Oncology Flashcards
(24 cards)
Febrile neutropaenia definition
Neut <0.5 OR <1 w/ expected decline
+ Fever
- Single >38.5 OR >38.0 for >1 hour
Febrile neutropaenia: low risk features
- Solid tumours
- Less intensive chemo regimens
- Neutropaenia <10 days
Febrile neutropaenia: common causative chemotherapy agents
Methotrexate
Carboplatin/cisplatic
Taxanes
5-fluorouracil
Doxorubicin
Cyclophosphamide
Febrile neutropaenia: common causative organisms
Gram positives
- Most common, but lower risk mortality
- Staph aureus
- Streptococci, enterococci
Gram negatives
- Used to be most common, higher risk mortality
- E coli, klebsiella
- Pseudomonas should be considered
Aspergillosis very high risk mortality
Neutropaenia nadir post-chemo
7-10 days, usual onset of febrile neutropaenia
Up to 4 weeks
Febrile neutropaenia: empiric antibiotic choice
Piptaz 4.5g q8hourly (6hrly if septic)
If systemically unwell:
- Add gent 7mg/kg
If shocked:
- Add vanc 1.5g (25mg/kg)
If suspected abdominal or perineal infection:
- Add metronidazole 500mg BD
Febrile neutropaenia risk index and items
MASCC febrile neutropaenia risk index
- Symptoms (none/mild, mod, severe)
- sBP (> or <= 90mmHg)
- Active COPD (y/n)
- Solid tumour (y/n)
- Prev fungal infection in haematological malignancy (y/n)
- Dehydration requiring IVF (y/n)
- Location at onset (outpatient vs inpatient)
- Age (< or >=60)
Higher score better
>=21 = low risk
<21 = high risk of complications
Superior vena caval syndrome: causes
Primary lung Ca - 70% (45% SCC)
Lymphoma - 10%
Metastatic neoplasm - 10%
Non neoplastic - 10% incl.:
- thrombosis
- benign tumours
- aortic aneurysm
- thyroid enlargement
- irradiation
- histoplasmosis
- TB
- syphilis
Superior vena caval syndrome: history and exam
History
- Headache
- Dyspnoea (common >50%)
- Chest pain
- Cough
- Voice hoarseness
- Stridor/dysphagia (rare)
- Epistaxis
- Syndrome
- Worse on bending forward or laying down
Exam
- Upper body oedema incl. face, neck, tongue
- Distension of neck veins
- Facial plethora or telangiectasia
- Pemberton’s sign +ve
- Severe: proptosis, glossal and laryngeal oedema, altered conscious state
Superior vena caval syndrome: management
Elevate head of bed
Oxygen
Treat primary cause
IVCs in lower limbs
Urgent anti-tumour therapy*
Angioplasty and stenting may be considered in severe symptoms and malignancy (quicker onset of relief)
*RTx for:
- NSCLC
- Other solid tumours
CTx for:
- SCLC
- Lymphoma
Surgery for:
- Benign tumours
Chemotherapy cardiac effects and most common causative agents
Arrhythmias
CCF
ACS
Venous thrombosis
Cisplatin
Vinblastine
Bleomycin
Tumour lysis syndrome: pathophys, onset and common malignancies
Mass destruction of rapidly proliferating neoplastic cells
Usually 1-5 days post-chemo
Rarely due to spontaneous necrosis of malignancies
Most common in haematological malignancies:
- Burkitt’s lymphoma
- Acute lymphoblastic leukaemia
- Other high grade lymphomas
- Occasionally with chronic leukaemias
Rare with solid tumours
Tumour lysis syndrome: metabolic features
Hyperuricaemia (causes AKI)
Hyperkalaemia
Hyperphosphataemia
Lactataemia
HYPOcalcaemia*
*Reciprocal to hyperphosphataemia due to release of intracellular phosphate
Tumour lysis syndrome: management
- Anticipate and pre-treat with allopurinol
- IVF
- Alkalinise urine - 1mmol/kg aim urinary pH >7.0
- Consider rasburicase
- Recombinant urate oxidate, converts urate to solid allantoin
- Expensive++ - Correct electrolytes
- Consider dialysis early
Allopurinol, rasburicase, bicarb, IVF, electrolytes, early dialysis
Immune checkpoint therapy examples and common clinical complications
Nivolumab
Pembrolizumab
Ipilimumab
Peak incidence 12-16 weeks post-initiation (approx. 4th dose)
All the -itises!
Puritis, rash, dermatitis
Colitis
Hepatitis
Headache, dizziness, sensory changes
Adrenal insufficience
Diabetes
Hypo/hyperthyroid
Myocarditis
Arthralgias/myositis
Pneumonitis
Managed initially with glucocorticoids
Differentiation syndrome: clinical features and treatment
Complication of treatment with all-trans retinoic acid or arsenic trioxide therapy
Acute promylocytic leukaemia
First month of therapy in 25% of patients
Life-threatening
Unexplained fever
Haemodynamic instability
Weight gain from oedema
Renal failure
Pulmonary infiltrates and/or effusions
Mx:
Corticosteroids
- Reduce mortality from 30% to 1%
Typhlitis: Presentation and management
AKA neutropaenic enterocolitis
Necrosis of caecum and adjacent colon
Usually following treatment of acute leukaemia
- Watery diarrhoea
- PRB
- Bacteraemia
IVABx
- Piptaz 4.5g 8hrly OR
- Cefepime 2g 8hrly + metro 500mg BD
NGT
Consider GCSF
Surgery if not improving after 24hr ABx
Haemolytic uraemic syndrome: onset and associations
Usually 4-8 weeks post-chemo
Mitomycin (most common)
Bleomycin
Cisplatin
BMT
Malignancies:
- Gastric
- Colon
- Breast
Malignancy may not be clinically apparent in up to 35% at presentation
Haemorrhagic cystitis: pathophys and management
Following CTx with cyclophosphamide or ifosfamide
-> metabolised to acrolein -> excreted in urine -> chemical irritant to bladder
Prevented with 2-mercapto-ethanesulonate (MENSA)
- Detoxifies metabolites
- Co-administered with instigating drug
Mx:
- Maintain high urine flow with fluids
- Irrigate bladder with 0.37-0.74% formalin solution for 10 mins
- NAC considered
- Cystectomy in extreme cases
Comparison of anaemias - for study only
Malignancies that metastasise to bone
Breast
Prostate
Lung
Thyroid
Kidney
Types of bone metastasis
- Osteoblastic
- Prostate, SCLC - Osteolytic
- MM, RCC, GI, uterine - Mixed
- Breast, lung, cervical, testicular
Isolated raised ALP differential
May be indicative of bone turnover
Paget’s disease
Bony metastasis
Vit D deficiency
Growth spurts in kids
Risk factors of tumour lysis syndrome
Malignancy factors:
Haematological malignancy
High tumour proliferation rates
Large tumour burden
Sensitivity to CTx
Bulky disease >10cm diameter
Leukocytosis >25x10^6
Patient factors:
Pre-existing renal impairment
Pre-existing hyperuricaemia
