Oncology complications

Question 1

A 67yo woman with known ovarian cancer presents due to abdominal distension + nausea. O/E: abdo. distension, flank dullness, shifting dullness, fluid thrill.

What are the 2 main mechanisms for ascites in malignancy?

Answer 1

1. Peritoneal malignancy: increased peritoneal permeability + lymphatic obstruction causing exudate
2. Portal hypertension: due to hepatic mets or cirrhosis causing transudate

Question 2

How would you determine whether a malignant ascites is a transudate or an exudate?

Answer 2

Diagnostic paracentesis to measure SAAG: (serum albumin) - (ascitic albumin)

• high gradient (>11g/L): transudate - caused by portal HTN
• low gradient (<11g/L): exudate - caused by peritoneal cancer (or peritoneal infection, nephrotic synd., hypoalbuminaemia)

Question 3

What is the usual Mx for malignant ascites?

Answer 3

Paracentesis (can drain up to 5L over 1st 4hrs without IV fluid replacement)

Question 4

Suggest common causes of malignant pleural effusion.

Answer 4

1. primary pleural malignancy: malignant mesothelioma

2. secondary pleural malignancy: lung (men), breast (women)

Question 5

A 72yo male with a Hx of lung cancer presents with increased SOB. Examination suggests presence of a pleural effusion.

Which investigations should be performed?

Answer 5

1. cCT chest
2. thoracic USS + pleural fluid sampling
3. thoracoscopy + pleural biopsy

Question 6

What are the Mx options for a patient with a symptomatic malignant pleural effusion?

Answer 6

1. therapeutic pleural aspiration: for transient Sx relied in pts with poor PS + short life expectancy
2. intercostal tube drainage + pleurodesis (with sclerosant): preferred option
3. indwelling pleural catheter

Question 7

A 73yo woman with metastatic ovarian cancer presents with N+V, abdo. distension + absolute constipation.

How would you investigate?

Answer 7

1. AXR

2. abdo. CT/MRI

Question 8

What Mx options are there for malignant bowel obstruction?

Answer 8

1. surgery or endoscopic stent
2. PEG + aspiration
3. palliative Tx

Question 9

Suggest causes for new onset seizures in oncology patients.

Answer 9

1. brain or meningeal metastases
2. chemotherapy e.g. cisplatin, or cranial RT
3. toxic-metabolic encephalopathy e.g. TLS
4. CNS infections
5. neurological paraneoplastic syndromes

Question 10

A 34yo woman with known breast cancer is brought to ED due to new onset tonic-clonic seizure.

Which Ix should be performed?

Answer 10

1. brain MRI (gadolinum enhanced): ?brain mets, ?infection
2. U+Es: ?metabolic disorder
3. serum/CSF drug assays
4. LP (cytology + culture): ?brain mets/tumours, ?infection

Question 11

A 34yo woman with known breast cancer is brought to ED due to new onset tonic-clonic seizure.

Which Tx does she need in immediate setting? Long term?

Answer 11

Immediate
- LORAZEPAM IV

Long term
- LEVETIRACETAM or other non-enzyme-inducing AED