Bone & Oncologic Emergency Flashcards
For Hypercalcemia of Malignancy, what are some of the most common tumor types that can cause it?
- Lung, Breast, Hematologic, Prostate
What is the Pathophysiology of HCM?
- Increased Parathroid hormone
- Increased resorption - Bone Breakdown
- Decreased Elimination - Kidney Failure
What are some of the the reasons for HCM?
- Humoral: Boney metastase that breakdown the bones –> caused by that parathyroid hormone stimulating osteoclast
What is the way that we calculate Corrected Calcium?
- Serum Ca + 0.8 (4 - Serum Albumin)
What are some of the stages that could occur in HCM?
- MILD: <12mg/dL
- MODERATE: 12-14mg/dL
- SEVERE: >14mg/dL
What is important to know about Mild HCM [<12mg/dL]?
- HYDRATE!! [stop Ca supplements]
- Bisphosphonates for Moderate symptoms [Zoledronic Acid or Panmidronate]
What are some of the signs and symptoms for Mild HCM?
- Constipation, Fatigue [dont know you have it]
What is important to know about Moderate HCM [12-14mg/dL]?
- HYDRATION!! [should lower Ca levels in 24-48 hours –> faster than bisphosphonate]
- DONT give loop diuretics UNLESS overloaded
- Bisphophonates [Zoledronic Acid IV over 15 mins; x7d]
What are some of the signs and symptoms for Moderate HCM?
- N/V, Lethargy, Confusion, Weakness
What is important to know about Severe HCM [>14mg/dL]?
- HYDRATION!!!!!!!!!
- Bisphosphonates
- Calcitonin [only after Hydration and Bisphosphonates]
What is important to know for Calcitonin in Severe HCM?
- Tachyphylaxis after 48 hours
What are some of the signs and symptoms for Severe HCM?
- Seizures, Coma, Heart Block, Arrhythmias, Asystole
When having refractory HCM, what is the specific treatment that should be used?
- RANK-L Inhibitor: Stops the osteoclasts from breaking down bones [Denosumab]
When experiencing Chronic HCM, what are some of the treatments to use?
- Zolendronic Acid IV over 15 minutes monthly
- Pamidronate IV over 2 hours monthly
What is do the IV bisphosphonates due in HCM?
- Inhibits osteoclast activity by apoptosis and stops differentiation
- Decreases bone resorption
- Concentrates at bone remodeling
What is the epidemiology of Bone Metastases in SREs?
- Cancers that affect the bone [Breast, PROSTATE, Myeloma, Lung, Kidney]
How do you know if you have SREs?
- Bony pains [pinpointed]
- Radionucleotide bone scan
- CT, MRI, PET scans
What are some of the risk factors for fractures in women with SRE?
- BREAST CANCER
- Aromatase Inhibitors, Age > 65, Smoking
What are some of the risk factos for fractures in men with SRE?
- PROSTATE CANCER
- Androgen Deprivation Therapy, Smoking
What is the general treatment overview for Bone Metastases in SRE?
- Palliation of symptoms
- Radiation, Chemotherapy, IV Agents, Radioisotopes
What is important to know about Radiation Therapy in SRE?
- Helps with pain relief within 1-2 weeks [do not use longer than 6 weeks]
- Radioisotopes
What are some of the radioisotopes that are used with Radiation for SRE?
- 131-Iodine: Thyroid Cancer
- Radium-223: PROSTATE CANCER
- Strontium & Samarium: Breast and Prostate
What is important to know about the Radioisotopes in Radiation for SRE?
- Expensive
- Myelosuppression
What are the IV agents that are used for SRE?
- Bisphosphonates
- Pamidronate IV 2 hours month
- Zolendronic Acid IV 15 minutes monthly or bimonthly
Do the IV Bisphosphonates need renal adjustment for SRE?
- NEEDS RENAL ADJUSTMENT DOSING [only for SRE not HCM]
How do we calculate CrCl?
- = (140-age) x IBW / 72 x Scr
- x 0.85 if female
What is Denosumab?
- RANK L inhibitor
What are the other types of Denosumab used for SRE?
- More for refectory
- BONE METS = Xgeva every 4w
- Osteopenia = Prolia every 6w
What are some of the considerations for Denosumab for SRE?
- SubQ
- NO renal adjustments
- EXPENSIVE [~$2500]
What are some of the main side effects that can occur from the SRE or HCM treatments?
- Osteonecrosis of Jaw
- Renal Dysfunction
- Hypocalcemia
What drugs are more likely going to cause Osteonecrosis of the Jaw from SRE or HCM?
