Oncological Emergencies

  • Created on: 14-12-12 17:18
What is Tumour Lysis Syndrome?
Series of metabolic derrangements (hyperuricaemia, hyperkal, hyperphos, hypocal) due to massive and abrupt release of intracellular contents during a period of rapid malignant cell lysis; with initiation of radiotherapy and chemotherapy agents.
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Which cancers commonly lead to tumour lysis syndrome?
Tumours with highly proliferative or high tumour cell burdens - Leukaemia, lymphoma, germ cell tumours.
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What are the consequences of tumour lysis syndrome?
Renal failure (oliguric AKI - acute tubular necrosis), cardiac arrhythmia, tetany, hyperreflexia/tonia, seizures
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What are the relevant investigations that form the "tumour lysis screen"?
U+E (look at urea, creatinine, K+), Ca2+ profile, phosphate, LDH, uric acid
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What is the preemptive management of tumour lysis syndrome?
High risk - >chemo [IV fluids, Rasburicase (urate oxidase -)]; Moderate - IV fluids, >chemo allopurinol (do TLS screen 4-6hrs into chemo); Low - oral fluids, allopurinol (xanthine oxidase -).
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Are there any additional supportive measures that can be taken?
Haemodialysis, ITU support, need to try and alkalinise the urine to enable filtering of the uric acid compenent.
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Define Metastatic SC Compression (MSSC).
Compression, indentation, displacement or encasement of the SC's thecal sac from the presence of a metastatsis in the bony vertebrae or direct extension from intra-thoracic or intra-abdominal tumour
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Which cancers commonly cause MSSC?
Breast, Lung, Prostate, Renal, Thyroid OR/ 10% due to an unknown primary or 1st presentation of cancer
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How can MSSC present?
Paraparesis/weakness (off-legs). Autonomic dysfunction (bladder, bowel disurbance). Senosory level. Back pain (location, progressive lower, severe unremitting, nocturnal, radicular, aggravated by straining)
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What is the differential diagnosis for paraparesis?
Trauma-induced, vertebral artery infarct, MS, Guillian-Barré, transverse myelitis
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How spine stability determined?
Clinical: Presence of pain on movement. Radiological: surrounding vertebrae affected, vertebral body/pedicles/spinous process affected. 2/3 radiological + clinical findings = unstable spine.
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How is MSSC investigated?
Plain spine XR (?collapse/obvious mets) MRI whole spine w/in 24hours [reconstructed CT scan of whole spine - if MRI is contraindicated] w/neurological sxs/signs suggesting MSSC or w/in 1wk+sxs suggestive of spinal mets. Tissue diag. @1st presentation
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What is the management for an unstable spine?
Nurse flat (log rolling, slipper pan for toilet) using a neutral spine alignment (Brace) - DO NOT ALLOW PT. TO WALK FREE. Pain relief (morphine).
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Emergency management of MSSC
Reducing dose of dex(8mg, BD). SURGICAL DECOMPRESSION (unstable spine, ?histology, c/o diagnosis of malignancy/unknown 1o, previous radioT to area)1-2 V up/down+adjunct radioT; RadioT [extensive mets, poor prognosis, not fit for surgery, abN. bones]
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Additional management for MSSC
Physiotherapy (rehabilitation), analgesia, catheter/bowel care, DVT/UTI, monitor pressure areas
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What is superior vena cava obstruction (SVCO)?
Obstruction of flow through the SVC due to external compression, invasion or intraluminal thrombus
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Causes of SVCO are?
Mediastinal mass: 1o neoplasia: lung cancer, 2o neoplasia: lymphoma, oesophageal ca., nodal metastases from breast ca., thymoma, thyroid ca, sarcoma, germ cell tumour; Thrombosis (factor 5 Leiden deficiency)
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Symptoms of SVCO are?
Acute or chronic shortness of breath, flushed face, swollen face, neck, arm (bilateral), cough and nasal congestion, headache, dizziness, syncope
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Signs of SVCO are?
Elevated JVP (non pulsatile, no elevation with hepatojugular manouvre), venous distension on neck, upper chest, collateral vessels, plethoric facies (dusky cyanosis), papilloedema (raised ICP),
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Inital management of SVCO:
Sit patient up and give 02. Hydrate. Dexamethasone (8mg, BD). Anti-coagulation (if thrombus is present or catheter-related)
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What investigations are performed for SVCO?
CXR (looking for hilar fullness - mediastinal widening); CT chest with contrast (SVCO @ thoracic inlet due to a large mediastinal mass)
