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Okay. So for everyone who has just joined a man is Miranda in the Oncology Lead for mind the bleep, a part of the oncology team. Um This evening we have Doctor Little, um, giving us a talk on um, oncology emergency presentations. Um She's a registrar in London and at the moment is doing a year in education. So it should be um a brilliant talk for us all this evening. So I'm without further a do, I'll hand over to doctor Little. Great. Thank you so much and welcome everybody. Um So yeah, this session going to be talking about the oncology emergencies and hopefully by the end of the session, you'll be able to know the clinical presentations for the common oncology emergencies. Summarize the initial investigations and management. Appreciate how time sensitive the initiation of treatment should be and hopefully apply this information in the future to oncology. Patient's you meet. So, um I don't know if people have their phones there if you could. I've got a little slide. Oh Going just for a few questions if you wanted to scan that QR code on your camera and that should take you to the slide Oh, quiz. I've got a few questions as we go through. Um, yeah. Okay. So I'll just give you a moment to do that and otherwise we'll get on. So the first question is, uh, do you know how many people, proportion of people in the UK? This is, we'll get cancer in their lifetime and that should be coming up on your, um, screens if you did, if you did the slide. Oh, if not, we'll just move on to the previous one. Should be, I'm just checking on my phone. Sorry. There we go. Let me see if it's working. Yeah, hopefully that should be there now. Great. I can see a few more people. Yeah. Okay. And yeah, the answer is one in to. Um so actually in the UK, there are 1000 cancer cases a day and cancer is becoming more and more of a problem. Um 50% of the cancers are breast prostate lung and bowel cancer and patient's are doing um increasingly better from cancer there surviving longer and their treatments getting more complex. Oh, I'm so sorry. Um Right. Okay. So in terms of the typical treatment, patient treatment pathway, um usually a typical patient will present to their GP with some red flag symptoms and then they'd get an urgent referral to the two week wait clinic at that clinic. They'll be seen by a doctor who will do a history and examination, they'll do some imaging scans which will vary depending on the type of cancer. Um And that will be for the staging. They might do blood tests including some tumor markers. And then ultimately, if the, if the imaging is suspicious for cancer, they'd go on to have some biopsy in order to confirm the diagnosis and work out whether it's a primary or secondary institute important terms in cancer. I'm sure you're aware of the staging. And this basically says how look is based on the imaging and says, how far has that gemma spread? And we normally use the TMM staging. So the tea is looking at the size of the primary tumour. So how big it is and whether it's invaded structures nearby, then the N is looking at whether lymph nodes, local lymph nodes are involved or not. And m is whether the disease is metastatic. So whether it's spread to other organs or areas outside of the original tumour, and then this will be different for different cancers. But they, we tend to stage it from stage one, which is the lowest to stage four, which usually means metastatic. And then and metastatic cancer tends not to be curable apart from the germ cell tumours can still be cured. Then grading is when we look at it under a microscope. So this is the histology, it's usually grade 1 to 3 with three being the most aggressive and most likely to spread. Um but some cancers have their own grading system. So once the diagnosis of cancer is confirmed, they all the patient's will be discussed in a multidisciplinary team meeting and then the patient will meet the oncologist. Um And in that oncology clinic, um you'll come up with a plan for the patient which had already been agreed at the M D T. Just some words there that are often thrown around just to check we're all on the same page. So broadly, patient's treatment is split into radical treatment, which is curative intent and palliative treatment. Palliative doesn't mean end of life or anything like that in this setting, it just means not able to cure and they can live for many years on. There can be multiple different palliative treatment options. Um Some of you might have heard Adjuvant and Neo Adjuvant. This basically means a treatment that is before or after the main treatment. So you might have neo adjuvant chemotherapy, which is before the main treatment and the main treatment, for example, in breast cancer, the main treatment is surgery, but they have chemo before or if they have the chemotherapy afterwards, it's called adjuvant and then B S C is best supportive care when a patient isn't fit or doesn't wish to have any treatment at all. And all of this will depend on the stage, the grade the patient's performance status. And we mean we mean by that is how fit they are, their age comes into it. Although we try and not be ageist and the patient's wishes. Um An important side note is oligo metastatic disease, which is a sexy new term we like to use. That basically means although the cancer has spread outside of the primary site, it's not spread to very many areas. So it means few metastases. Normally, we say less than five. And um we still can treat those patients' quite aggressively in terms of treatment options as loads of different ones. But the broadly, it tends to be surgery, radiotherapy or sacked and and sacked stands for systemic anticancer treatment. I've actually got another page on that. So that includes chemotherapies. And these are sort of are typically the older agents that we've had for ages, they just act on any fast growing cell and kill it. They're not specific. Then we have antibodies um such as the trastuzumab, which is the Herceptin, which we use in breast cancer and a variety of different other ones. We've got small molecule ones. So these are the TKI small molecules and they tend to be an oral drug that the patient's can take immunotherapy has come in. So that's using your body's own immune system to fight the cancer and hormonal therapy, which is often used in breast and prostate. And all of that comes under the broad category of, of sacked, we call it, um this is just briefly on radiotherapy. So at the bottom, right, you've got just a CT scan and all patient's would have what we call a planning ct scan before they start the radiotherapy treatment. And that's what we use to plan their treatment. Off. Top left