Oncologic emergencies

Question 1

renal hypercalcemia clinical manifestations

Answer 1

polyuria
polydipsia
dehydration
decrease in GFR

Question 2

Hypercalcemia

Answer 2

corrected calcium >10.5 mg/dL
corrected calcium= 0.8 x (4-Albumin) + serum calcium

Question 3

GI hypercalcemia clinical manifestations

Answer 3

constipation
anorexia
N/V

Question 4

neurologic hypercalcemia clinical manifestations

Answer 4

lethargy
confusion
irritability
muscle weakness
seizure
stupor
coma

Question 5

cardiac hypercalcemia clinical manifestations

Answer 5

shortened QT interval
widened T wave
heart block
asystole
atrial and ventricular arrhythmia

Question 6

mechanisms of. hypercalcemia

Answer 6

humoral (most common)
bone invasion
Rare causes

Question 7

humoral mechanism

Answer 7

Increased parathyroid hormone related peptide–> increased renal tubular reabsorption of calcium–> increase phosphorus excretion through urine–> hypercalcemia and hypophosphatemia

common in squamous cell carcinomas of the head and neck, lung, colon

Question 8

bone invasion mechanism

Answer 8

local osteolytic activity that leads to secretion of calcium–> increase in calcium through signaling from tumor cells to release cytokines –> activation of osteoclasts + bone resorption through RANK + RANKL process

common in multiple myeloma, metastatic breast cancer

Question 9

Rare causes mech

Answer 9

1) Increased production of calcitriol (vit d intoxication)
-increased calcium resorption
-common in hodgkin lymphom
2) ectopic PTH production
-common in patients with history of head and neck irradiation and chronic lithium therapy

Question 10

increase calcium excretion

Answer 10

IV fluids normal saline
bolus of 1-2 L followed by continuous infusion at 200-500mL/hr
furosemide 20-40mg: reserved for volume overload or HF

Question 11

inhibition of bone resorption

Answer 11

Bisphosphonates: inhibits osteoclast activity
-pamidronate or zoledronate
Denosumab: binds to RANKL to inhibit interaction between RANKL and RANk to prevent osteoclast formation
Calcitonin: directly inhibits osetoclastic bone resorption and increases excretion of calcium, phosphate, sodium, magnesium, and potassium

Question 12

bisphosphonates

Answer 12

for corrected calcium >12 mg/dL
single dose over 2-24hours may repeat after 7 days

pamidronate warnings: bone fractures, musculoskeletal pain, flu-like illness, osteonecrosis of the jaw.

Common ADE:
hypophosphatemia, hypocalcemia, hypomagnesemia, hypokalemia, nausea, anemia, infusion site reaction

Question 13

denosumab

Answer 13

warnings: increased risk of infection, bone fracture risk, osteonecrosis of the jaw, musculoskeletal pain
ADEs: hypophosphatemia, hypocalcemia, headache
no renal adjustment

Question 14

calcitonin

Answer 14

works rapidly
warnings: hypocalcemia
ADEs; facial flushing
Limit therapy to 24-48 hours due to tachyphylaxis

Question 15

glucocorticoids

Answer 15

inhibits 1-alpha-hydroxylase and lowers 1,25-dihydroxyvitamin-D levels
prednisone 60mg/day for 10 days
hydrocortisone 200-400mg/day for 3-4 days, then prednisone 10-20mg/day for 7 days

Question 16

TLS

Answer 16

mass number of cancer cells lysing in a short period of time
increased: potassium, uric acid, phosphate
decreased: calcium

Question 17

higher risk of TLS in pts with

Answer 17

elevated baseline uric acid
nephropathy
hypotension
left ventricular dysfunction/ HF

Question 17

TLS incidence

Answer 17

non-hodgkins lymphoma
acute myeloid leukemia
acute lymphoblastic leukemia
burkitt’s lymphoma

Question 18

clinical TLS

Answer 18

laboratory TLS plus at least one:
-AKI (creatinine >1.5x ULN)
-seizures, neuromuscular irritability
-cardiac arrhythmia

Question 19

TLS treatment approach

Answer 19

Lab monitoring every 4-6 hours
NS 150-300 mL/hr
Allopurinol or Rasburicase

Question 20

Low risk treatment approach

Answer 20

monitoring

Question 21

intermediate risk treatment approach

Answer 21

hydration
allopurinol
if hyperuricemic- rasburicase

Question 22

high risk treatment approach

Answer 22

hydration
rasburicase
allopurinol- after rasburicase

Question 23

risk factors for febrile neutropenia

Answer 23

> 65 yo
previous chemo or radiation
pre-existing neutropenia or bone marrow infiltration with tumor
poor performance status
gender
comorbidities
Low BMI or BSA
specific genetic polymorphisms

Question 24

febrile neutropenia

Answer 24

ANC <500 or ANC<1000 and expected to drop in 48 hours

single temp >38.3C (100.9F) or >38C (100.4F) for over an hour

Question 25

low infection risk

Answer 25

chemo for most solid tumors
anticipated neutropenia <7days

Question 26

intermediate infection risk

Answer 26

autologous hematopoietic cell transplant
lymphoma
multiple myeloma
chronic lymphocytic leukemia
purine analog therapy
anticipated neutropenia 7-10 days
CART cell therapy

Question 27

high infection risk

Answer 27

allogenic hematopoietic cell transplant
acute leukemia
alemtuzumab
moderate- severe graft vs host disease
anticipated neutropenia >10 days

Question 28

initial empiric therapy low risk

Answer 28

ciprofloxacin +augmentin and levo or moxifloxacin

Question 29

initial empiric therapy high risk

Answer 29

cefepime
zosyn
meropenem