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Rosens > 112. Oncologic Emergencies > Flashcards

112. Oncologic Emergencies Flashcards

1
Q

Febrile neutropenia definition

A

ANC below: mild: 1000 to 1500, moderate 500 to 1000 less than 500 severe. current guidelines suggest that and see less than 500 or expected drop below the threshold within 48 hours

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2
Q

How to calculate the absolute neutrophil count

A

Percent granulocytes plus percent bands times total white blood cells divided by 100

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3
Q

Where are the most common sources of neutropenic fever?

A

Pneumonia, anorectal lesion, skin infection, pharyngitis, or urinary tract infection

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4
Q

Definition of fever in federal neutropenia

A

Single temp greater than 38.3 or a greater or sustained temperature of 38 for one hour or more

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5
Q

Diagnostic testing for neutropenia

A

Blood cultures from two sites, one can be done from the central line. Where is the other should be done properly, white blood differential, urine analysis and urine culture, chemistries and renal and hepatic function tests. BBG for lactate.
Consider CDiff, chest x-ray

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6
Q

When should patients were a febrile neutropenia receive antibiotics?

A

Prior to confirming infection given high mortality
Parental broad-spectrum, antibiotic, such as pip, Tazo or Carbapenem

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7
Q

Multinational Association of Supportive Care in Cancer: clinical features

A

age <60
onset of fever while outpatient
overall moderate sx burden
absence dehydration
no prior fungal infection or solid tumor tyoe
no copd hx
absence of hypotension
asx or overall mild symptom burden

score >/=21 suggests low risk complication; likely resolution fever <5d

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8
Q

Clinical features and corresponding point value of clinical index of stable febrile neutropenia:

A

eastern coop oncology group performance status >/=2
stress induced hyperglycemia
copd
chronic cardiovascular disease
mucositis of grade >/=2
monocyte coun <200 per microL

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9
Q

If pt with febrile neutropenia show signs of shock, what should they add to broad spectrum beta lactam with antipseudomonal coverage?

A

+ FQ or aminoglycoside

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10
Q

What abx for neutropenic pt with CAP?

A

levo 750mg IV a24h or azithro 500mg IV q24h and doxy 100mg BID

TMP for pcp if necessary

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11
Q

For neutropenic pt with GI sx, what abx to give?

A

cefepime 2g IV q8h and metronidazole 500mg PO q8h

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12
Q

What febrile neutropenia patients can be managed as outpt?
criteria:

A
  1. low risk criteria MASCC 21 or less
  2. no evidence of pneumonia, line infection, cellulitis or organ failure
  3. reliable daily f/u with oncology
  4. clinical stability in ER 4h or longer
  5. low suspicion of infection with drug R organism
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13
Q

Metastatic SC compression: where does lesion most often come from?

A

extradural

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14
Q

Metastatic SC compression: how does cord injury normally occur?

A

occlusion of epidural venous plexus leading to breakdown of BBB and vasgenic edema
if untx - arterial obstruction –> cord ischemia and infarct

less common direct compression

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15
Q

Metastatic SC compression: what cancers typically cause this?

A

prostate
breast
lung ca

RCC
nonHodgkin lymphoma
MM

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16
Q

Metastatic SC compression: where mc?

A

thoracic

lumobosacral

cervical

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17
Q

Metastatic SC compression: clinical features?

A

back pain (mc)
weakness (extremity often first pre. weakness)
sensory loss
autonomic function loss

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18
Q

Metastatic SC compression: diagnostic testing

A

MRI

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19
Q

Metastatic SC compression: tx in ED

A

CS: 10mg bolus IV then 16mg oral per d
if paraplegic consider first dose of 100mg IV then 96/day orally in divided doses
initiation of defin tx - surgery, rad therapy or both

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20
Q

Metastatic SC compression: how do steroids work?

A

temporize vasogenic cord edema but damage occurs without source control

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21
Q

Malignant pericardial disease: mc three?

A

pericarditis
neoplasm
effusion

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22
Q

Malignant pericardial disease: how can this occur as an effusion?

A

lymphatic flow becomes obstructed by proximal malignant LN
so mets spread to pericardial lining

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23
Q

mc cancers causing pericardial effusion?

A

lung
breast
heme
melanoma

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24
Q

Kussmaul sign

A

paradoxial incr in JVP with inspiration

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25
Q

Beck’s triad

A

hypotension
elevated JVP
muffled heart sounds

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26
Q

Malignant pericardial disease: ddx?

A

acs
hf or valve failure
pe
pleural effusion
pneumonia
ptx

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27
Q

Malignant pericardial disease: pericardial effusion work up?

A

cxr
ecg
tte

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28
Q

Malignant pericardial effusion findings on ecg?

A

nonsp st or t change
low amp qrs
electrical alternans

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29
Q

Malignant pericardial disease: management of pericardial effusion?