is picture of a patient having radiotherapy and that machine they'll stay still on the couch and the machine moves around them and the beam of radiotherapy will move to the air to their cancer and kill the cancer cells. Um You can give radiotherapy at the same time as chemotherapy and that's called con commitment and it can be given in the radical so curative setting and that's often in head and neck cancers for instants. Radiotherapy is the main form of treatment. And in the palliative setting, it can be really good at helping with symptoms. Patient's can get such as tumor's that bleed or with pain from bony metastases. It can help with that. Um The unit we prescribed to in radiotherapy is called grey and we give it in fractions, which just means number of sessions. So we'll write up our prescriptions say for 60 gray in 20 fractions. So that means it would be 20 sessions of treatment. And there are some other forms of more focal high dose radiotherapy, which is called stereotactic. The top right is just a picture of a radiotherapy shell. Um So that's a bit of plastic that's molded to a patient's face and we'll clip to the radiotherapy couch and that's so the patient can't move during the treat. So, in terms of oncology emergencies. Um We broadly spit it into two categories. So some patient's may, this may be the first time they present, they may not know they had cancer prior to this and this would be their first emergency at the presentation or patient's that have known cancer. The emergencies can either be from the cancer itself or from our treatment side effects. And there's all sorts of different emergencies. We can split them broadly into structural metabolic or hormonal hematological or treatment related. And I put a list of not a non exhaustive list there, but the main ones that we will be covering today, neutropenic sepsis, um hypercalcemia, metastatic cord compression, superior vena cava obstruction, brain metastases and immunotherapy side effects. But there are many, many more. So we'll just move on to the next question if that works. Um Yeah, that should be up now. So, um the question is what proportion of cancer diagnoses in the UK present as an emergency and see if you can, should be back on the mentee slides, sorry, on the, on the slide. Oh, yeah. Yeah. Um So I think these are, yeah, so actually a really high proportion of patient's unfortunately present um in an emergency situation and this is increased since COVID it's 19 to 25% and these patient's tend to do worse, they have a later stage at diagnosis. Um but they tend to have worse outcomes and survival irrespective of the stage they present at actually, um, they tend to be an older patient group. They tend to come from socially deprived backgrounds and often it's the cancers that don't have any specific symptoms. So that often present late such as ovarian cancer, for instance. Um, so I've got a little case study to start us off. Let me just move on to the next question. So, a 45 year old male with metastatic colon cancer. So he's having treatment with chemotherapy. That's full fox is just the name of two different chemo's together. And he last had his treatment eight days ago. He's come to a and e with a temperature of 38 degrees. The rest of his obs are all right. They're done there and A and E have done some bloods, a chest X ray and a urine dip. And the question is, what should you do next? So the options are take blood cultures, oral fluids, oral antibiotics and escalate to intravenous. If they're found to be neutropenic or take blood cultures, start antibiotics intravenously whilst you wait for the blood results or number. See, take blood cultures but only start the antibiotics. If those observations get worse or the temperature persists for more than an hour and the patient is found to be neutropenic, just give you a minute to answer that one. Okay. So moving on with the case after 30 minutes, he, his temperature has come down but his heart rate's gone up and his blood pressure's gone down in his boots to 60/30. So this is a case of neutropenic sepsis. Um So the correct answer on the previous question was you should not wait for the blood results and you should start antibiotics straight away. So it was be um so neutropenic sepsis is in patient's on usually chemotherapy. Um and chemotherapy, one of the side effects of it is it can cause your, all your full blood count, all your blood cells in the bone marrow to go low. So that includes the white blood cells. Um and the peak of this is um 7 to 10 days after they've had the chemotherapy, but actually, they're at risk of it. Um In the six weeks after chemo, we say that would be unlikely to be six weeks later. But in anyone that's had chemotherapy in the last six weeks, you should consider it. And the risk is they don't have an immune system. So if they get an infection, they can get really sick really quickly. Um And so we need to give them antibiotics straight away to cover them for infection. So the definition of it, actually, the neutropenic definition seems to vary on where you look it up. Some sources say less than neutrals, less than one but are nice guidelines saying neutrals less than naught 10.5 having a fever as well or any symptoms and signs of sepsis and you particularly chemotherapy, it can be some of the other cancer treatments, but usually chemotherapy in the last six weeks, but some of the antibodies can also do it. So, as you say, untreated, it's a significant cause of mortality, risk factors for doing poorly on it. Our patient's that are older. So over 65 patient that's co morbid and not got a good performance status to begin with if they've had previous episodes of neutropenic sepsis, and if they're having combined chemotherapy with radiotherapy or they've got poor nutrition, generally a poor reserve. So in terms of what you should do, so you basically treat them like any sepsis. Um And you need to give them antibiotics within an hour, you need to do your A B C D assessment, you need to start the sepsis six. And if they're unwell, you need to resuscitate them with fluids alongside the antibiotics. Um If their BP is not responding to the fluids, um you need to get I T U involved early and that's particularly important for patient's that are having curative treatment. Quite often, these patient's will potentially have had say a bowel cancer or breast cancer, they've had their main surgery. So they're already cured of their cancer. And this chemotherapy might just be to reduce the risk of the cancer coming back. So to potentially mop up any microscopic cells there. Um So if somebody were to get some well and, and died from neutropenic sepsis, when they were having a curative