This is the most common cause of attendance in the emergency department for any cancer patient and must be always considered in any patient who is unwell within a month of chemotherapy. Neutropenic patients are at high risk of bacterial and fungal infection. Symptoms incl. fever >37.5, nausea, diarrhea, drowsiness, breathlessness. The critical test is the full blood count and patients with neutrophils <10x10^9/L are managed by the immediate introduction of broad-spectrum antibiotics and fluid resuscitation. Low risk patients managed with oral antibiotics.
Pulmonary embolus
This is a common complication of the coagulopathy of cancer and as a side-effect of chemotherapy. Patients often present with unexplained breathlessness and episodic exacerbations from multiple small emboli. Confirmation of emboli is through CT pulmonary angiogram. Prophylactic anticoagulation is given to all immobilized patients.
Superior vena caval obstruction
Superior vena caval obstruction can arise from any upper mediastinal mass but most commonly associated with lung cancer and lymphoma. The patient presents with difficulty breathing and/or swallowing with stridor, swollen oedematous facies and arms with venous congestion in the neck and dilated veins in the upper chest and arms. Treatment is with immediate steroids, vascular stents, anticoagulation and mediastinal radiotherapy or chemotherapy. Ventilatory support may be required until treatment has had time to relieve obstruction.
Spinal cord compression
Spinal cord compression needs to be rapidly diagnosed and urgent treatment arranged within 24h of onset of paresis to salvage as much functional capacity as possible. Treatment should begin with high-dose steroids and a joint neurosurgical and oncological consultation.
Tumour lysis syndrome
Tumour lysis syndrome occurs if treatment triggers a massive breakdown of tumour cells, leading to increased serum urate, potassium and phosphate and secondary hypocalcaemia.
This biological change can lead to:
- Cardiac arrhythmias
- Seizure
- Renal failure (due to urate deposition in renal tubulues)
Raised intracranial pressure presents with headache, nausea an vomiting. Treatment is by high dose steroids and surgery.
Hyperviscosity
Hyperviscosity can affect those with very high hematocrit (hb), white cell count or platelet cell count from untreated leukemia or myeloproferative disorder. Clinical features include hypoxia, pulmonary infiltrates, confusion, headache, visual disturbances, papiloedema, retinal venous dilation, cardiac failure and priapism. Treatment is by leucopheresis or plasmapheresis followed by urgent treatment for underlying malignancy.
Malignant bile duct obstruction present with cholestatic jaundice. Treatment is usually palliative with stents.
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