Oncologic Emergencies: Key Points Flashcards
What are the three major oncologic emergencies?
Hypercalcemia of malignancy
Tumor Lysis Syndrome
Febrile Neutropenia
What kinds of cancers can cause hypercalcemia of malignancy? (6)
Non-small cell lung cancer
Squamous cell cancer [head and neck]
Breast cancer
Urothelial carcinomas
Multiple myeloma
Ovarian cancer
What calcium level defines hypercalcemia?
Corrected Ca ≥ 10.5 mg/dL
What corrected calcium level is MILD hypercalcemia?
10.5 - 11.9
What corrected calcium level is MODERATE hypercalcemia?
12-13.9
What corrected calcium level is SEVERE?
≥ 14
What is the corrected calcium equation?
0.8 x (4 - Albumin) + serum calcium
What are RENAL symptoms of hypercalcemia of malignancy?
Polydipsia/polyuria
Dehydration
Decreased GFR
What are GI symptoms of hypercalcemia of malignancy?
Constipation
Anorexia
N/V
What are NEURO symptoms of hypercalcemia of malignancy?
Lethargy
Confusion/stupor
Irritable
Muscle weakness
Seizure
Coma
What are CARDIAC symptoms of hypercalcemia of malignancy?
Shortened QT interval
Widened T wave
Heart block
Asystole
Arrhythmias
What are FOUR mechanisms of hypercalcemia of malignancy?
HUMORAL - increased PTH-related peptide causes increased renal reabsorption of Ca
Bone invasion - increased local osteolytic activity
RARE:
Vitamin D intoxication
Ectopic PTH production
What are the 3 steps to approaching hypercalcemia of malignancy treatment?
- Fluids (increase excretion)
- Stop bone resorption
- Reduce intestinal absorption of Ca
What fluid is used for hydration in hypercalcemia of malignancy? What additional drug may help flush out excess Ca?
NS - 1-2 L bolus, then 200-500 mL/hr infusion
Furosemide 20-40 mg lowers calcium in volume overload or HF pts
What agents can be used for inhibiting bone resorption in hypercalcemia of malignancy?
Bisphosphonates: Pamidronate, Zoledronic acid
RANKL inhibitor: denosumab
Calcitonin
What are some AEs of bisphosphinates? What is a major clinical pearl for dose adjustment?
AEs:
Pamidronate = fractures, musculoskeletal pain, flu-like illness, osteonecrosis of jaw
Zoledronic acid = electrolyte abnormalities, nausea, anemia
AVOID IN RENAL IMPAIRMENT!
(Pamidronate - CrCl<30 mL or SCr > 3, Zoledronic acid - SCr > 4 mg/dL)
If bisphosphinates cannot be used in hypercalcemia of malignancy, what is the next best option and in WHAT PATIENTS might it be preferred?
Denosumab
Preferred in RENAL IMPAIRMENT (bisphosphinates not recommended in these pts)
Calcitonin: what kind of therapy is it (adjunctive/standalone)? What is one major AE? Why do we have to limit use to <48 hrs?
Adjunct therapy to IV fluids and bisphosphonates
AE = facial flushing
Limit to <48 hr due to tachyphylaxis
What drug class is used to reduce intestinal Ca absorption in hypercalcemia of malignancy?
Glucocorticoids
Prednisone 60 mg/day x 10 days
In TLS, what INCREASES?
Potassium
Uric acid
Phosphate
In TLS, what DECREASES?
Calcium
Patient risk classification for TLS depends on what TWO factors?
Cancer type
WBC count (higher count = higher risk)
How does tumor lysis syndrome occur?
Chemo effectively destroys cells, allowing its contents to flood the body
According to the Cairo-Bishop Definition of TLS, what are the CUTOFF levels for each of the four electrolytes?
K ≥ 6 mEq/L
Uric acid ≥ 8 mEq/L
Phos ≥ 4.5 mg/dL
Ca ≤ 7.0 mg/dL
[OR 25% increase from baseline]
What are the most common clinical presentations of TLS? (4)
AKI
Seizures
Arrhythmias
Altered mental status
For TLS, what are the steps for LOW RISK treatment?
Monitor only
For TLS, what are the steps for INTERMEDIATE RISK treatment?
Hydration (NS)
Allopurinol
(If cont. hyperuricemia, then +rasburicase)
For TLS, what are the steps for HIGH RISK treatment?
Hydration (NS)
Rasburicase
(Consider allopurinol if extra treatments needed)
What is the MoA of allopurinol? What is the standard dosing?