treatment that would be really terrible. So, it's really important to treat these patient's early, identify that they can get really sick and escalate to I T U if required, the masks wall is something that can be used to help work out what, how, how at risk they are of getting really unwell and can help you identify when you can switch to oral antibiotics and when they might be able to be managed as an outpatient rather than an inpatient. So the next case study, let me just move on on my thing. Yep. So this is a 72 year old male. He's got metastatic prostate cancer and he's come to A and E with back pain and leg weakness. He's had a neurological exam which has shown power three out of five on the left leg and four out of five on the right leg. And he's also got numbness up to his shins bilaterally. And the question is, what should you do next? So a is do a spinal X ray. Um And if there are any bony mets shown on that, do an MRI of the spine or give him some steroids and do a spine, X ray or do an urgent MRI spine. And if it's confirmed cord compression, then give steroids or d give steroids and then arrange the MRI whole spine, just give you a moment for that one. And yeah, so the answer for that is, so we're suspicious here of metastatic cord compression. So we want to give him steroids, straightaway, high dose steroids, 8 mg twice a day. And then we want to do the MRI whole spine. So this is a typical MRI spine and it's the T two images you want to look at and in t to water appears white. So if you see in the center here, the dark as your spinal cord or your nerves and either side of it, this white is the CSF fluid and there should be a nice line either side of the spinal cord. And you can see here you can't see any CSF and there is a metastasis in this vertebra that is pushing out from the vertebra and pressing into the spinal column. So um called metastatic cord compression, it can, as it says, either extrinsic compression. So usually from a bony metastases that presses into the spine or it can be a soft tissue mass that's growing nearby that can press in rarely. You can also get some soft tissue mets in the actual spinal cord itself. So they're called intra medullary mets. Uh They tend to be rarer but they are possible and they'd cause the same symptoms. Although it would, it would be a blob within the CNS that you'd see on the, on the scan CSF sorry. So in terms of sites, the cord compression, um so the majority of cord compression, 60 to 65% happens in the thoracic spine. Um the lumber spine is the next most common. However, if you note I've written at the bottom in 15 to 20% they actually would have cord compression at multiple levels. And this is why it's so important to do an MRI of the whole spine and not just one site of the spine. So if anybody phones me and says I've done a C spine, MRI and I've got a cord compression there. I will always ask them to MRI the rest of the spine. Even if we know called compressions at one point, because cord, nearly a quarter will have called compression in more than one site. So in terms of the cancers that tend to get called compression, it can be any, but it tends to be those that have bony metastases. So that's usually prostate lung or breast of the most top three, most common. And again, unfortunately, a quarter of patient's who get called compression, this will be their first presentation of cancer. So presenting as an emergency, um, the signs and symptoms of called compression. So the first symptom is usually back pain and that happens in 95% of patient's. This pain tends to be worse on movement and lying down and it's ridiculous er, in nature. So that means it usually starts from the spine at the back and it spreads around either side in a band and the pain is also worse at night. That tends to be the first symptom and occurs usually weeks before any neurological symptoms occur. Weakness is the next most common symptoms. So that's usually symmetrical um in the lower limb. Well, it depends where the good compression is but will be bilateral, followed by um sensation. And this can be either positive, so, tingling or negative. So, loss of sensation. And that's why it's really important to do your neuro exams. And sometimes you can find out an exact sensory level where they've lost the sensation and you can work out where the level of cord compression is before you even got the MRI, which is quite satisfying. If they've got a cord compression lower down a quarter, a Queener, the symptoms would be bladder and bowel dysfunction, um loss of anal tone. So it's important to do a pr exam and also loss of perennial sensation. I have to say the majority of patient's are how terrible historians and usually present with generalized a bit weak here or there, the classic off legs. And so if you've got somebody with metastatic cancer with known bony Mets, and they say they're a bit weaker with some back pain, I would always do an MRI to check. Unfortunately, 10% of patient's and this is the risk if you leave, it will present completely paraplegic and if that occurs, then less than 5% will recover any neurological function, whatever treatment they have. So this is just again. So that's the importance of your neurological exams, um you can work. These are the dermatome is to tell you where they'll have the sensation loss and the myotomes, which muscles will be affected depending on where the cord compression is. So the nice guidelines basically say that anybody who has neurological symptoms or signs with a known who has a high risk of metastatic cord compression should have a whole spine MRI and a treatment plan agreed within 24 hours of when you suspect it. So they basically, in order to get that done, need to be admitted, what you need your job as the junior seeing and straight away would be to give them high dose steroids. So 16 mg of dexamethasone. So we give that in 8 mg in the morning and 8 mg at lunchtime because if you give it in the evening, they tend to not sleep and they'll need PPI cover. So omeprazole for that as it can be damaging to the stomach and you need to arrange the MRI whole spine plus contrast. Um In the meanwhile, that's happening, there are some conservative measures I've written on the right hand side. So until you've got the MRI spine, they should ideally be on bed rest and spinal precautions because they're in pain, you need to sort out their pain. Um They're staying still, so they're high risk of DVTs. They'll need their DVT prophylaxis and they need their potential risk of pressure sores as well. So that should be addressed if they've got quarter require, er, and um, urine Khonsari, urine incontinence or retention, they might need a catheter and they'll