- Zolendronic Acid & Denosumab > Pamidronate
- Monthly > yearly
- IV > PO
What drugs are more likely to cause Renal Dysfunction in SRE or HCM>
- Zoledronic Acid > Pamidronate > Denosumab
- Bisphosphonate NOT CrCl < 30
What is Tumor Lysis Syndrome within Oncologic Emergenices?
- Death of Malignant cells that release intracellular contents into he blood [life threatening]
What are some of the risk factors for TLS in Oncologic Emergenices?
- Based on the type of cancer [Solid tumor wont do it BUT hematologic cancers can]
- Tumor specific
- Patient Specific: age, renal impairment, uric acid?
When the tumor cells lysis, what are some of the things that can happen?
- Hyperkalemia [Increased K]
- Hyperuricemia [Increased Uria]
- Hyperphosphatemia [Increased P]
- Hypocalcemia [Decreased Ca]
What is are some of the side effects based on pathophysiology for TLS in Oncologic Emergenices?
- Hyperkalemia = cardio issues
- Hypocalcemia = caused by the hyperphosphatemia
- ALL pass through the kideny SO kidney failure increases all them
What are some fo the prinicple of management for TLS in Oncologic Emergencies?
- Identify high risk patients
- Monitoring Electrolytes
- HYDRATION
- Control the Hyperuricemia
What are the patients that are more high risk for TLS in Oncologic Emergencies?
- Those with Lymphoma or Leukemias
What are some of the Prophylaxis measures to take for TLS in Oncologic Emergenices?
- Montoring & Hydration
- Low and Moderate: Allopurinol
- High: Rasburicase
What is the way that Allopurinol can help within TLS?
- Uric Acid and Xathine can lead to AKI
- Allopurinal STOPS FUTURE production of uric acid NOT breakdown current
- Use before chemo
What is MOA for Rasburicase in High Risk TSL?
- Can stop breakdown CURRENT and FUTURE uric acid in 4 hours
- Use in patients that cant use Allopuinol
What are some of the limitations for Rasburicase in High Ris TSL?
- G-6-P deficiency
- CONTRAINDICATED in pregnant or breast-feeding
- $$$$$$
Within TSL, what are some of the ways that we can manage electrolyte abnormalites?
- Hyperkalemia [K]: Calcium Gluconate, Dextrose, Insulin, Sodium Bicarb, loop diuretices
- Hyperphophatemia [P]: Phospate Binder
- Hypocalcemia [Ca]: DONT treat asymptomatic; Symptomatic = calcium gluconate
What is Malignant Spinal Cord Compression within Oncologic Emergenics?
- Compression of spinal cord that is caused by Breast, Lung PROSTATE cancers
- THIS IS AN EMERGENCY!!!!
What are some of the Symptoms of MSCC?
- Pain: back pain is most common
- Motor Deficit: weakness & gait
- Sensory Deficit: numbness of toes or fingers
- Autonomic Dysfuction: cant make it to the bathroom [RED FLAG]
If you suspect someone to have MSCC, what is important to do first?
- STERIODS [Dexamethasone]
- MRI of the WHOLE spinal cord
What are some of the treatment options for MSCC?>
- STEROIDS IMMEDIATELY: Dexamethazone 10 mg
- Surgery & Rads are the only treatments that has immediate relief
What is important to know about Radiation & Surgery in MSCC?
- Radiotherapy: stops further growth
- Surgery: Laminectomy, Vertebroplasty, Kyphoplasy [concrete balloon]
What is Superior Vena Cava Syndrome in Ocologic Emergenies?
- The compressing of the SVC causes a decrease in drainage from the head, neck, and upper extremities
- NOT really an oncologic emergency??
What are some of the signs and symptoms for SVC?
- Facial and Arm Edema, Cough, Stridor, Dysphagia
What is the way that we treat SVC syndrome ?
- Alleviated the symptoms & treat cause
- Stents, anticoag?
- Elevate the head [decreased edeme], Steroids [inflammation], Diuretics [decrease fluids]
What is a Malignant Pleural Effusion in Onologic Emergenceies?
- Fluid in the plural space by the lungs
- Can be causes by Lung, Breast and Lymphoma
What are the symptoms PE and how do we diagnosis it?
- NO real symtpoms: SOB & Pain
- Chest x-ray is 1st
How are we able to manage MPE?
- Thoracentesis: Needle that removes fluid from pleural area [drain 1-1.5L; could cause infections]
- Cathator
