q

What are some complications of neutropenic sepsis?

A

Single / multi-organ failure (renal failure, heart failure, ARDS)

VTE (PE)

DIC

Delerium

Psycholigical complications (anxiety around future infections and chemo treatment)

Delays in chemo leading to worse cancer outcomes

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20
Q

What is the spinal cord?

A

Part of CNS - main communication between brain and peripheral nerves

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21
Q

What is the spinal cord surrounded by?

A

Meninges

Dura

Arachnoid

Pia mater

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22
Q

What is the thecal sac?

A

Component of the dura mater (outermost meningeal layer)

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23
Q

What is malignant cord compression defined as?

A

Radiological evidence of indentation of the thecal sac

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24
Q

What is the cauda equina? (syndrome included in cord compression)

A

Lumbar, sacral and coccygeal nerve roots that descend from the end of the spinal cord at L1

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25
Where does the **spinal cord originate and end**?
**Base of medulla oblongata** (exiting through the skull through foramen magnum) - ending at level of L1 / L2 spinal vertebrae
26
How many **segments** are there of the **spinal cord**?
31 segments
27
What is the **terminal end** of the **spinal cord** called? (Beyond which is cauda equina / horses tail)
**Conus medullaris**
28
When does **malignant spinal cord compression occur**?
Secondary to **metastatic deposits** within the **spinal column**
29
Which cancers are associated with cord compression?
Lung Breast Kidney Prostate Thyroid
30
What are the **other causes** of **cord compression**?
**Trauma** **Intebertebral disc prolapse** **Haematoma** **Episural asscess** (secondary to osteomyelitis or discitis) **Cervical spondylitic myelopathy**
31
Where does malignant cord compression most commonly occur?
**Thoracic spine**
32
What can cause **vertebral metastasis**?
**Arterial seeding** **Shunting of blood** through **epidural venous plexus** (in prostate cancer)
33
What are the **features** of **cord compression**?
**Pain** - severe, progressive, radicular character **Weakness** - symmetrical, pyramidal (affects the extensors in upper extermities and flexors in lower) UMN lesions = increased tone **Hypereflexia** - below level of lesions e.g. extensor plantar reflex (positive babinski) **Sensory symptoms** - less common than motor symptoms
34
What are the **features of cauda equina syndrome**?
**Lower motor neurone pattern** Unilateral features **Saddle anarsthesia** **Reduced anal tone** **Painless urinary retention** (overflow incontinence) Impotence Absent ankle jerk
35
What is the **investigation** in **malignant cord compression**?
**MRI scan** Other imagine (myelography, CT, bone scan, plain radiographs)
36
What is the **management** of **acute cord compression**?
**Surgical emergency** - prompt recognition and treatment **General measures** (analgesia from WHO ladder, VTE prophylaxis - TED stockings, LMWH, catheter) **Glucocorticoids** (high-dose dexamethasone, reducing oedema, relieving compression) **Definitive treament** (External beam RT - adjuvant or stand alone) Stereotactic body radiotherapy - enables **higher doses** of **radiotherapy** to be targeted more directly at the tumour - useful if radioresistant e.g. sarcoma, renal cell carcinoma
37
What are the **surgical management options** for **cord compression**?
**Surgical decompression** and reconstruction Vertebroplasty Kyphoplasty
38
What is **malignant hyperclacaemia** defined as?
**Serum calcium** \> 2.6 mmol/L secondary to a **malignant process**
39
What are the **most common causes of hypercalcalcaemia**?
Primary hyperparathyroidism Malignant hypercalcaemia
40
Where is **calcium stored**?
Bone (99%) Intracellular Extracellular (ionised - free pool, bound to albumin and globulin, complexed with phosphate and citrate)
41
How is the **balance between stored calcium** and extracellular calcium managed?
PTH (parathyroid hormone) Vitamin D Calcitonin
42
How does the **body respond** to **decreased extracellular calcium**?