need their blood sugars monitoring whilst they're on those high dose steroids. And it's important to do regular neurological exams. So I think the guidelines say twice a day, which would be great in an ideal world, but once a day, if not, and that's just to check for any deteriorating neurology whilst you're coming up with a plan. Um, what you need to do once you've got the MRI, um, obviously see if it confirms called compression or not. And then you just speak to oncology or the neurosurgeons, usually both. And that's because you need the neurosurgeons for two reasons. The first reason is it's up to them to decide if the spine is stable or not. So the patient should be on bed rest until that's decided. And the second question is, are they for neurosurgery? And if a patient isn't for neurosurgery, then the second option for treatment is radiotherapy in a patient that doesn't have known cancer, but they have a cord compression, they'll need some more investigations to work out what the cause of their cord compression is. And also in a patient with known cancer, we need to know how the rest of their disease is and is it well controlled. So if they haven't had recent staging imaging, so a CT scan of the rest of their body, then I'd get one of these done as well. And that's because treatment decisions will depend on how well controlled the rest of their disease is. So, yeah, as we say, if the MRI is positive, then steroids they're already on. But the treatments are either surgery and surgery is always followed by radiotherapy as well. But that would be eight weeks after the surgery radiotherapy. Or if they're not fit for either of those, then best supportive care. Yeah. In terms of surgery, actually, if a patient is well enough to have surgery, surgery is the better option for treatment. It's the most definitive option that will last longer term. Whereas radiotherapy is usually only controls that, um, neurological deterioration for a few months. So if a patient is going to live longer than that, we really want to push for them to have surgery and often neurosurgeons are quite good at saying, oh, no, the patient has cancer. No, they're going to die. So it's really up to us to push for patient's to have surgery if that's appropriate and fight for our patient so that they get the best possible treatment reasons that surgery would be better than radiotherapy. As I say, is a patient who's got a good prognosis is going to live a long time. Normally they're neurosurgeons like to have at least six months to live. Patient's got disease well controlled elsewhere in the body. Ideally, no organ metastasis. A younger fitter patient with no co morbidities. And if there's only called compression at one level in the spine and know mets anywhere else, then really, they should have surgery that's in this oligo metastatic category. We want to treat them as aggressively as we can to give them the best possible chance patient's as well do better with surgery if they don't have any neurological symptoms. So the earlier we treat them, the better other reasons to do surgery would be if we don't have a known diagnosis. And this is their only site of disease that would uh surgery that sample could be sent to the lab for histology to get a diagnosis. If their spine is unstable, radiotherapy cannot help an unstable spine. So, neurosurgery would be the best option here. And finally, if the patient had already had radiotherapy and had record despite that, then neurosurgery would be a better option, but that's usually a harder sell to the neurosurgeons. So this is radiotherapy for cord compression. So in terms of the practicalities for radiotherapy, the patient would need to be able to lie flat on that quite hard radiotherapy couch for 15 minutes for treatment. So often these patient's are in a lot of pain and they often turn up for the radiotherapy and they can't tolerate it. So actually on the wall, it's really important to sort out their pain relief before they have the radiotherapy treatment and they'd have one appointment for the radiotherapy scan and then either one or five appointments for the treatment daily depending on how fit they were. Radiotherapy beam comes from the back and goes through the front. And this diagram here is showing that the highest dose is going to the spinal cord and then it drops off the dose afterwards in terms of side effects of radiotherapy. Um, the generalized ones are that you can get tired. Actually, they can get a pain flare in the short term and their skin can get a bit red just on the area you're treating. Other side effects depend on where in the body you're treating. So, if a cord compression was higher up, then you'd be treating the esophagus and a bit of lung potentially. So they might get pain swallowing and a cough, they might get a little bit sick and lower down if you're near the bowels or the bladder, they might get some diarrhea or some pain on urinating. So this is just a thing for you to have a think about. This is our next case. And the question here is, what is the diagnosis? And do you know just based on that scan alone? Um, just have a think about that yourselves. I'm going to give you a bit more information now. So he's a 60 year old male with metastatic prostate cancer. His symptoms are, he's increasingly confused. He's passing more urine, he's feeling sick and more tired. Does that give you any more clue? And these are finally his blood results and I'm sure you've seen at the bottom there, his calcium is 3.9. Um So the next question is, what does this patient need first? Now, let me just get the questions up again. There we go. Should be on the one now. So, is it IV bisphosphonates, oral, bisphosphonates IV fluids or oral fluids? I'll just give you a moment to answer that one. Yeah. And the answer for this. So the first thing he needs is IV fluids. So this is malignant hypercalcemia. Um, so, um, investigations for this, our blood. So calcium and should also check the user knees, vitamin D and P T H and all the usual bloods really, it's really important these patient's to do a fluid balance there often really dehydrated. Now, lots of patients have chronic hypercalcemia, sort of, um, maybe in the upper 2.82 point nine. If they've had that for ages, they probably won't have any symptoms. However, it becomes an emergency. If it goes normally above three, we would say to admit to hospital, but it definitely above 3.4. And the reason we get all worried about it is that they can get heart arrhythmias and eventually it could lead to a coma. Um, but all the classic symptoms and signs of high calcium are the ones we learn about in medical school. I forget that silly thing, groans, moans bones as I