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What is the definitive treatment for proven SVCO?
Vascular stent (rapid improvement of Sxs), Radiotherapy (not suitable with ?histology - tumour may not be radiosensitive)
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A patient presents with new onset shortness of breath, intermittent dizziness and fullness of the neck. What are the potential differential diagnoses?
Infective: EBV, TB, cervical lymphadenitis; Neoplastic: lymphoma, malignant SVCO; Vascular: R-heart failure, pericardial effusion/itis
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What the 3 types of cerebral oedema?
1. Vasogenic: increased cap. permeability - tumour, trauma, ischaemia, infection; 2. Cytotoxic: cell death (hypoxia); 3. Interstitial: obstructive hydrocephalus
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What are the causes of raised intracranial pressure?
Primary or metastatic tumours, head injury , haemorrhage (subdural/extradural/subarachnoid/intracerebral), meningoencephalitis, brain abscess, hydrocephalus, cerebral oedema, status epilepticus
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What is the range for normal ICP?
0-10 mmHg
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Symptoms of RICP:
Neuro (headache, drowsy, fits, ataxia, changes in personality + behaviour), Nausea and vomiting, Visual disturbances
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Signs of RICP:
Neuro (slow pulse and raised BP - Cushing's reflex; reduced GCS); Ophthalm (6th N. palsy, visual field loss, loss of spontaneous venous retinal pulsation, papilloedema); focal signs (depend on the site of the tumour within the brain)
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What investigations are performed for RICP?
U+E, FBC, LFT, Glu, clotting, CXR + CT brain (most tumours); MRI (sensitive for small mets, meningeal disease, 4th ventricle obstruction w/hydrocephalus); histological sample (not appropriate with multiple mets/other sites of met disease)+/- LP
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What is the treatment available for RICP?
Elevate head of bed, Dex. (8mg, BD, w/gastric protection), rapidly falling GCS (mannitol), fluid restrict 1.5L/d, ANALGESIA,. Single Met: neurosurgery + RT. Multiple Mets: whole brain RT. Palliative care depending on age and fitness and cause of RICP
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What is SIADH?
Hyponatraemia and reduced plasma osmolality in the presence of inappropriately concentrated urine (urine osmolality >500mM/Kg) - inappropriate secretion of ADH: failure to excrete dilute urine, hypoNa+, fluid retention
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Causes of SIADH:
Small cell lung cancer, some chemotherapy agents, ACE inhibitors, antidepressants
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How does SIADH present?
Asymptomatic; Symptomatic (fatigue, nausea, anorexia, muscle cramps, behavioural changes, seizures, coma, death); incidential findings on bloods
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Investigations for SIADH are:
U+E, TFTs, cortisol. Check medications.
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Treatment for SIADH is:
Fluid restriction (0.5 - 1L/d) --> no response: try demedocycline (has diuretic effect by altering the effect of ADG on renal fluid resorption). Tx malignancy. In emergency: IV 1.8% NaCl (high risk of osmotic demyelination syndrome)
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What is hypercalcaemia?
Ca2+ >2.65mmol/L/>3.5mmol/L (severe)
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Causes of HyperCa2+:
Benign: iatrogenic (thiazide) diuretics, hyperparathyroidism. Malignant: myeloma, bony mets, paraneoplastic (squamous cell lung cancer, head + neck cancers, breast cancer, bladder ca., ovarian ca.)
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What is the mechanism for malignant Hyper Ca2+?
It is either due to the increased bone resorption (osteolysis) +/or humoral mechanisms (release of parathyroid hormone-related peptide - as part of a paraneoplastic syndrome)
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Investigations for HyperCa2+:
Ca2+ profile, phosphate, U+Es, ECG, radioisotope bone scan (if not known to have bone mets), +/- PTH level
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What is the treatment for HyperCa2+?
ASx - rehydrate + monitor (if <3mM/L); Sx or >3mmol/L: hydration (3l/24hr saline), monitor fluid balance, stop thiazide diuretics, correct other abN, IV bisphosphonates( monitor U+E, Phosph, Ca, K levels)
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Card 2

Front

Which cancers commonly lead to tumour lysis syndrome?

Back

Tumours with highly proliferative or high tumour cell burdens - Leukaemia, lymphoma, germ cell tumours.

Card 3

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What are the consequences of tumour lysis syndrome?

Back

Preview of the front of card 3

Card 4

Front

What are the relevant investigations that form the "tumour lysis screen"?

Back

Preview of the front of card 4

Card 5

Front

What is the preemptive management of tumour lysis syndrome?

Back

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