exam 2 lecture 6 bone modifying agents Flashcards
what percent of cancer causes hypercalcemia? what are the most common tumor types that cause these bony metastases? Non malignant causes?
20-30% of all cancer patients. (has decreased due to bisphosphonate use)
lung and breast are most common
non malignant cause- renal failure, hyperparathyroidism
What are the types of HCM (hypercalcemia)
- humoral (80% of cases) caused by PTHrP (parathyroid hormone).
- local osteolytic hypercalcemia
- 1, 25 OH secreting lymphomas
signs an symptoms of HCM (include levels)
mild- asymptomatic (maybe polyuria/polydipsia)
10-12
moderate
12-14
dehydration, lethargy, confusion
severe >14
renal failure, cardiac issues
Corrected calcium calculation
Serum calcium + 0.8 (4 - serum albumin)
tx of mild HCM
fluids/hydration
tx of moderate HCM
Hydration, 200-400 mk/hr NS
bisphosphonate use (zolindronic acid/ pamidronate)
loop diuretics for patients who develop fluid overload
severe HCM tx
> 14
HYDRATION HYDRATION HYDRATION (NS)
Bisphosphonates
calcitonin after bisphosphonates
treatment of treatment refractory HCM
Denosumab
chronic HCM management
zoledronic acid
pamidronate
bisphosphonates MOA
inhibit osteoclast activity
increase mineralization
decrease bone resorption
what are cancer with affinity to bone
Prostate (most common)
breast
myeloma
lung
kidney
diagnosis of SRE (skeletal related events
symptoms of bony pain/tenderness
bone scan
risk factors for fractures
smoking
FH
history of fracture
age
treatment of bone metastases
radiation
chemo
IV bone modifying agents (RANK L inhibitors and bisphosphonates)
what to know about radiation therapy in bone metastases
85% response rate. Pain relief within 1-2 weeks. If no relief after 6 weeks, unlikely to see benefit
What are the bisphosphonates used for skeletal related events? WHat to keep in mind?
Pamidronate and zoledronic acid
ALWAYS dose ADJUST FOR RENAL DOSING
we prefer zoledronic acid because it is quicker to give
do we dose adjust zoledronic acid and pamidronate for HCM? WHat about for skeletal related events
NO ADJUSTMENT FOR HCM
ADJUST FOR SRE
WHat type of drug is denosumab? What is it used for?
RANK-L drug
Use 1- bone metastases from solid tumors (drug name is xgeva)
Use 2- osteopenia for women at high risk for fracture and receiving aromatase inhibitor for breast cancer and men receiving ADT (drug name prolia)
What to do before denosumab initiation
correct hypocalcemia
no renal adjustment needed (this may be why we pick it over bisphosphonate)
Calcium and vit D supplement (same with bisphosphonate)
side effects of bisphosphonate
osteonecrosis of jaw
compare renal dysfunction of zolendronic acid, pamidronate and denosumab?
hypocalcemia?
renal-Zolendronic acid> Pamidronate>denosumab (not renally eliminated)
hypocalcemia- denosumab>zoledronic acid
How does TLS happen
tumor lysis syndrome is a massive release of intracellular contents into blood stream that overwhelms homeostasis. Serious and life threatenig.
What type of cancers do we see TLS in? What are the risk factors?
associated with aggressive hematologic malignancies, but also in solid tumors.
tumor specific risk favtors- high tumor burden, high tumor grade, rapid cell turnover
Patient specific- age, renal impairement
how does TLS present
Hyperkalemia
hyperuremia (AKI)
hyperphosphatemia
hypocalcemia
they cause acute renal failure
How to prevent TLS
Identify high risk pts
monitor electrolytes
aggressive hydration
Control hyperuricemia
it is an oncologic emergency
prophylaxis of TLS
monitoril
hydration
allopurinol (for low and moderate risk)
(rasburicase for high risk)
Difference between allopurinol and rasburicase
when TLS occurs, allopurnol does not facilitate breakdown of uric acid, but stops manufacturing of more uric acid
rasburicase can decrease existing uric acid
rasburicase limitation?
rasburicase
EXPENSIVE
CI in pregnant and breast feeding
what is MSCC
malignant spinal cord compression. It is an oncologic emergency.
Early diagnosis and treatment is ESSENTIAL to prevent paralysis
What is the most common cause of MSCC? symptoms?
Prostate most common
Pain, motor deficit, sensory deficit
MSCC diagnosis
MRI of spine
MSCC treatment
STEROIDS IMMEDIATELY (dexamethasone)
surgery (needs pt to be good performance status)
radiotherapy
If pt has good PS, surgery immediately, if not, radiation therapy
use bisphosphonates after surgery
What is SVC?
superior vena cava syndrome.
SVC gradually compressed by tumors
it is also an oncolytic emergency
signs and symptoms of SVC
facial and arm edema, capillary formation, hypotension
SVC syndrome treatment
use some type of stent to maintain breathing while we do biopsy to figure out what we are dealing with
alleviation of symptoms- elevation of head, steroids, diuretics
depending on severity, we can do radiation, chemo, anticoag
malignant pleural effusion (MPE) common cancer? symptoms?
lung, breast, lymphoma
symptoms
1. pleural effusion- accumulation of fluid in pleural space
ranges from no symptoms to acute respiratory distress (dyspnea most seen symptom)
MPE management
Thoracentesis (drain fluid) and send to lab for analysis
thoracentesis minimizies acute symptoms temporarily, but fluid re accumulates within 30 days
pleurodesis- activates cascade leading to adhesion of pleural layers.
pleural catheters- used to drain fluid frequently. Might cause infection.