Detected by **calcium-sensing receptor** (CaSR) on parathyroid glands **Parathyroid glands** release **PTH** (stimulating resorption of calcium from bone, activation of vitamin D and increased renal tubular reabsorption of calcium)
43
How does **activated vitamin D** cause increases in calcium?
**Calcium absorption** from **enterocytes**
44
What effect does a **rise in extracellular calcium** have?
Reduction in release of PTH Stimulates the release of **calcitonin**
45
What is the **normal calcium** range?
**2.2-2.6** mmol/L
46
What are the **grades of hypercalcaemia**?
**Mild** = 2.6-3.0 **Moderate** = 3.0-3.5 **Severe** \> 3.5
47
What is calcium corrected for?
The **amount binded to albumin**
48
What does **acidosis** do to the levels of calcium?
**Decreases** level of calcium
49
Which are the most **common malignancies** associated with hyperclaemia?
**Breast cancer** **Muliple myeloma** **Lymphoma** **Lung cancer**
50
What are the **three mechanisms** which cause **malignant hypercalcaemia**?
**Osteolytic metastasis** **PTH-related protein (PTHrP) secretion** **Increased 1,25-dihydroxyvitamin D production**
51
What does PTHrP cause?
Increased **bone resorption** ## Footnote **Distal tubular calcium absorption** **Inhibition of proximal phosphate transport**
52
What is **osteolytic metastasis** most linked with?
**Breast cancer**
53
Why does **calcium rise** in **osteolytic metastasis**?
**Deposition** of **tumour cells** in bone causes local **inflammatory cytokines** and other mediators, stimulating **osteoclasts** causing **bone resorption**
54
Which cancer causes **increased expression of activated vitamin D** (causing increased absorption from GI tract)?
**Hodgkin's lymphoma**
55
What are the **clinical features** of **malignant hypercalcaemia**?
**Stones**, **bones**, abdo **groans**, psychiatric **moans** Stones = renal calculi Bones = pains, fractures Groans = abdo pain, pancreatitis moans = mood disturbances, fatigue thrones = polyuria, constipation
56
How does **milde hypercalcaemia present**?
Often **asymptomatic** **Polyuria** **Polydipsia** Mild **cognitive impairment** **Dyspepsia** **Nausea**
57
How does **severe hypercalcaemia** present?
**Abdo pain** **Vomiting** **Cardiac dysrhythmias** **Pancreatitis** **Coma**
58
How is **malignant hypercalcaemia** diagnosed?
Measurement of **serum calcium level** Identification of **underlying cancer**
59
How to **investigations differentiate** between **hyperparathyroidism** and **malignant hypercalcaemia**?
**PTH** should be suppressed
60
Which **investigations** are usually indicated in suspected malignant hypercalcaemia?
Full examination (including breast) Myeloma screen (immunoglobulins, protein electrophoresis, urinary light chains) CT
61
What form the **management** of **malignant hypercalcaemia**?
**IV rehydration** (prompts calcium diuresis - if HF loop diuretics may be required) **Calcitonin** (promotes urinary calcium excretion, inhibits bone resorption) **Bisphosphonate therapy** (inhibit osteoclasts e.g. pamidronate or zoledronic acid) **Admit if serum calcium \> 3 mmol/L** (if less then managed as outpatient with oral hydration (3-4 L / day)
62
What is **malignant superior vena cava obstruction** (SVCO)?
**Obstruction to the flow of blood** through the **superior vena cava** secondary to a cancer
63
What does the SVC provide drainage for?
Upper limbs Head Neck
64
What unites to form SVC?
**Brachiocephalic veins**
65
Which cancers commonly cause SVC obstruction?
**Lung carcinoma** (small cell) ## Footnote **non-Hodgkin's lymphoma**
66
Which **collateral systems** may develop in SVC?
Azygous system Internal mammary Long thoracic
67
Which **lung cancer** mostly causes **SVCO**?
Non-small cell lung cancer
68
How does **SVCO** present?
**Dyspnoea** ## Footnote **Facial swelling** **Head fullness** **Cough**
69
Which signs may warrant **urgent management** in **SVCO**?
**Airway obstruction** (stridor) **Neurological symptoms** (cerebral oedema)
70
What are the **signs** and **symptoms** of SVCO?
**_Symptoms_** Dyspnoea Facial swelling Head 'fullness' Symptoms exacerbated by bending forwards / lying down Cough Dysphagia **_Signs_** Facial swelling Distended neck veins Upper limp oedema Facial plethora Cyanosis Cognitive dysfunction Coma
71
What is **pemberton's sign** in **SVCO**?
Pt elevates both arms above head for **1-2 minutes** **Positive** if causes **congestion**, **cyanosis** and **respiratory distress** (increased venous return exacerbates obstruction)