think what it is. But basically, they get thirsty, they get constipated, they get abdominal pain and they can get confused and get all sorts of other things. But I think the main thing that I have seen really is confusion and that's a bad sign and we need to treat it. The first thing we need to do for treatment is rehydrate them. And that's because they're, they're usually all dehydrated and actually the bisphosphonates, which is the definitive treatment um can affect your kidney functions. You want to make sure your hide well, hydrated first and it might be that just hydrating them, helps um improve that calcium. So initial management is rehydrate. So we give them 2 to 4 liters of normal saline a day, stop anything that's causing that calcium to be worse. So stop any diuretics, dehydrating them, stop any calcium supplements and carefully monitor they're using these as you give them all this fluid. If it's still high. Despite that, then they need to be given IV bisphosphonate's. But don't give that until they've got a good use and ease of improved and their urine outputs better. Um As we put at the top, it's, it can be life threatening. It's a very common thing. It's not common to be life threatening, but common to get it. So treat it if you find it usually um it occurs in patient's with boney metastasis, but it can occur just from tumor burden producing. Um I think it's the P trh hormone, which then leads to high calcium. But the common cancers it occurs in is prostate breast and lung and thyroid untreated. If you left somebody of a calcium 3.4, that's when you get into problems and can lead to heart arrhythmias in comas. Actually, it's a really poor prognostic sign to have malignant hypercalcemia and the one year survival is only 31%. So this is another one just to have a think about um what is the diagnosis looking at these pictures alone? I'll give you a little bit more information. So the patient has small cell lung cancer. He's had worsening shortness of breath, facial and neck swelling, which is worse when he wakes up in the morning, worse when he lies flat and worse when he bends over. As you can see there, he's got distended neck veins and also collateral veins on his chest. This is his CT scan and you can see a big mass of me, these a mediastinal lymph nodes um compressing this blood vessel here. So this is um S VCO so superior vena cava obstruction. Um and it's usually either caused by um lymph nodes compressing externally compressing on it or you can get lymph nodes or cancer invading directly into the vessel or you can have a thrombus in the vessel. Um And only CT scans here, you can see this is nicely patent S V C and here it's all up in the bottom one it's all obstructed and narrowed from the tumor. Um So when the S P C is obstructed, um this means the venous drainage from the head, neck, upper extremities and chest is um reduced. And so the blood tries to get back to the heart by collateral roots. The most common cause of this in terms of cancer is lung cancer, up to 80% followed by lymphoma. And then the rest of it is usually either mediastinal germ cell tumor, us, thymic tumor's or breast, but large in a way, it's lung cancer that causes it. And you can also get non malignant causes as well in terms of symptoms. So it's all the ones that guy was showing you can get short of breath, cough and chest pain, facial swelling. The patient's complain of headaches and feeling full in the head and they can get blurred vision and all these symptoms are worsened when they lean forwards or lie down. As we said, signs, the neck and the face can become swollen. They can get distended veins from the collateral veins forming on their neck and chest, upper limit edema. And in in serious emergency cases, they can get stridor and cyanosis, cognitive dysfunction and coma. You can do this sign called pemberton sign where you get patient's to elevate their arms above their head for 1 to 2 minutes. And if all their symptoms get worse, that's a positive sign. And that's because of the increased rhenish return from the upper extremities which are worsening the obstruction. So investigations to do for these patient's actually, most patient's will have an abnormal chest X ray. So even doing a chest X ray will probably hint to you what's going on and then followed closely by a ct chest with contrast. And we saw there, you could see the contrast in the vessel clearly or not. Again, if we don't have a known diagnosis of cancer in order to work out the overall treatment, they'll need staging investigations and a biopsy. That's not the acute management. Of course. So the acute management in a patient that's unstable. So presenting with strider and low oxygen levels, so you do your emergency management A B C D E sit them up because lying down makes it worse and give them oxygen. Again, our favorite treatment, steroids. So high dose dexamethasone, 8 mg twice a day and again, give your PPI cover. And actually, if it's an emergency situation, it's a stent that you tend to go for in an emergency, nothing else is going to um isn't going to act as quickly. But actually, in order to have the stent, you need to be stable. So it's really the steroids and conservative management in that emergency short term. And if they've got a thrombus causing it, then you can give them anti coagulation. So once they're stable and actually most patient's present a bit more gradually with this, you actually have time normally to treat um rather than being that emergency stride or situation. Still, the first option is a stent to relieve the obstruction. So that's with interventional radiology, unless they are either a small cell lung cancer, a germ cell cancer or lymphoma is, these are really chemo sensitive. So they might just shrink away from that vessel with some chemotherapy and otherwise you can give radiotherapy. Um but actually the main treatment is obviously treating the cancer. So it depends on what the cancer is as to what the treatment would be. Again, this is a poor prognostic sign and patient's usually live for less than six months once they have this. So this is another one for you to think about. We've got a 56 year old female, she had a locally advanced lung cancer treated several years ago and she's had a four week history of worsening headaches. These are worse in the morning and she's had some blurring of vision. So have a think about what you think that might be and think about what you would do next. This is what I would do next. Hopefully, you thought the same. So this patient needs a full neurological examination and she needs in the first, probably should have some positive signs on that. But even if she didn't, I would be doing that