Teaching clinic: Oncology emergencies Flashcards
Oncological emergencies
- spinal cord compression
- malignant hyperCa
- tumor lysis syndrome
- SVCO
- thromboembolism
- cardiac tamponade
- cerebral edema, status epilepticus
- treatment toxicities e.g. febrile neutropenia, immune related AE
63yo women with stage 4 breast cancer
1 month history of back pain
sudden onset of clumsiness on going up stairs and 2 recent falls
progressed to bilateral leg weakness
no sensory deficit
next step?
- X ray spine, MRI whole spine
- IV dexamethasone 8mg BD (don’t wait for MRI)
- Pain control: analgesics +/-thromboprophylaxis
- Bloods (hyperCa)
- RT/ surgery (depends on solitary/multiple lesion, duration of neurological impairment, spinal stability, bone compression
Etiology of malignant spinal cord compression
Prostate, lung, breast cancer (15-20%) –> renal carcinoma, myeloma (5-10%)
Site: thoracic (60%) >lumbrosacral (30%)>cervical (10%)
Can be initial presentation of a malignancy in 20%
elderly man metastatic prosate CA involving bone. recent worsening of back pain with constipation
fluctuating levels of consousness
cause of constipation?
What to do if patient comes in constipation with pain?
cause of fluctuating level of consiousness?
Painkillers (Opioids) –> give lactulose
Give subcutaneous morphine (to relieve pain)
Do AXR to observe for faecal loading. Than can switch back to oral painkillers after clearing.
Hypercalcemia of malignancy (acute): nausea, vomiting, constipation, confusion, fluctuating levels of consiousness (lower threshold in elderly), back pain
SS of hypercalcemia
(will not have stones (in chronic condition to form stones)
Hence will not have groans (pain)
elderly man metastatic prosate CA involving bone. recent worsening of back pain with constipation
fluctuating levels of consousness
CBC normal
RFT normal except mildly raised CR and urea
LFT normal, albumin 28
Blood glucose normal
Calcium: 4mmol/L
Adjusted calcium = measured Ca + (0.02x (40-albumin)) = 4.2mmol/L
Albumin low (poor prognostic sign): malnourished, cachexic
Proportion of malignant hypercalcemia causes
PTHrP: 80%
bone met:20%
Calcitriol production: rare
Bone resorptive cytokines: rare
Ectopic PTH: rare
Mx of malignant hypercalcemia
- NS hydration q4-6, guided by urine output or CVP+/- loop diuretics (consider only after patient rehydrated): Need to assess the patient every liter (assess hydration not the calcium status). Close monitoring of Na/K/Ca/Mg/fluid status. May need to replace K because given alot of Na
- Bisphosphonate/RANKL inhibitor: pamidronate (used in renal impairment), zoledronate: works faster and longer (requires dosage adjustment in renal impairment). Wait 2 days for pamidronate effect.
- Calcitonin
- Systemic steroids may be helpful in lymphoma, but avoided if specific dx not made yet
- Treatment of cancer
67yo man presented with fatigue, profuse sweating and abd pain after treatment for bulky extensive stage small cell lung cancer
ABG: metabolic acidosis
Ur 12.1 mmol/L, Cr 177umol/L
K7.3 mmol/L, Ca 1.75 mmol/L, po4 4.68mmol/L
Urate 890 umol/L
LDH 270 IU/L
dx?
How to prevent dx?
tumor cell lysis syndrome (SCLC, germ cell, terminal cancer –> responsive to chemo –> should be able to expect TLS)
Give allopurinol and fluid hydration beforehand
60yo man chronic smoker, 1 week history of increasing SOB and cough, 1 month history fo weight loss
swollen face, neck and upper limbs
dilated veins over upper chest
dx and Mx?
SVCO
* Steroid: dex 4mg qid
* RT
* Chemotherapy: used with/without RT in chemosensitive tumors e.g. lymphoma, germ cell tumor, SCLC
* Intraluminal stenting
Contraindications for stenting:
* Venogram absent: cant pass a guidewire through (almost absolute occlusion)
* Lots of clots: may get dislodgement
Patient with dyspnea cancer px cause
- Pleural effusion
- Pulmonary embiolism
- Drug related pneumonitis
- Radiation induced pneumonitis
- Interstitial lung disease (immune checkpoint inhibitors)
- Cardiac tamponade from pericardial effusion
- Congestive heart failure (anthracycline, herceptin, immunotherapy)
- Bronchial obstruction with lung collapse
- Lymphangitis carcinomatosis (cancer spread through lymph channel: impairs oxygen transfer from alveoli to blood vessels)
- Anemia
Appearance of pleural effusion naive treatment, post treatment and cancer?
Loculated fluid: prenaive treatment
talc pleurodesis: will see highlighted white line
Thickening of pleura: cancer affecting pleura
Methods of pleurodesis
Surgical: deflate the lung half way –> video assisted talc
Medical: chest drain –> drain –> than insert talc and roll the patient around to distribute talc around.
If the lung is expandible its good prognosis. If not expandible i.e. pleural effusion for too lung (lung collapse loses its elasticity) –> hydropneumothorax. If do talc it will not be able to stick together.
Reasons for talc pleurodesis failure
- Lung unable to expand (i.e. prolonged pleural effusion and prolonged lung collapse)
- Cancer of the pleural lining: bulky areas cannot stick together causing loculation (air bubbles)
- If patient was given steroids (as pleurodesis relies on fibrin deposition (inflammation) by fibroblasts –> so ideally give NSAIDs for better outcome)
Saddle embolism
Tumor compressing bronchus causing lung collapse
Ground glass appearance: pneumonitis
Lympangitis carcinomatosis
Faecal impaction
Fluid levels
Dilated bowel loops
53yo male with metastatic RCC involving lung
Post C1 nivolumab and ipilimumab (CTLA4 inhibitor)
Diarrhea after antibiotics for tooth destriction
Post C2 nivolumab and ipilimumab
Profuse diarrhoea (grade 3: 6x a day)
Tx: oral prednisone, methylprednisolone, infliximab (anti TNFa, used for resistance against steroids)
67yo male 15 pack years
stage 4 NSCLC of adenocarcinoma
Mediastinal nodes and bone
PDL1 >50%
2 weeks after c1 pembrolizumab, worsening dypsnoea and hypoxia
Cause and Mx?
Pnuemonitis, COPD
High dose prednisolone
Cease anti PD1
Immune related toxicities