72
What are the **investigations** in **SVCO**?
**Initially** Abnormal **chest radiograph** (FINDINGS = mediastinel widening and malignant pleural effusion & helps exclude other causes of breathlessness) **Diagnostic** Extent and level of obstruction, presence of collateral vessel formation and underlying cause (PET CT, CT abdo / pelvis / MRI to identify mets) **Duplex ultrasound** may be used to diagnose SVCO (indwelling catheters, MRI and contrast venography are rarely used)
73
How may a **histological diagnosis** be obtained?
**Minimally invasive** **procedures** = sputum / pleural fluid cytology, lymph node biopsy, bone marrow biopsy **Invasive** = bronchoscopy, mediastinoscopy, video assisted thoracoscopy
74
What is the **emergency management** of **SVCO**?
(treats respiratory distress / cerebral oedema) Thrombus related = stent / thrombolysis Not thrombus related = stent
75
What is the **general and definitive management** of **SVCO**?
**General** = elevation of head and neck, titrated oxygen, glucocorticoids to reduce swelling (dex) **Definitive** = stenting, RT, CT
76
How to choose between RT and CT in **SVCO**?
**RT** = NSCLC and lymphomas **Chemo** = SCLC and NHL
77
What is the **life expectancy** of patients presenting with **SVCO**?
6 months
78
What causes **tumour lysis syndrome**?
**Metabolic disturbances** arising from **breakdown of malignant cells** following initiation of treatment for malignancy
79
What are the **electrolyte imbalances** in **tumour lysis syndrome**?
**Hyperkalaemia** **Hyperphosphataemia** **Hypocalcaemia** **Hyperuricaemia** (from metabolism of nucleic acids)
80
What may result from **tumour lysis syndrome**?
AKI Arrythmias Sudden death
81
Which tumour factors are associated with increased risk of TLS?
High **proliferation rate** **Chemosensitivity** **Large tumour burden** Follwogin initation of cytotoxic therapy
82
Which **clinical factors** also increased likelihood of developing TLS?
**Pre-existing metabolic abnormalities** e.g. hyperuricaemia, hyperphosphataemia ## Footnote **Renal impairment**
83
Why does **hypocalcaemia** occur in **TLS**?
Secondary to **hyperphosphataemia** (calcium precipitates in soft tissues)
84
When do features of TLS occur after initiation of chemo?
**First 72 hours** (up to 7 days post-treatment)
85
What are the **symptoms** and **signs** of **TLS**?
**Symptoms** = lethargy, N&V diarrhoea, anorexia, muscle cramps, syncope, pruritus, arthritis **Signs** = fluid overload, haematuria, tetany & paraesthesia (hypocalcaemia), bronchospasm (wheezing)
86
Which **investigations** are **essential** to assess and diagnose severity of **TLS**?
**Renal function** **Electrolytes** **Serum urate**
87
Which other investigations may be required for **TLS**?
**Urine dip** **Urine microscopy** (for uric acid crystals) **Serum lactate** **Lactate dehydrogenase** (LDH) **ECG** **Cardiac monitoring**
88
How is **TLS** diagnosed?
**Cairo-Bishop definition** **Lab diagnosis** = 2 / more abnormal serum values in **three days prior** or **seven days after treatment** (uric acid, potassium, phosphate or calcium) **Clinical diagnosis** = if lab diagnosis with presence of raised serum creatinine, cardiac arrhythmias, sudden death or seizure (can't be attributed to therapeutic agent)
89
What **hypouricaemic** agent may be used to **prevent hyperuricaemia**?
Allopurinol Rasburicase
90
What is the **MOA** for allopurinol?
**Xanthine oxidase inhibitor** (doesn't act on pre-existing uric-acid)
91
How does **rasburicase** work?
Metabolises **uric acid** to **allantoin**
92
What are the **options** for **prophylaxis** against **TLS**?
Oral hydration IV hydration Allopurinol Rasburicase
93
What is the **management** of **TLS**?
**Hyperphosphataemia** = hydration, dietary restriction, haemofiltration **Hyperkalaemia** = IV calcium gluconate, insulin / dextrose infusion, nebulised salbutamol **Hypocalcaemia** = shouldn't be treated, causes increased calcium phosphate deposits in kidney if treated (if arrythmias then treat) **Hyperuricaemia** = hypouricaemic agents
94
When is **haemofiltration** indicated in **TLS**?
Intractable **fluid overload** Refractory **hyperkalaemia** Hyperphosphataemia-induced **symptomatic hypocalcaemia** **High calcium-phosphate product**

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