some sort of imaging of the brain, which usually in the first instances going to be a CT cause you can get that done quickly. With contrast, if you can't, if you have to wait at all for the CT, I'd start this patient on steroids. Otherwise I'd wait for the CT. If it was going to be done, then and there in A and E and if there's anything shown on the brain with any signs of edema, she needs to again be started on high dose steroids plus PPI ultimately, if anything's seen on the CT scan, then we're going to need an MRI head. We want to know what's going on in the rest of the body. So do a CT cap, chest, abdomen and pelvis. And we want to refer these patient's to the neuro oncology. MDM. This is the next question on the pole. So on the left, we have scan A and on the right, we have scan B and for you, it's for you to guess this is an MRI T one post gadolinium. And it's for you to guess the diagnoses they are different. And the, the question is, is a a primary brain tumor and be a metastasis. Is it the other way round or is a metastasis and be tuberculosis? Um Hopefully you can see that one on your um slide. Oh, and just have a guess. Uh Okay. So the correct answer for this. Oh Is um somebody's still answering. Sorry is the second option. So this scan here that you can see still, I'll just go back. This is a metastasis and this scan is showing a primary brain tumor. And the reason I put this up is to show you that's actually really hard, they look very similar. Um And brain metastases often mimic lots of things. Um The reason that this is more likely to be a metastasis is because there's more than one. So this is a second area here and it would be unusual to have more than one primary brain tumour. But both of them are showing this is the ring contrast enhancing lesion and you can see a Deemer surrounding it. This is a second lesion here where this one is, this is the main lesion here and there's a Deemer surrounding it. So if you get given any kind of imaging and see a space occupying lesion, your differential should always include a brain metastasis because they can mimic absolutely anything, especially in the patient with a history of cancer. Also, in your differential should be a primary brain tumor as well as non malignant causes. So, TB abscess meningioma, etcetera in terms of symptoms, patient's get with brain metastasis. So that's what this patient in this scenario had. Um Firstly, if they have a dumb a, they're going to get symptoms of raised intracranial pressure. So this is going to be the classic headache that's worse when they lie flat. So it's worse. First thing in the morning, they're going to feel sick and potentially vomit and they can have blurred vision and all, any of those things really need steroids. If they've got any of those or any edema on a scan, then depending on where the metastasis it is, depends on what symptoms they can get. Um, so you'll probably remember the different areas of the brain control different things. They can really get anything depending on where it is. So, it's really important to do your cranial nerve exam properly and all your full neurological exam. And I think there are some fantastic doctors that can identify where the lesion in the brain is exactly before they do a scan based on their neuro assessment, which I think is very clever. Also, they could potentially get seizures, particularly if the METS are in the temporal lobe. But just having a Deemer can get put you at risk of seizures. Um And if a patient getting recurrent seizures, then I would also give them steroids, sorry, it would give them um anti seizure medication alongside the steroids. This is again, just another thing with the um different areas of the brain and the anatomy, they correspond with different symptoms. Um Again, you guys all know that can look at it. So the management of the brain meth. So again, as per everything we've spoken about, it really depends on a number of different things. And that's why we discuss all of these patient's in the NeuroOncology MDM, which has oncologists and neurosurgeons present. And um if we can give aggressive treatment, then we would want to. But it depends on these things I've written here. So how many brain mets are there? How big are they? And where are they in the brain? If there's just a small one and it's in a peripheral area of the brain, then that might be really good one to do neurosurgery. Um Whether it's in the center of the brain that's not really very accessible for them or if there's numerous all around the brain, obviously, you can't resect the entire brain. So that really depends. Then the neurosurgeons would want to know how is the disease outside of the brain. Is it actually that they really well controlled everywhere else? And this is just they're only side of disease or have they got disease everywhere all over the body and they are very fit in which case again, is it worth putting them through a massive operation? So the prognosis of the cancer and what the treatment plan for the, for the cancer as a whole is important and how fit the patient is if a patient has um favorable. So all those things are in, it's in their favor and they're fit, then neurosurgery should be encouraged. If it's in an area that is difficult to access of neurosurgery, we can give stereotactic radiotherapy. Um So long as it's with under a certain size and that's giving a really high dose to that area which can potentially oblate the met in that area. So it's an aggressive treatment as well to control disease. So it's not quite as good as neurosurgery, but it's still a good intense treatment option to try and get some local control if the patient is not fit. Um And they've got numerous brain mets, then we can give a lower dose of radiotherapy to the whole brain. But this can have quite a few side effects. Patient's can be fatigued and that can be prolonged. So you've really got to work out the benefit risk ratio this and it might be just best supportive care. So, no treatment and just giving them the steroids is the best thing in terms of which cancers give brain mets. It can be any the most common are breast lung and melanoma and renal cancer. And this is my uh last um emergency to talk about. So this is immunotherapy, which I'm sure you've all heard of hopefully. But if not, this has been a breakthrough in cancer recently. So it came in in 2013 and was the front page of science and it's significantly changed our cancer care since then. Um this scan is just showing dramatic responses with tumors shrinking in patient's having immunotherapy. This is a big liver met going down. Um and lots of different cancers have immunotherapy as part of their treatment now. So, um in terms