A

drainage by subxiphoid approach
likely will recur so needs LT f/u
fluid sampling for cytology or tumor marker analysis

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30
Q

Hypercalcemia: what two main hormones incr serum ca regulation?
what decr?

A

PTH
calcitriol - incr serum ca

decr: calcitonin

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31
Q

Hypercalcemia: what are two places active vitamin D works on?

A

bone - osteoclast activation to release
GI - to incr dietary ca uptake and dietary phosphate

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32
Q

Inactive vit d to active by which enzyme?

A

1 alpha hydroxylase

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33
Q

To incr ca: PTH acts on what two organs

A

kidneys: incr ca reuptake, decr phos reuptake

bone: osteoclast

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34
Q

How do cancer patients experience Hypercalcemia: 4 methods

A

synthesis PTHrP
overproduction calcitriol
bone osteolysis due to direct tumor spread
less common ectopic production of PTH

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35
Q

PTHrP producing cancers?

A

squamous.- head and neck, lung, esophageal, cervical, ovarian, endometrial

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36
Q

Cacitriol overproduction in which cancers?

A

hodgkin and non lymphomas

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37
Q

Hypercalcemia: sx

A

weakness
lethargy
confusion
abdo pain
n/emesis
constipation
polyruia
polydipsia
kidney injury

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38
Q

Hypercalcemia: ecg

A

qt interval shortening
to dysr and heart block

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39
Q

Hypercalcemia: which ca measurement needed?

A

free ca as lots bound to albumin

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40
Q

Hypercalcemia: Tx ED

A
  1. fluids ++ as helps to incr removal: 1-2L bolus, then 200-250ml/hour
    –>. +/- dialysis above if needed to support u/o
  2. bisphosphonates: inhibit bone turn over: pamidtronade 90mg over 2-4 hours or zolendronate 4mg over 15-30 mins
    *expect decr 3-4mg/dl but probably not for 7-10d
  3. calcitonin SC 4-8 units/kg q6h (faster 12-24h onset)
  4. Denosumab to block RANK ligand * esp if renal clearance bad
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41
Q

Rosen’s indications for admission for Hypercalcemia:

A

Ca >14
acutely incr

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42
Q

TLS: why does this occur?

A

desctruction of malignant cells so rapid that body mechanism for unwanted products are overwhelmed

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43
Q

TLS: 4 abnormal electrolyte/lab values

A

Hyperuricemia
HyperK
Hyperphos
HYPOcalcemia

AKI often as well

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44
Q

TLS: what other organ affected often

A

kidney

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45
Q

TLS: typical cancers causing this?

A

Burkitt lymphoma
ALL

46
Q

TLS: PT risk factors (aside from type of ca)

A

preexisting renal failure
hypovolemia
hyperuriciemia

47
Q

TLS: sx/presentation

A

nausea/emesis
lethargy
confusion
edem
seizure
myalgias and tetany
dysrh –> cardiac arest

48
Q

TLS: ecg

A

qt interval prolongation due to hypoca, p wave flattening, PR and QRS interval prolongation
T wave peaking due to hyperk

49
Q

TLS: diagnostic testing

A

chem 10 - K, phosphate, ca (ionized), BUN, Cr
uric acid ON ICE if had rasburicase already
LDH

50
Q

TLS: management ED

A
  1. 3L/m2/d (as high as 5-6L /d)
  2. DialysisCRRT if Cr really bad/oliguria at BL
  3. Limit dietary intake
  4. Don’t tx cca as secondary to excess phosphate
  5. shift K (insulin, bicarb, beta agonist), ca gluconate if needed, etc usual tx
  6. hyperuric: allopurinol, febuxostat or rasburicase
51
Q

TLS: nephrotoxic compound of ca phosphate: how to hypocalcemia tx or when to?

A

don’t tx as higher risk for getting this

only time to tx is cardiac dysr, neurologic (seiz, coma), hyperK

52
Q

TLS: mechanism allopurinol in hyperuriciemia

A

analog of uric acid precuros hypoxanthine to competitively inhibit enzymatic conversion of xanthine to uric acid
xanthine watch kidneys though!!

53
Q

TLS: hyperuricemia with tx of feboxostat - how does this work?

A

noncompetitive inhib of xanthine oxidase enzyme

not as good as allopurinol

54
Q

TLS: hyperuricemia - how does rasburicase work?

A

recombinant enzume of urate oxidase, turns uric cid into allantoin

55
Q

TLS: rasburicase dose

A

0.05-0.15mg/kg x1 dose (adult typc 6mg)

56
Q

What is a CI to rasburicase?

