Oncology

Dr. Amy Izon FY1 General Medicine

Objectives
Basic concepts Oncological emergencies: Case Studies
Hypercalcaemia Tumour lysis syndrome Neutropenia Spinal cord compression Cauda equina syndrome Superior vena cava obstruction

Mini images examination

Basic concepts
Common signs & symptoms:
History
Bleeding & Hb Blood clots Weight loss Focal neurology & seizures Persistent symptoms: cough, headache, constipation, diarrhoea, N&V

Examination
Lumps & bumps

Basic concepts
Investigations:
Bloods
Which ones?

Imaging Tissue sample

Referral:
Cancer of unknown origin: Acute Oncology Service referral Specific cancer: Speciality referral (telephone & written), MDT referral

Case 1.
A 54 year old woman presents to A&E with new onset confusion, poor appetite and vomiting, she has a PMH of breast cancer

Case 1.

Case 1.

Na+

139

Hb

105

ALT

20

TFT

NAD

K+
Urea Creat

4.3
9.2 98

WCC
Plt CRP

6.1 x 109
235 x 109 11

Bili
AlkP Alb

18
458 32

AdjCa2+
Mg2+ PO43-

3.7
0.76 0.6

Case 1. Hypercalcaemia
Signs & symptoms:
Bones, stones, groans, psychic moans

Management:
IV fluids: 0.9% saline 3-4 litres in 24hrs d/w senior ? Furosemide Single dose bisphosphonate Management of underlying malignancy ?Calcitonin

Case 2.
A 62 year old man presents to A&E with back pain for 5/52, new onset leg weakness. On examination bilateral reduced power, brisk knee and ankle reflexes & upgoing plantars

Case 2.
Investigations:
Urgent MRI

Case 2. Spinal cord compression

Spinal cord compression
Lesion above L1/2 Upper motor neurones signs below level of lesion:
Leg weakness Brisk reflexes Upgoing plantars Urinary incontinence

Cauda equina
Lesion below L1/2 Lower motor neurone signs:
Saddle anaesthesia Leg weakness Reduced reflexes Normal plantar reflexes Urinary retention

Case 2.
Management:
d/w senior High dose steroids: Dexamethasone 16 mg Radiotherapy: single high dose fraction Surgical decompression

Case 3.
A 75 year old patient with known NSCLC presents to A&E with new stridor and shortness of breath, on examination

Case 3. Superior vena cava obstruction

SVCO occurs when the SVC becomes obstructed by either local pressure from tumour or thrombosis: Commonly caused by:
bronchial carcinoma Lymphoma Neoplastic lymphadenopathy

Management
Chemotherapy Radiotherapy

Case 4.
A 53 year old man with SCLC presents to A&E following an unwitnessed seizure. No previous episodes, no recall of the event.
Na+
K+ Urea Creatinine

116
4.3 5 105

Case 4.
Investigations:
Bloods
U&E Random cortisol Serum osmolality

Urine sample
Sodium Urine osmolality

Imaging
CXR CT head

Case 4.
Hyponatraemia Hypovolaemic Hypervolaemic

Urine Na+ < 20mmol/L: Vomiting Diarrhoea Skin loss (burns, sweat)

Urine Na+ > 20mmol/L: Adrenocortical defi Renal failure Diuretics Cerebral salt wasting

Urine Na+ < 20mmol/L: CCF Cirrhosis Nephrotic syndrome Primary polydipsia

Urine Na+ < 20mmol/L: Renal failure

Euvolaemic

Urine Na+ < 40mmol/L: Psychogenic polydipsia Poor diet

Urine Na+ > 40mmol/L: SIADH Glucocorticoid defi Severe hypothyroidism

Case 4. SIADH
Management:
If severe:
Aim for 4-6 mmol/L Na+ over 1-2 hours initially

If non-severe:
Hypovolaemic: 0.9% saline Normovolaemic: fluid restriction 500-1000ml/day, oral sodium replacement, ?hypertonic 3% saline Hypervolaemic: fluid restriction 500-1000ml/day, furosemide

Case 5.
A 35 year old lady presents to acute oncology unit with a temperature of 38.9 C and feeling generally unwell one week after chemotherapy.

Case 5. Neutropenic sepsis

NICE guidance:
Temperature > 38C Neutrophils 0.5 x 10^9

Sepsis:
Temperature <36C or >38C Heart rate >90bpm Respiratory rate >20 /min or PCO3 <32 White cell count <4 x 109 or >12 x 109 Infection

Case 5.
B lood cultures U rine output F luid challenges A ntibiotics L actate O xygen

Case 6.
A 12 year old receiving chemotherapy for acute lymphoblastic leukaemia becomes generally unwell with reduced urine output complaining of tingling lips and weakness

Case 6.

Na+

135

Ca2+

Hb

132

K+
Urea

5.2
5.2

Mg2+
PO43-

0.74
1.43

WCC
LFTs

5.01
NAD

Case 6. Tumour lysis syndome

Common in haematological malignancy. Complications:
Acute kidney injury Death

Management:
0.9% saline Acetazolamide & allopurinol Treat electrolyte abnormalities

Image 1.
Q:
1. What is the diagnosis? 2. What investigation is shown? 3. Which tumour marker would be helpful?

Image 2.
Q:
1. What is the diagnosis? 2. Which nerves are affected?

Image 3.

Q:
1. What is this clinical finding better known as? 2. Which malignancy may be responsible?

Image 4.
Q:
1. What is this lesion? 2. How is it managed?

Image 5.
Q:
1. What finding is seen on x-ray? 2. What is the diagnosis?

Image 6.
Q:
1. What is the likely diagnosis? 2. Name two further investigations that could help provide a definitive diagnosis.

Image 7.
Q:
1. What characteristic finding is shown in the blood film? 2. What is the diagnosis?