of how it works, it's actually making your own immune system fight the cancer. So, the immune system normally has checkpoints which turn on or off as part of the immune response. And cancer cells are clever and they managed to evade the immune system by turning off these important checkpoints and inhibiting them. So the immunotherapy targets these checkpoints and turns back on the immune system so that it can then um fight the cancer and the immune response to cancer can occur. Um So because of that, it's basically causing your own immune system to go into a bit of overdrive and all the side effects associated with immunotherapy. Uh basically inflammation to all the immune side effects and it can be an inflammation or an itis of absolutely anything. So you can get um, uh colitis which would be diarrhea from an inflamed bow. You can get pneumonitis which would be shortness of breath and a cough from inflamed lungs. You name it, you can get it. Um, not everyone will get it at all. But um, interestingly, the side effects can occur even years after you've finished the immunotherapy. So, it's important to consider if a patient has ever had immunotherapy. And the management of this is always steroids to dampen the immune response comparing immunotherapy versus chemotherapy in terms of toxicity, in terms of those worst grade 34 toxicity. So that's the worst, most disabling side effects, immunotherapy has only 16%. Whereas chemotherapy has 50%. So it tends to be a bit less toxicity and different toxicity that they get. So it's less of the neutropenic sepsis with immunotherapy. I've just got one little immunotherapy case study. So this is a 45 year old male with metastatic melanoma and he's on ipilimumab, which is a long word about an immunotherapy. A nivolumab which is another immunotherapy. So, he's on dual immunotherapy. He's come to A and E with diarrhea eight times a day and some blood in the stool and he's got abdominal pain. These are his observations, his BP is a bit low. His pulse is a little bit up question is what is the best management for this patient? We've got four options there. Um, oral, the para mide IV fluids, oral steroids and fluids or IV steroids and fluids. I'll just give you a minute for that. And yeah, so the answer for this is IV steroids and fluids. And actually your best port of call for immunotherapy guidelines, immunotherapy side effects is the asthma guidelines. If you google them, they've got a document that has really clear tables like this for all of the immunotherapy side effects. But basically you grade the side effect depending on their symptoms. So in this case, this gentleman was grade three. So down here and that's because he was opening his bows more than seven times a day and he had some abdominal pain which counts and then based on that, you go across the table and he needs IV steroids and we give really high doses of IV test steroids, we give 1 mg per kilogram per day. And actually, if they don't respond to that, we then give other treatments, immune immune treatments such as Infliximab. And we would, for this case would involve the gastro team. Whereas if it was pneumonitis, we've involved the respiratory team, they can get really sick from these. And again, patient's can need escalating to I T U if they're really sick, immunotherapy as often again, curative treatment after the main treatments happened. So again, we want to escalate early. If we're worried, they're unwell because we don't want somebody dying from a curative treatment side effect. So that's the end of all my case studies. So just to go over some take home message is um so when you're seeing oncology, patient's in the future, um I think it's important to work out what treatment your patient is having and what's going on with their cancer. So know if they're having curative or palliative treatment because that really will depend on what um you know, that it depends how the next steps on how you're treating them for their emergency. It's also important to know when they last had their treatment particularly for the chemotherapy with the risk of neutropenic sepsis. No. Do they have metastatic disease or not? And where are their metastasis? Because that would help you if they've got boney metastasis, they would be at risk of cord compression. So you should think about that and you should think about high calcium in those cases as well. And the importance of a careful examination and correlating this of your diagnostic tests. So the neurological examination for the cord compression and the brain mets. Um so in all the oncology, patient's always think about the emergencies. So for neutropenic sepsis, as we said, don't wait for the blood results to check their neutropenic, treat them with antibiotics straight away. If it turns out they're not neutropenic, you can de escalate the treatment that's fine, but they can get really sick if you don't treat them straight away. If the patient's got known bony mets and presents the classic unhelpful off legs, I'd treat this is called compression until proven otherwise. And I'd give them steroids and do the MRI whole spine in a confused patient with known cancer, check their calcium and do brain imaging again, headaches and vision changes, image their brain an immunotherapy. As we said, they can affect any single organ in the, in the body. The so if a patient ever had immunotherapy, think about it and the delay of those symptoms can be years after the radio after the immune therapies finished. Um If a patient's getting more and well, despite the initial treatment, please escalate to I T U early, um particularly if they're having curative treatment. And if you're in doubt, every single hospital should have an acute oncology team who will be able to advise you about this and there's always a friendly oncology registrar on call 24 hours a day. So I think that was the end if any, anybody have any questions at all. But I'm just gonna see, I'm just gonna exit my screen so I can see the chat. Uh Right. There's been a few here. How do you qualify, quantify a patient's performance status? Uh Yeah, that's a good question. So I think it's quite an oncology. Word that performance status, we basically have two different scales for assessing performance status. One is the who performance status scale, which we give a score of 0 to 4 and basically it depends on what they're doing on a daily basis. But if somebody's completely bedbound and needing help of all their activities of the dressing and washing, that's a four. And if they're completely independent and fit, then that's a zero. And the, I think if they sat down for more than half the day, that's a three, it's less than half a day. That's a