Oncologic Emergencies

Question 1

Tumor Lysis Syndrome :

1. Whats elevated in the blood and what’s decreased?
2. What are some clinical abnormalities?

Answer 1

1. Elevated : Potassiium , phosphorus, uric acid
   decr : calcium
2. Kidney injury and failure
   -abnormal heart rhythms
   -muscle cramps and weakness
   -seizures

Question 2

what are some pt related RF’s for TLS? (7)

What are some disease related rf’s ? (7)

Answer 2

1. Exog potassium
2. pre existing renal failure
3. dehyration/volume depletion
4. preexisting hyperuricemia (> 7.5 mg/dL)
5. acidic urine
6. hypotension
7. exposure to nephrotoxins
8. Intensity of initial anticancer therapy
9. Cancer cell sensitivity to chemotx
10. high rate of cancer cell proliferation
11. extensive metastasis
12. bulky tumors
13. WBC > 25 x 10^9
14. Elevated LDH : > 2x ULN

Question 3

What are some characteristic findings of TLS? (4)

Answer 3

HYPERuricemia,kalemia, phosphatemia
HYPOcalcemia

Question 4

Signs and Sx’s of :
1. Hyperuricemia (1)
2. Hyperkalemia (6)
3. Hyperphosphatemia (3)
4. Hypocalcemia(3)

Answer 4

1. Acute renal impairmet or failure
2. Muscle weakness, paresthesias, ventricular tachycardia, fibrillation
   -cardiac arrest
   -lethargy
   -N/V
3. N/V/D
   - lethargy or seizures (severe cases)
   -Calcium phosphorous precipitation
4. Cardiac arrhythmias, muscle cramps, tetany , hypotension

Question 5

TLS definition
1. Uric acid thats ?
2. Potassium ?
3. Phosphorous?
4. Calcium ?

Answer 5

1. > = 8 mg/dL or 25% incr from baseline
2. > = 6 mg/dL or 25% incr from baseline
3. > =4.5 mg/dL or 25% incr from baseline
4. <= 7 mg/dL or 25% decr from baseline

Question 6

TLS Risk Stratification Acute Leukemias : HRD

1. ACute myeloid leukemia with WBC _____
2. ACute lymphoblastic leukemia with WBC ___ or WBC ___ + LDH ____
3. Burkitt Lymphoma / Leukemia in which stage?
   - If the burkitt lymph/leuk is in early stage, what does the LDH have to be to make it HRD?

Answer 6

1. > = 100 x 10^9 /L
2. > = 100 x 10^9 /L
   < 100 x 10^9 /L , >=2x ULN
3. advanced stage
   - LDH >=2xULN

Question 7

Algorithm for Prevention and TX of TLS :

1. Low risk
2. Intermediate RISK
3. High risk

Answer 7

1. Clinical judgememt and monitor
2. Hydration + initial management with allopurinol (rasburicase may be considered in initial management of pediatric pt’s)
   - If hyperuricemia develops–> initiate rasburicase tx
3. Hydration + initial management with rasburicase

Question 8

TLS PREVENTION :
-Monitoring, Hydration, Allopurinol, Rasburicase

1. Low risk
2. Intermed Risk
3. High risk
   - What would be a CI to rasburicase?

Answer 8

1. monitoring, oral hydration, +/- allopurinol
2. monitoring, hydration +/- loop diuretic, YES allopurinol
3. Monitoring, hydration +/- loop diuretic, YES allopurinol if CI to rasburicase due to G6PD deficiency, yes rasburicase

Question 9

TLS Prevention :
1. When should u start it?
2. Eliminate ___
3. Hydration amount ? urine output?
4. What can be used to promote diuresis if necessary?
5. Why is sodium bicarb not recc anymore to promote urinary alkalinization ?

Answer 9

1. ideally 24-48 hrs prior to chemotherapy initiation
2. pharmacotherapy that may contribute to electrolyte abnorms
3. 2-3L/m^2/day of IV fluids w/urine output of 80-100 mL/m^2/hr
4. Loop diuretics
5. no evidence of efficacy and may potentiate risk of calcium phos precipitation

Question 10

TLS TREATMENT :
1. Pt’s who present with or develop TLS during therapy need continuous ____, frequent (q4-6hr) monitoring of ? (3)

2. IV hydration using what?
3. CAn use ___ to facilitate urinary excretion of uric acid and electrolytes
4. R

Answer 10

1. cardiac monitoring
   - electrolytes, Scr/BUN, uric acid
2. Normal saline (2-3 L/m^2/day) for urine output of 100 mL/hr
3. Loop diuretics
4. Rasburicase

Question 11

Electrolyte Abnormalities :

