Oncological Emergencies

1. Cancer Studies

2. Oncological Emergencies Spinal cord compression Bone marrow suppression/ neutropenic sepsis Superior vena cava obstruction Raised intracranial pressure/Brain METS Stridor Acute blood loss Obstruction Biochemical crisis: hypercalcaemia Pulmonary embolism

3. Spinal cord compression Bone involvement from cancer LBTKP Commonly: lung, breast, lung, myeloma, lymphoma Less common: thyroid, kidney, bladder, bowel, melanoma Can be initial presentation of malignancy: prostate, breast, myeloma Crush fracture or tumour extension common Occasional intramedullary METS 66% cases: thoracic cord Symptoms: Back pain: within a nerve root, worse on coughing/straining Saddle anaesthesia Urinary retention/dribbling/incontinence – late Constipation/dribbling/incontinence of faeces – late Loss of power and sensation distal to area of obstruction Limb weakness/unsteadiness when walking Brisk reflexes early, absent reflexes late

4. Spinal Cord Compression Signs: Reduced tone in legs Reduced reflexes late. Brisk early. Decreased power and sensation Reduced anal tone Upgoing plantars (late) Investigations MRI whole spine Bone scan (radioisotope) If no Hx of malignancy, investigate for malignancy – CT chest/ abd /pelvis Management Bed rest and catheter DEXAMETHASONE 8MG BD IV/PO Analgesia Surgery or radiotherapy to METS (20Gy in 5fractions over 5days) Indications for surgery: survival likely >3m, single site compression, no systemic disease, previous radiotherapy to spine, unknown 1o requiring Dx , bone fragment compressing cord, no response to steroids, no cancer

5. Cauda Equina Syndrome Tumours below L1/L2 level Symptoms: Bilateral sciatic pain Bladder dysfunction (retention/incontinence) Impotence Saddle anaesthesia Loss of anal sphincter tone – MUST DO PR EXAM!!! Weakness and wasting of gluteal muscles Diagnosis by MRI spine Rx: dexamethasone 8mg IV BD, RT, Sx

6. Pulmonary Embolism Cancer patients are more prone to PE as they can be in a HYPERCOAGULABLE state. This can be due to cancer related blood constituent changes or pressure on vessel walls causing stasis/altered blood flow Active cancer is on the WELLS score criteria for DVT Symptoms: SOB Pleuritic chest pain Dry cough May have calf pain/swelling Signs Raised JVP Tachycardia and tachypnoea, S1Q3T3 “gallop rhythm” – high output states Peripheral/central cyanosis Vesicular breath sounds in most areas

7. Pulmonary Embolism Investigations ABG: decreased PaO2, decreased PaCO2 (due to reduced ventilation), can cause respiratory alkalosis ECG: right heart strain S1Q3T3. rule out MI D-dimer: raised (non-specific) CTPA/VQA scan: identify non-perfused part of lung CXR: wedge infarct Treatment: Oxygen therapy Enoxaparin 1.5mg/kg/day Consider starting warfarin for 6m Analgesia: NSAIDs ENOXAPARIN works best for cancer patients

8. Neutropenic Sepsis Chemotherapy can cause bone marrow suppression , leading to pancytopenia. The reduction in WCC (neutropenia) leaves the patient at risk of developing infections. This can quickly lead to sepsis and septic shock Cannot judge sepsis by temperature!!! Symptoms and Signs: Drowsy, decreased level of consciousness, confusion Cold peripheries Tachycardia Hypotension May be signs of infection e.g. cough in chest infection Investigations: Cultures: blood, urine, throat, current lines (hickmans, catheter) Venous access, IV fluids: colloids Catheter to monitor urinary output Oxygen IV Abx in accordance with hospital guidelines Granulocyte Colony Stimulating Factor (CGSF) if haemodynamically unstable/slow response Give GCSF prophylactically with next dose of chemo

9. Chemo Induced Thrombocytopenia Bone marrow suppression leads to thrombocytopenia, leucopenia and anaemia Signs & Symptoms Increased tendency to bleed, difficult to stop Petechiae Large haemorrhage  hypovolaemic shock Investigations FBC Coag screen D-dimer: raised may indicate DIC Management Give platelets until above 10, 20 if septic May need packed red cells if haemorrhage If DIC: fresh frozen plasma required DIC occurs when the coagulation and fibrinolysis systems are dysregulated. This can commonly occur in lung, pancreas, stomach and prostate cancer, as well as APL . Many small clots form and are subsequently broken down. This process leads to the consumption of clotting factors and platelets leading to increased risk of bleeding.