two and one is just a little bit worse than zero. There's also another score which is the Karnowski is performance scale which again just Google, it comes up in med Kalg, that's a score out of 100 and the net puck case 100 is good and 20 is bad. So yeah, um it tends to be quite an oncology thing to do performance status, but it's useful for lots of other diseases as Well, um then the question from George, how would you transport a patient? Should you encounter the patient in outpatients? Not in the hospital, considering the patient might have unstable metastatic spinal cord compression. Yeah, good question. I mean, obviously this is all saying, you know, in an ideal world, you do log roll the address until you've got the MRI in practice. I don't, I think only about 20% of patient's will have an unstable spine. So in practice, we don't tend to do to, you know, we normally just get them to go on the MRI couch on their cells. If they're, if they're not in a setting where you have the nursing staff to do the logroll just do the best you can. Normally, as I said, most of them don't have an unstable spine, so it's usually safe. Um but obviously you would never advise that, but if there was no other options, then they just walk to the MRI scan, er, and do the best you can. Um, what is the recovery from brain met neurosurgery symptoms to look out for? Is it just general of neuro obs? Um, so I'm not a neurosurgeon but um I know following following neurosurgery, be that for brain mets or a primary brain tumour, think they can take six weeks to recover and they're quite high risk of and they can still get a Deemer after the, they can get all those raised intracranial pressure symptoms. So, most of them would be on some sort of steroids that you'd wean down after the surgery. And if they're headaches and things got worse as you were weaning off the steroids, then you need to go back up on the steroids in that case. And also they can get seizures following um, neurosurgery. That'd be something to look out for as well. Um, so they might need Capra, is there a limit to steroid loose when treating bony mats? Um So the um the maximum dose of steroids we give each day in oncology is 16 mg a day. Um And that high dose is used for all of pretty much all of the emergencies. I've mentioned, I know hematology for some of their patients' do actually give more than that. So I think there isn't, I'm not sure. I think they give 8 mg three times a day I've seen. But in terms of the risks of steroids is that is the risks of long term steroids. So it's all those steroid side effects such as, you know, muscle wasting and then the hormonal side effects they can get. So, ideally, we don't want to keep patient's on long term steroids and also the risk of being on the high dose steroids is it they all tend to get um steroid induced diabetes. So, ideally that initial high dose would not be for very long, often patient's don't need that high dose um for long. So in a cord compression in a confirmed cord compression, I would start to wean once they've had their radiotherapy. So if they've had their, if having five sessions of radiotherapy treatment, you can even start to wean it after day one. Normally, what I do with the weaning is I'd, if they're on 8 mg twice a day, I'd go to 8 mg once a day and then I'd reduce by 2 mg every three days until they stop. Um If the symptoms be that the cord compression symptoms got worse on the steroid wean, again, you'd have to go up a level and with the brain mets, um steroids that high dose, you kind of have to, if you only have a little bit of a Dema you might not need that high dose for very long. Um or at all. So we say 8 mg twice a day, but if they only just have a little bit, 4 mg might be enough. Um It really varies, but ideally you want the lowest dose of steroids to control the symptoms, but it's just in that initial emergency, give the high dose to begin with. Um then we've got in S VCO do you only give decks if they are unstable or have stridor or to everyone? Um So death again, this is a, I think in the in the emergency situation. So if they've got low oxygen sats, they're unstable or have stride or I give the 8 mg twice a day if I just identify, sometimes you identify SPC on a scan and a patient might not have any symptoms of that at all. Um, they might not need any steroids or I might just give a low dose of 4 mg and, and potentially once they've had the stent, I'd stop that. If they have no symptoms at all, they might not need any steroids, but I'd probably give them an emergency pack in case they get symptoms. But if it's just mild, I'd give them a lower dose. Yeah. Um How do you treat malignant hypercalcemia if they are not responding to IV fluids and IV bisphosphonates another good question. So the answer to that is you phone um endocrinology but other things we can give if it's not responding is um calcitonin denosumab is another thing and steroids again, which is our favorite thing for most things in oncology. Um And I think that's the end of the questions. Um So thank you all so much for attending. Um There is a link to the feedback that I'll just leave up on the screen there and I think otherwise a link has been sent to you. Thank you so much. Okay. Thank you so much, Doctor Little. I'm sure everyone will agree. That was a fantastic talk. Um Please, everyone also make sure you do do the feed buckets really important for us because they're all voluntarily giving their time to teach us. Um And in addition please see the two links which um are for the next Tuesday um talks we've got coming up one next Tuesday. Um and then Doctor Little will be speaking for us again in three Tuesdays time and that will be about careers and applications. Thank you all. See you soon. Uh So Nicholas asked about hypo Magnesia, I would say the the Yukons. Um So that's the Acute Oncology Nurses Society. U K O N S has quite good guidelines on Hypo Magnesia. It is a real problem, particularly patient's with chemo getting low magnesia magnesium. So I have a look at those. Um I have been at some trust that I've had good guidelines but I agree some have terrible ones. But the, I'll just show you these are the, it's the U K O N S Oncology Nursing Society does say about the low magnesium, but often they just need loads and loads of IV magnesium and I've had patient's needing magnesium three times a day or really long term following, following our chemotherapy, which can just completely deplete it. So more is better, I would say, but it's I'd go to those guidelines first. All right. Well, thanks very much guys. I'm going to go now, but I look forward to seeing you in a few weeks. Time to be always should do oncology. Thanks. Bye.