1. HYPERphosphatemia
   Moderate >6 mg/dL restrict ___ and admin of ___
   Severe : ____
2. HYPOcalcemia :
   Calcium < 7 or ionized calcium < 0.8
   Asx –> ___
   Symptomatic –> ____
3. Hyperkalemia :
   Moderate and asx (6-7 mEQ/L) should restrict ___, perform ____ and ___ monitoring? and can admin ____

Severe and or symptomatic (>7) –> follow regimen above … what to add if EKG changes? (4)

4. Uremia (renal dysfunction) –> ____ and ___ management, how to adjust meds?

Answer 11

1. phosphorous intake, phosphate binder ( sevelamer, lanthanum carb, calcium acetate, calcium carbonate, aluminum hydroxide)
   - Dialysis
2. no therapy
   - calcium gluconate 1 gram with EKG monitoring
3. K+ intake, EKG, cardiac rhythm, sodium polystyrene sulfonate 15-30 g PO repeat q4-6 h

• calcium gluconate, IV insulin + dextrose, sodium bicarb, albuterol

4. Fluid electrolyte, uric acid + phosphate, renally adjust

Question 12

Allopurinol :
1. Dosing ?
2. Whats the prophylactic option for medium risk ?
3. Signif dose adjustments for ___/____ required when used concurrently ?

Answer 12

1. 100mg/M^2/dose every 8 hrs or 10mg/kg/day divided every 8hrs PO
   Max : 800 mg/day

200-400 mg/m^2/day IV in 1-3 divided doses IV
Max : 600 mg/day

2. 300 mg PO daily renally adjusted if necessary. Initiate 24-48 hrs before chemotx and continue for up to 3-7 days
3. 6mercaptopurine/azathioprine

Question 13

Febuxostat :
1. When do we use it ?

2. Advantages
3. disadvantages

Answer 13

1. Hyperuricemia who cannot tolerate allopurinol in a setting in which rasburicase is either not avail or CI
2. dose adjust not needed in pt’s with mild to moderate renal impairment
   - fewer DDI’s than allopurinol
3. more expensive

Question 14

Rasburicase :
1. Dosing ?
2. What must u do with blood samples?
3. CI in which pt’s ?

Answer 14

1. 0.2 mg/kg daily x 5 days (FDA)
   -Clinical practice : 3 mg X 1 dose, repeat if clinically indicated
2. place on ice
3. G6PD deficient pt’s

Question 15

HYPERcalcemia of Malignancy Signs/Sx’s :

1. Neuro and psychiatric
2. GI (ACAN)
3. Cardio (AHIIS)
4. Renal (PPDHHH)

Answer 15

1. Lethargy, drowsy, confusion, delirium, hypotonia, decr deep tendon reflexes , coma
2. anorexia , constipation, N/V, Abd pain
3. Arrhythmias, HTN, incr myocard contractility, incomplete AV block , shortened QT interval
4. Polyuria, polydipsia, dehydration , HYPO natremia, magnesemia, kalemia

Question 16

What’s the corrected calcium equation ? **

TX algorithm : for each, state the corrected serum calcium and what u do for each state

1. mild
2. mod
3. severe

Answer 16

Serum calcium + 0.8(4-Serum albumin)

1. < 12 mg/dL –> hydration and consider diuretic
2. 12-13.9 –> hydration +/- diuretic and biphosphonate
3. > 14 mg/dL –> hydration +/- diuretic + biphos + calcitonin

Question 17

TX options :

1. Hydration using _____
   - caution in pt’s with ____
2. Diuretics : Which agent and dose?
   -administer when ?
   -WHat should be avoided?
3. Biphosphonates
   -Onset of action ?
   -Advantage of Zoledronic ACid > Pamidronate is?
   -When can u re-dose?
4. Calcitonin
   - hypocalcemic responses to this tx only lasts how many days?
   -whats not recc?
   -onset ?
   -duration of use limited by ?
   -Avoid in pt’s with ?

Answer 17

1. NS @ 200-500 mL/hr
   -CHF
2. Furosemide 40 mg IV Q12-24h
   - After adequate hydration
   - thiazide diuretics
3. ~2-3 days, nadirs at 1 week
   - faster infusion of 15 mins vs 2 hrs
   - 7 days
4. 4-7 days
   - use of > 8 days
   - 2-4 hrs
   - tachyphylaxis
   - salmon allergy

Question 18

Other TX options :
1. Glucocorticoids, Gallium nitrate, dialysis, denosumab (in pt’s refractory to bisphosphonates)

2. avoid factors that can aggravate hypercalcemia such as ?

Answer 18

2. Thiazide diuretics, lithium carb therapy, volume depletion, prolonged bed rest or inactivity , high calcium diet (> 1000 mg/day)

Question 19

HYPERCALCEMIA –> Drugs and doses see chart

Answer 19

See chart