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.
1 of 40
Which cancers commonly lead to tumour lysis syndrome?
Tumours with highly proliferative or high tumour cell burdens - Leukaemia, lymphoma, germ cell tumours.
2 of 40
What are the consequences of tumour lysis syndrome?
Renal failure (oliguric AKI - acute tubular necrosis), cardiac arrhythmia, tetany, hyperreflexia/tonia, seizures
3 of 40
What are the relevant investigations that form the "tumour lysis screen"?
U+E (look at urea, creatinine, K+), Ca2+ profile, phosphate, LDH, uric acid
4 of 40
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 -).
5 of 40
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.
6 of 40
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
7 of 40
Which cancers commonly cause MSSC?
Breast, Lung, Prostate, Renal, Thyroid OR/ 10% due to an unknown primary or 1st presentation of cancer
8 of 40
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)
9 of 40
What is the differential diagnosis for paraparesis?
Trauma-induced, vertebral artery infarct, MS, Guillian-Barré, transverse myelitis
10 of 40
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.
11 of 40
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
12 of 40
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).
13 of 40
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]
14 of 40
Additional management for MSSC
Physiotherapy (rehabilitation), analgesia, catheter/bowel care, DVT/UTI, monitor pressure areas
15 of 40
What is superior vena cava obstruction (SVCO)?
Obstruction of flow through the SVC due to external compression, invasion or intraluminal thrombus
16 of 40
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)
17 of 40
Symptoms of SVCO are?
Acute or chronic shortness of breath, flushed face, swollen face, neck, arm (bilateral), cough and nasal congestion, headache, dizziness, syncope
18 of 40
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),
19 of 40
Inital management of SVCO:
Sit patient up and give 02. Hydrate. Dexamethasone (8mg, BD). Anti-coagulation (if thrombus is present or catheter-related)
20 of 40
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)
21 of 40
What is the definitive treatment for proven SVCO?
Vascular stent (rapid improvement of Sxs), Radiotherapy (not suitable with ?histology - tumour may not be radiosensitive)
22 of 40
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
23 of 40
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
24 of 40
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
25 of 40
What is the range for normal ICP?
0-10 mmHg
26 of 40
Symptoms of RICP:
Neuro (headache, drowsy, fits, ataxia, changes in personality + behaviour), Nausea and vomiting, Visual disturbances
27 of 40
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)
28 of 40
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
29 of 40
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
30 of 40
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
31 of 40
Causes of SIADH:
Small cell lung cancer, some chemotherapy agents, ACE inhibitors, antidepressants
32 of 40
How does SIADH present?
Asymptomatic; Symptomatic (fatigue, nausea, anorexia, muscle cramps, behavioural changes, seizures, coma, death); incidential findings on bloods
33 of 40
Investigations for SIADH are:
U+E, TFTs, cortisol. Check medications.
34 of 40
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)
35 of 40
What is hypercalcaemia?
Ca2+ >2.65mmol/L/>3.5mmol/L (severe)
36 of 40
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.)
37 of 40
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)
38 of 40
Investigations for HyperCa2+:
Ca2+ profile, phosphate, U+Es, ECG, radioisotope bone scan (if not known to have bone mets), +/- PTH level
39 of 40
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)
40 of 40

Other cards in this set

Card 2


Which cancers commonly lead to tumour lysis syndrome?


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

Card 3


What are the consequences of tumour lysis syndrome?


Preview of the front of card 3

Card 4


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


Preview of the front of card 4

Card 5


What is the preemptive management of tumour lysis syndrome?


Preview of the front of card 5
View more cards



Similar Health & Social Care resources:

See all Health & Social Care resources »