Exam 3 Flashcards
Corrected Calcium calculation
Corrected Ca = Measured Ca + 0.8*(4 - serum albumin)
HCM management
- Hydration
- Diuresis with furosemide
- Bisphosphonates: zoledronic acid > pamidronate
- Adjunctive: calcitonin, denosumab
ANC calculation
ANC = (% segmented + % bands) * WBC/100
What is febrile neutropenia?
- Severe neutropenia ANC <500
- Fever (101+ F)
FN low risk criteria
- MASCC 21+, CISNE <3
- Outpatient when having fever
- No comorbid illness requiring hospitalization
- Short duration <7 days
- Good performance score ECOG 0-1
- No hepatic or renal insufficiency
FN high risk criteria
- MASCC <21, CISNE 3+
- Inpatient when having fever
- Comorbid illness or clinically unstable
- Prolonged duration 7+ days
- uncontrolled/progressive cancer
- Hepatic or renal insufficiency
- pneumonia or other infections
- HSCT or hematologic malignancy
FN high risk empiric therapy
- Pip/tazo, cefepime, meropenem, imipenem/cilastatin
- Carbapenems if ESBL
FN low risk empiric therapy
- Cipro + amoxicillin/clavulanate
- Cipro + clindamycin, levofloxacin, moxifloxacin
FN Vanco addition
- MRSA or PCN-resistant
- Skin and soft tissue infection
- Pneumonia
- IV catheter-related infection
- Gram+ culture
- Clinical instability: HoTN, shock
TLS complications
- Hyper: phosphatemia, kalemia, uricemia
- Hypocalcemia
- AKI
TLS uric acid abnormality
> 8.0 mg/dL
TLS phosphate abnormality
> 4.5 in adults, >6.5 in children
TLS potassium abnormality
> 6.0 mg/dl
TLS calcium abnormality
Corrected calcium <7.0 mg/dl or measured calcium <1.12
TLS low risk management
IV fluids, allopurinol, daily labs
TLS intermediate risk management
IV fluids, allopurinol, labs Q8-12H
TLS high risk management
IV fluids, rasburicase, labs Q6-8H, cardiac monitoring
TLS established management
IV fluids, rasburicase, labs Q4-6H, cardiac monitoring
TLS fluids backbone
crystalloids
TLS hyperkalemia backbone
- Stabilize myocardium: calcium gluconate/chloride
- Intracellular shift of K: regular human insulin, sodium bicarb, albuterol
- Elimination of K: loop diuretics, sodium polystyrene, sulfonate, hemodialysis
TLS hyperphosphatemia backbone
Calcium carbonate/acetate, Sevelamer, Lanthanum
TLS hypocalcemia backbone
Treat if symptomatic with IV Ca2+
TLS hyperuricemia backbone
- Allopurinol
- Rasburicase: high UA >7.5
Breast cancer risk factors (12)
- Female
- > 65 yrs
- non-Hispanic whites & blacks
- Higher endo/exogenous estrogen exposure
- Genetic mutations: BRCA1/2, TP53, PTEN
- FH of breast & ovarian cancer
- Personal hx of BC
- DCIS, LCIS
- Benign breast disease
- Breast density
- Prior thoracic irradiation 10-30 yrs
- Environment/lifestyle
BC risk factor: higher endogenous estrogen exposure
- Early menarche <11 yrs
- Older age at birth of first child (>30 yrs) or nulliparity
- Later menopause >55 yrs
BC risk factor: higher exogenous estrogen exposure
- Risk of postmenopausal estrogen replacement therapy & OC controversial
- OC: benefits far outweigh the small increased risk of developing BC
BC when to use Gail model
> 35 yrs with a family history
BC when NOT to use Gail model
- Predisposing genetic mutation
- Hx of thoracic radiation
- Prior hx of BC
BC NCCN screening recommendation
40+ yrs annual mammogram with tomosynthesis
BC ACS screening recommendation
- 40-44 optional annual mammogram
- 45-55 annual mammograms
- 55+: mammograms every 1,2 yrs
BC USPSTF screening recommendation
- 40-49: optional mammograms every 2 yrs
- 50-74: mammograms every 2 yrs
BC chemoprevention agents
Tamoxifen, raloxifene, anastrozole, exemestane
BC: node-, HER2+, ER/PR+
- <0.5cm: none
- 0.6-1 cm: endocrine
- > 1cm: endocrine + chemo + trastuzumab
BC: node-, HER2+, ER/PR-
- <1cm: none
- > 1cm: chemo + trastuzumab
BC: node-, HER2-, ER/PR+
- <0.5cm: none
- 0.6-1cm: Oncotype DX RS <26 = endo, RS 26+ = endo + chemo
- > 1cm: same as above
BC: node-, HER2-, ER/PR-
- <1cm: none
- > 1cm: chemo
BC: node+, ER/PR+
- Endo + chemo
- If HER2+: trastuzumab + pertuzumab
BC: node+, ER/PR-
- Chemo
- If HER2+: trastuzumab + pertuzumab
BC Stages I-III, HER2-
- Dose-dense AC -> T = doxorubicin (Adriamycin) and Cyclophosphamide + Paclitaxel
- TC = docetaxel (Taxotere) and Cyclophosphamide
BC anthracyclines toxicities, monitor
- Cardiotoxicity
- Echocardiogram or MUGA
BC Stages I-III, HER2+
- TCH +/- pertuzumab = Docetaxel (Taxotere), Carboplatin, Trastuzumab (Herceptin) +/- pertuzumab
- Paclitaxel + trastuzumab –> reserved for low risk, not eligible for other regimens
BC HER2i toxicities, monitor
- Cardiotoxicity
- ECHO or MUGA
BC adjuvant endocrine therapy for premenopausal
Tamoxifen
BC adjuvant endocrine therapy for postmenopausal
- TAM
- AI (preferred): Anastrozole, Letrozole, Exemestane
BC Stage IV, ER/PR+, HER2-
- AI + CDK4/6i
- Fulvestrant + CDK4/6i
BC Stage IV, ER/PR+, HER2-, visceral crisis or endocrine refractory
- BRCA mutation vs no
- BRCA1/2: PARPi (olaparib, talazoparib)
- No: single chemo
BC Stage IV, ER/PR+, HER2+
- AI +/- trastuzumab or lapatinib or both
- Fulvestrant +/- trastuzumab
- TAM +/- trastuzumab
BC Stage IV, ER/PR-, HER2+
Pertuzumab + trastuzumab + docetaxel (preferred) or paclitaxel
BC Stage IV ER/PR-, HER2- (TNBC):
- PDL1+ vs -
- PDL1+: pembrolizumab + carboplatin + paclitaxel/albumin-bound/ gemcitabine
- PDL1-: BRCA1/2 = PARPi or platinums vs no mutation = single chemo