Dose = 300 mg daily
Does NOT lower existing uric acid levels, only prevents more uric acid from forming
What is a key monitoring parameter of rasburicase? What is the standard dosing?
Must obtain a “rasburicase uric acid” level, put it on ice to prevent progressive uric acid breakdown [more accurate to body levels]
Flat dosing = more common
1.5 or 3 mg IV x1, repeat if uric acid ≥7.5
What is the treatment of hyperkalemia in TLS? (Remember from crit care!)
Calcium chloride/gluconate
Insulin
Bicarb
Loop diuretic
HD
What is the treatment of hyperphosphatemia in TLS?
IV fluids +/- diuretics (if overloaded)
Phosphate binders
- calcium acetate/carbonate
- aluminum hydroxide
- Lanthanum
- Sevelamer
What is the treatment of hypocalcemia in TLS?
DO NOT TREAT UNLESS SYMPTOMATIC!
Ie. Arrhythmias, seizures or tetany
Treatment = calcium gluconate (like hyperkalemia)
What are risk factors for febrile neutropenia?
Age ≥ 65
Pre-existing neutropenia
Gender
Low BMI
Hx of chemo/radiation therapy
Poor performance status (not mobile)
Comorbidities
[Bone involvement by tumor
Recent surgery or open wounds]
Define febrile neutropenia by its FEBRILE and NEUTROPENIC levels
Febrile = temp > 38.8 C x1 OR temp > 38 C x 1 hr
Neutropenia = ANC < 500 OR ANC < 1000 expected to drop to <500 in next 48hr
What kinds of cancers/neutropenia duration indicates LOW infection risk in febrile neutropenia pts?
Solid tumors
Neutropenia < 7 days
What kinds of cancers/neutropenia duration indicates INTERMEDIATE infection risk in febrile neutropenia pts?
Autologous hemo cell transplant
Lymphoma
Multiple myeloma
Chronic lymphocytic leukemia
Purine analog therapy
Neutropenia 7-10 days
What kinds of cancers/neutropenia duration indicates HIGH infection risk in febrile neutropenia pts?
Also genie hemo cell transplant
ACUTE leukemia
Alemtuzumab use
Graft-vs-host disease
Neutropenia >10 days
What kinds of treatments should be used/considered for LOW infection risk PROPHYLAXIS in febrile neutropenia pts?
Viral ONLY if hx of HSV
What kinds of treatments should be used/considered for INTERMEDIATE infection risk PROPHYLAXIS in febrile neutropenia pts?
Antiviral
Consider: antibiotics, antifungal, anti-PJP
What kinds of treatments should be used/considered for HIGH infection risk PROPHYLAXIS in febrile neutropenia pts?
Antibiotics, antiviral
Consider: antifungal, anti-PJP
What 4 antibiotics can be used in infection prophylaxis for febrile neutropenia?
Levofloxacin
Cirpofloxacin
Cefpodoxime
Penicillin VK
What 5 antifungals can be used in infection prophylaxis for febrile neutropenia?
Fluconazole
Posaconazole
Voriconazole
Isavuconazole
Micafungin IV
What antiviral can be used in infection prophylaxis for febrile neutropenia?
Acyclovir
What anti-PJP agent can be used in infection prophylaxis for febrile neutropenia?
Bactrim daily on MWF OR BID on Sat + Sun
In febrile neutropenia, what is the MASCC score cutoff for LOW RISK or HIGH RISK patients?
≥ 21 - low risk
< 21 - high risk
Recall: higher MASCC score = better!
If a LOW risk febrile neutropenia pt is currently on levofloxacin/ciprofloxacin prophy, what is the treatment of choice?
Cefepim
If a LOW risk febrile neutropenia pt is currently NOT on levofloxacin/ciprofloxacin prophy, what are the treatments of choice?
Levofloxacin
Moxifloxacin
Augmentin + ciprofloxacin
If a febrile neutropenia pt is HIGH risk, what are the treatments of choice?
Zosyn
Cefepime
Meropenem (last line, too broad but if beta lactam allergy then use)
Should MRSA coverage be regularly added to febrile neutropenia treatment?
No, unless high risk for MRSA
What kinds of febrile neutropenia pts should get fungal treatment?
Consider in high-risk patients who have hematologic malignancies/ are hemodynamically unstable or septic
Add at 4-7 day mark
If febrile neutropenia is of an UNKNOWN source, when should treatment be D/Ced?
If neutrophils ≥500: D/C
If neutrophils <500: Deescalate to prophylaxis and continue until neutropenia resolved
If febrile neutropenia is from a documented infection, generally how long is treatment duration?
5-14 days