A

G6PD deficiency as hydrogen peroxide is a byproduct of drug and can trigger hemolytic crisis

57
Q

Complications of rasburicase

A

methemoglobinemia
hemolytic crisis of G6PD deficient

58
Q

Leukostasis level

A

CLL 500 vs AML <100 (really depends on ca)

59
Q

Leukostasis: complications

A

retinal hemorrhage
CNS typical
MI
acute limb ischemia
priapism
Renal vein thrombosis
renal infarction

60
Q

Leukostasis: what might you see on VBG o2 if it waits to be sent?

A

leukocytes will eat o2 so it looks falsely low

61
Q

Leukostasis: ED management

A
  1. reduction of blood viscosity via IV fluids
  2. avoid RBC as will incr viscosity
  3. leukaphresis
    and or
  4. dose of hydroxyurea (works 24-48 hr)
    and or
  5. chemo agents per oncology, but watch for TLS
62
Q

SVC syndrome: when is flow compromised?

A

20-40mmhg

63
Q

SVC syndrome: mc malignancies causing?

A

lung ca
lymphoma

64
Q

SVC syndrome: outside of neoplasm, what is second mc cause?

A

thrombus

65
Q

SVC syndrome: hx symptoms

A

upper extreimity, chest or face edema or erythema
-possible sobm dysphagia, cp, cough

66
Q

SVC syndrome: signs on PE

A

elevated JVD
edema, flushing or cyanosis of the face, arms, upper trunk
vc paralysis blurred vision, horner sydrome are possible
pleural effusion

67
Q

SVC syndrome: dx

A

cellulits or deep tissue infection of face neck (ludwig angina)
thoracic inlet syndrome
obstruction of -DVT in IJ or subclavian vein)

68
Q

SVC syndrome: diagnostics

A

thoracic and contract enh CT
typically like to know what ca prior - may ned bronch/bx

69
Q

SVC syndrome: tx

A

Elevated HOB, supplemental o2, anticoag if b thrombus

know the cancer
+/- rads if appropriate
+/- endovascular stenting

70
Q

Monoclonal antibody therapies: mc ca?

A

lymphmas
colon
lung
h+N
Breast

71
Q

Monoclonal antibody therapies: basic physiology

A

nonconjugated antibodies bind to tumor target, marking tumor for kill by antibody depn cell mediated cytoxicity and compliment dependent

72
Q

Monoclonal antibody therapies: typical infusion reaction for alemtuzumab, ibritumomab, trastuzumab

A

type I anaphylaxis like

73
Q

Monoclonal antibody therapies: which one causes sudden cardiac death?

A

cetuximab
colon/lung/H+N

74
Q

Monoclonal antibody therapies: which specifically causes cardiomyopathy?

A

trastuzumab

75
Q

Monoclonal antibody therapies: which specifically causes hepatotoxicity?

A

inotuzumab

76
Q

Monoclonal antibody therapies: how to work up

A

if looks like sepsis, infectious w/u
if cardiac - usual
neuro - brain imaging

77
Q

Monoclonal antibody therapies: management

A

Largely supportive
High temp - antipyretics, mild infction - histamine blocker
HD sypport as needed
if worried about anaphylaxis tx it

78
Q

Monoclonal antibody therapies: which can cause PML?

A

brentuximab
ofatumumab
rituximab

79
Q

Monoclonal antibody therapies: rituximab notable complications?

A

severe infusion reaction
TLS
severe mucocutaneous reactions
PML

80
Q

T lymphocyte checkpoint inhibitor therapies and complications: how do these work?

A

reduce T cell tolerance to allow T cell immune response against tumor specific antigen bearing cancer cells (as these attack T cells normally)

81
Q

T lymphocyte checkpoint inhibitor therapies and complications: which 2 checkpoints is self tolerance achieved by?

A

prevent mature t cells into peripheral tissues from attacking self antigen bearing cells (inhibit these) –> TLA-4, PD-1

82
Q

T lymphocyte checkpoint inhibitor therapies and complications: most feared complication?

A

hypophysitis - immune mediated pitu disease which can cause shock due to GC deficiency and colitis

83
Q

T lymphocyte checkpoint inhibitor therapies and complications: cardiac issues

A

pericardial effusion
myocarditis

84
Q

T lymphocyte checkpoint inhibitor therapies and complications: endocrine

A

hypophysitis: anorexia, fatigue, headache, nausea, diplopia, confusion, temp intol… 6-12 weeks post starting
thyroid dysfunc

85
Q

T lymphocyte checkpoint inhibitor therapies and complications: GI

A

colitis
diarrhea
hepatotoxicity

86
Q

T lymphocyte checkpoint inhibitor therapies and complications: hematologic

A

neutropenia
anemia
ITP

87
Q

T lymphocyte checkpoint inhibitor therapies and complications: skin

A

intraoral lesion
skin toxicity

88
Q

T lymphocyte checkpoint inhibitor therapies and complications: neurologic

A

MG
GBS

89
Q

T lymphocyte checkpoint inhibitor therapies and complications: pulmonary

A

pneumonitis

90
Q

T lymphocyte checkpoint inhibitor therapies and complications: renal

A

AKI

91
Q

T lymphocyte checkpoint inhibitor therapies and complications: rheum

A

vasculitis
myalgias
arthralgias

92
Q

T lymphocyte checkpoint inhibitor therapies and complications: general management