10. Bone M arrow Suppression Major dose limiting factor in chemotherapy RBC survive 120days, platelets 8days, neutrophils 1-2days so early problems are neutropenia and thrombocytopenia Neutropenia particularly if line/catheter in/previous infection/open wound… Management of neutropenic pt : Blood cultures (peripheral and central if line in) Sputum culture Urine analysis and culture CXR Physical exam, swabs Treatment: Wide spectrum Abx e.g. IV tazocin Low Hb : consider packed cells, investigate cause, rule out DIC

11. Lines Hickman: under clavicle Tunnel catheter Into subclavian vein, down to superior vena cava PICC: Peripherally inserted central catheter

12. Hypercalcaemia Common malignancy related causes: Parathyroid hormone related protein Local osteolysis due to bony metastasis Tumour producing Vitamin D metabolites Commonly seen with BREAST, LUNG ( nonsmallcell ), multiple myeloma and prostate Affects 20-40% pts with advanced cancer Signs and Symptoms: Bones: bone pain, pathological fractures Stones: polyuria, polydipsia, kidney stones Moans: confusion, depression, decreased level of consciousness/coma Groans: constipation, pancreatitis, epigastric pain Investigations: U&E: Na and K raised due to dehydration, calcium RAISED >2.6 Cause unknown: CTCAP, CXR, ECG: decreased QT interval Management 4-6l saline over 24hrs IV bisphosphonates e.g. zolendrenic acid Catheter to monitor urine output

13. Corrected Calcium Corrected calcium is calculated from the measured calcium. Calcium is bound to albumin so the amount of measured calcium depends on the level of albumin. Corrected calcium estimates the calcium level if the albumin was within the normal range. Corrected calcium = measured calcium + (40-Alb) x 0.02 E.g. Ca 3.46, Albumin 28 Corrected calcium = 3.46 + (40-28) x 0.02 = 3.46 + 0.24 = 3.7 mmol /l.

14. Differential Diagnosis thirst, polyuria, constipation Diabetes mellitus Diabetes insipidus Hypercalcaemia Hypernatraemia Psychogenic polydipsia

15. Brain Metastases/Raised ICP Raised ICP: space-occupying lesion, hydrocephalus, benign intra-cranial HTN Brain M increasing in prevalence since people are surviving longer with cancer 20-40% pts with advanced disease: Particularly LUNG, BREAST, MELANOMA Symptoms: Headaches- worse in the morning and on stooping N&V – worse in morning Confusion, altered behaviour Focal neurological signs Seizures Investigations CT brain Management DEXAMETHASONE 8MG BD IV/PO : shrink mass/inflammation to reduce risk of coning whole brain radiotherapy if 2+ METS Anti-epileptics for seizures: carbamazepine ***can’t drive ever again OSCE!!!!!!!!!!! Surgery: solitary met with controlled systemic disease, unknown diagnosis need sample, rapid deterioration, hydrocephalus (shunting)

16. SVC obstruction Obstruction of the SVC occurs commonly with lung tumours and lymphomas which can press on SVC (right sided tumours) Signs & Symptoms Raised JVP Puffy face and arms Dilated veins on chest wall Plethoric face Headache (worse on stooping), visual disturbance (papilloedema) Investigations CXR: widened mediastinum/lung tumour SVC venogram CT with contrast Management Oxygen Dexamethasone 8mg BD Stent/radiotherapy/chemotherapy as appropriate External compression: breast cancer, lung cancers, lymphoma, thymoma 90% Internal thrombosis: central line, pacing wire 10% DDx : heart failure, tamponade , external jugular vein compression

17. Stridor Benign or malignant causes: Non-malignant: foreign body, tracheal stenosis, vocal palsy Malignant: primary respiratory tract tumours, bronchial (carina) tumours/ thyroid, mediastinal lymphadenopathy or MET Signs and Symptoms Goitre Weight loss Clubbing Investigations CXR: widening of mediastinum, 1o lung cancer Bronchoscopy: biopsy/cytology CT scan Mediastinoscopy Treatment: Dexamethasone 8mg IV BD Tumour debulking : radio/surgery

18. Obstruction Intestinal Pelvic cancers: ovarian 6-42%, cervical 5%, colonic 10-30% May be complete, subacute or functional Signs & symptoms: N&V, colicky pain, constipation, disyension , dehydration, projectile vomiting Inv : erect and supine abdominal x-ray, barium studies, MRI Treatment: IV fluid, NG tube, surgery/radiotherapy Urinary Tract Causes: bladder, prostate, cervis , pelvic cancers Symptoms: asymptomayic , pain Inv : abdominal US, cystoscopy