ONC

Question 1

list 5 key oncological emergencies

Answer 1

1. neutropenic sepsis
2. tumour lysis syndrome
3. hypercalcaemia
4. SVC obstruction
5. metastatic spinal cord compression

Question 2

What are oncological emergencies?

Answer 2

• Complications of known cancer
• Complications of treatment
• Emergency presentations of new cancers

Question 3

Commonest organisms in febrile neutropenia

Answer 3

Gram +ve organisms commonest today
- Staphylococcus: aureus, coagulase negative
- Enterococcus
- Streptococcus: pyogenes, viridans, pneumoniae
- Corynebacterium pp

Gram –ve organisms commonest in 70s
E.coli, Klebsiella, Pseudomonas, Enterobacter

Question 4

1st line abx in neutropenic sepsis

Answer 4

IV piperacillin/tazobactam 4.5 g QDS

Plus Amikacin

(in penicillin allergy give Meropenem 1g IV TDS)

Question 5

2nd line abx in neutropenic sepsis

Answer 5

Meropenem 1g IV TDS

(if no response to 1st line in 48h or if the pt has a penicillin allergy )

Question 6

Prevention of febrile neutropenia

Answer 6

• Dose reduction of chemotherapy
• Prophylactic GCSF
  typically if risk with chemo regime is >20%
• Prophylactic antibiotics
  -> Not used routinely
  -> Increased antibiotic resistance and C diff.

Question 7

Mx of metastatic spinal cord compression

Answer 7

• Dexamethasone
• Pain control
• Bed rest/log role (spinal precautions).
• Prophylactic anticoagulation
• Contact the MSCC co-ordinator as soon as possible (but definitely within 24hrs).
• Quick management is vital, once neurological function is lost is may not return.
• neurosurg opinion
• +/- radiotherapy, chemotherapy

Question 8

Prognosis in metastatic spinal cord compression

Answer 8

Many patients have a poor overall prognosis

Question 9

what is 18-FDG

Answer 9

18-fluoro-deoxyglucose

Question 10

T4 dermatome

Answer 10

at the level of nipples

Question 11

S2 Dermatome

Answer 11

S2 dermatome is perineum and back of thigh/calf

Question 12

1st line med for metastatic spinal cord compression

Answer 12

dexamethasone

(pred is not strong enough)

Question 13

Causes of SVCO

Answer 13

Cancer responsible for >90%
- NSCLC (50%), SCLC (20%)
- Lymphoma (10%), other 7%
- GCT 3%
- 2-4% patients with lung ca develop SVCO

Non malignant cause e.g. CV catheter thrombosis

Question 14

signs of SVCO

Answer 14

SOB, stridor
- upper limb and facial oedema
- facial swelling and erythema
neck vein engorgement
dilated superficial veins (e.g. on chest)
- distended neck and chest wall veins as a result of a collateral circulation developing
- arm swelling and distended arm veins
- papilloedema (a late sign)
- stridor (if severe)
- cyanosis (less common).

Question 15

Mx of SVCO

Answer 15

• Dexamethasone
• +/- anticoagulation (if clot)
• Biopsy (if new presentation)

NB steroids may impact results so discuss with onc first if new presentation

• Stenting
  If haemodynamically unstable and/or chemotherapy or radiotherapy not possible.
• Chemotherapy
  For lymphoma, germ cell and SLCL, response rate up to 80%
• Radiotherapy
• Symptomatic improvement within 48hrs, effective in 50-95%, precludes subsequent biopsy.

Question 16

Do pts with SVCO get cannon A waves?

Answer 16

No

Cannon ‘a’ waves in the JVP are associated with ventricular tachycardia and 3rd degree heart block; they are not seen in SVCO.

Question 17

What are the commonest causes of SVCO?

Answer 17

1. lung cancer
2. non-Hodgkin’s lymphoma

Question 18

Causes of hypercalcaemia of mlaignancy

Answer 18

• 80% tumour production PTHrP
• 20% Osteolytic bone mets
• 1% ectopic PTH secretion, Vit D secreting lymphomas

Question 19

Mx of hypercalcaemia of malugnaancy

Answer 19

• Rehydration
  Normal saline
  Sufficient in mild cases (ca <3.0)
• Review medication
  Stop thiazides and Ca supplements
• Bisphosphonates
  Response within 2-4 days, Nadir 7-10 days, effective 90%
• Investigations
  PTH (?), PTHrP (?)
• Refractory cases
  Repeat bisphosphonates, calcitonin, steroids

Question 20

With what elevated calcium level will you develop significant sx

Answer 20

> 3.0 mmol/L

Question 21

severity of hypercalcaemia levels

Answer 21

Mild hypercalcaemia: 2.65–3.00 mmol/L.

Moderate hypercalcaemia: 3.01–3.40 mmol/L.

Severe hypercalcaemia: > 3.40 mmol/L.

adjusted calcium concentration

Question 22

Abnormalities seen in TLS

Answer 22

↑ PO4
↑K
↓Ca2+
↑Urate
Acidosis
Resulting in AKI/potential for cardiac arrhythmias/seizures

Question 23

What is TLS?

Answer 23

Tumor lysis syndrome

= group of metabolic abnormalities that can occur as a complication during the treatment of cancer, where large amounts of tumour cells are killed off (lysed) at the same time by the treatment, releasing their contents into the bloodstream.

Question 24

Mx of TLS

Answer 24

• FLUIDS!
• ↑ PO4 - Phosphate binder, furosemide, mannitol
• ↑K - Insulin/glucose, Ca gluconate

-↓Ca2+ - Correct phosphate

• ↑Urate - Allopurinol or rasburicase
• Early discussion regarding dialysis/renal replacement therapy

Question 25

Prevention of TLS

Answer 25

- Important in all intermediate/ high risk patients (e.g. high tumour burden with rapid response to treatment) - Prophylactic treatment – e.g. allopurinol/rasburicase (test for 6GPD deficiency) - Hydration - Monitor electrolytes

Question 26

How does alluporinol prevent TLS?

Answer 26

xanthine oxidase inhibitor less uric acid produced

Question 27

Which chemotherapy agent is associated with hypomagnesaemia?

Answer 27

cisplatin

Question 28

What cancer is CA 15-3 a marker for?

Answer 28

breast cancers (cancer antigen 15-3)

Question 29

Which chemotherapy agent is associated with pulmonary fibrosis?

Answer 29

Bleomycin may cause pulmonary fibrosis

Question 30

Which chemotherapy agent is known for causing cardiomyopathy?

Answer 30

doxorubicin

Question 31

What is the commonest cause of SVCO?

Answer 31

small cell lung cancer

Question 32

Which chemotherapy drug causes peripheral neuropathy?

Answer 32

vincristine

Question 33

Which chemotherapy agent causes haemorrhagic cystitis?

Answer 33

Cyclophosphamide

Question 34

Which opioids in severe renal impairment?

Answer 34

fentanyl or buprenorphine

Question 35

What is the first line medication for confusion and agitation in palliative care?

Answer 35

oral haloperidol