A

supportive, specific to presentation
if sp to qol - consider taking to oncology: prednisolone, methylpred if hypophysitis

93
Q

T lymphocyte checkpoint inhibitor therapies and complications: diagnosing and treating hypophysitis

A

visual field test, MRI brain, pitu function test
meythlpred 1-2mg/kg/d IV

94
Q

T lymphocyte checkpoint inhibitor therapies and complications: colitis dx and tx

A

ct imaging abdo pelvis, test for cdiff, colonoscopy/endoscopy considerations

consider predn and if severe, infliximab

95
Q

Adoptive cell transfer therapy and complications/Chimeric Antigen Rector (CAR) - T cell therapy: what is this?

A

pt own t cell is reprogrammed to attack ca cell after harvest from leukophoresis

96
Q

Chimeric Antigen Rector (CAR) - T cell therapy: what CD are these 2 (tisagenleleucel and axicabtagene ciloleucel) designed to attack?

A

CD-19, B cell sp

97
Q

Chimeric Antigen Rector (CAR) - T cell therapy: 2 major complications

A

cytokine release syndrome

immune effector cell associated neurotoxicity syndrome

98
Q

Chimeric Antigen Rector (CAR) - T cell therapy: Cytokine release syndrome - what is this?

A

uncontrolle ck release leading to life thr inflamm (60% pt so ++ prevalent) –> end organ dysfun and looks like spesis as fever, malaise, fatigue, rash, hypotension

99
Q

Chimeric Antigen Rector (CAR) - T cell therapy: Cytokine release syndrome onset from therapy?

A

~3d

100
Q

Chimeric Antigen Rector (CAR) - T cell therapy: immune effector cell-associated neurotoxicty syndrome -what is this?

A

cns undergo immune cell mediated damage (50% CAR-T)

101
Q

Chimeric Antigen Receptor (CAR) - T cell therapy: Immune effector cell associate neurotoxicity syndrome: symptoms

A

confusion, aphagsia, headach,e tremor, behaviour change, peripheral numbness
**expressive aphasia

102
Q

Chimeric Antigen Receptor (CAR) - T cell therapy: Immune effector cell associate neurotoxicity syndrome: which type of aphasia is very sn and sp to this?

A

expressive

103
Q

Chimeric Antigen Receptor (CAR) - T cell therapy: Immune effector cell associate neurotoxicity syndrome: median onset post tx

A

4d

104
Q

Chimeric Antigen Receptor (CAR) - T cell therapy: Immune effector cell associate neurotoxicity syndrome: how to work up in ED

A
  1. tx as sepsis until provden otherwise and or stroke if necessary: image, septic work up, +/- eeg/ +/- LP

MRI may show t2 hyperinensity in wm and thalami, csf can show elevated levels of pro nad leykocytes (needs cultures to r/o meningitis)

105
Q

Chimeric Antigen Receptor (CAR) - T cell therapy: Immune effector cell associate neurotoxicity syndrome: management in the ED (once know not sepsis, stroke, etc):

A

Low grade CRS: tx symptomatically
More severe: Tocilizumab and CS following this if no response
Supportive: IVF, vasopressors, respiratory support

106
Q

Chimeric Antigen Receptor (CAR) - T cell therapy: Immune effector cell associate neurotoxicity syndrome: how does tocilizumab work for this?

A

anti IL 6 receptor antibody for Cytokine release syndrome

107
Q

What antibiotics have antipseudomonal coverage

A

with imipenem, meropenem, ceftazidime, or cefepime is as effective as traditional dual therapy with an antipseudo- monal penicillin (piptazo) and aminoglycoside

108
Q

When should vancomycin be included for febrile neutropenia pt?

A

Hypotension or cardiac involvement
suspected cath infection
+ blood cultures of a + organism
known colonization with MRSA or cephalosporin R pneumococcus

109
Q

Cairo Bishop score for TLS

A

Meet more than 2/4 of lab in same 24h criteria:
lab TLS: uric acid >8
K >/=6
Phos >/=4.6
Ca </=7
(greater than 25% incr)

Clinical:
AKI as Cr >/=1.5 x ULN N

cardiac arrh

seizure tetany or other symp

110
Q

Which cancers cause hypercalemia

A

Hem: leuk, lymphoma, MM

Head and neck

Breast
Lung
ovarian
renal
endometrial

Rosens (40 decks)

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