Oncologic Emergencies Part 1

Question 1

Define Extravasation

Answer 1

leakage of intravenous fluid out of a vein into interstitial tissues

Question 2

Symptoms of Extravasation

Answer 2

 Local pain and burning sensation
 Swelling and erythema
 Lack of blood return
 1-3 weeks: skin ulceration and skin necrosis

Question 3

Define Vesicant

Answer 3

an agent that causes redness, pain, and blistering which may progress to ulceration and tissue necrosis

Question 4

Known Vesicants

Answer 4

Vinca alkaloids (vincristine, vinblastine)
Anthracyclines (doxorubicin)
Mycins (dactinomycin, mitomycin)

Question 5

Mechanism of Tissue Destruction

Answer 5

1. DNA Binding

2. Non-DNA Binding

Question 6

DNA Binding Destruction

Answer 6

 DNA complexes are formed and cell death occurs
 New complexes are released and bind freely with DNA of surrounding cells causing persistent cell destruction
EX: anthracyclines

Question 7

Non-DNA Binding Destruction

Answer 7

 Causes immediate cell destruction in soft tissue
 Shorter duration of tissue destruction and better healing prognosis
EX: vinca alkaloids

Question 8

***Patient-Related Risk Factors

Answer 8

o Multiple venipunctures
o Very young or very old
o Heavily sedated (aka can’t tell you when it starts to irritant them)
o Paresthesia (aka can’t tell you when it starts to irritant them)
o Inability to communicate (aka can’t tell you when it starts to irritant them)

Question 9

***Prevention of Extravasation

Answer 9

o Central venous catheters
o Use flexible catheters
o Repeat venipunctures should be proximal to prior needle insertion site
o Check for frequent blood return during infusion
o Site is very important!!!
o Patient education

Question 10

General Treatment Strategies

Answer 10

o Stop infusion immediately
o Aspirate as much drug as possible from cannula before it is removed
o Apply heat for vinca alkaloids & epipodophyllotoxins—cold can increase risk of ulceration3. Use cold compresses for all anthracyclines.
 Controversial: Sodium bicarbonate: increase pH leads to increase tissue uptake
 Controversial: Glucocorticoids

Question 11

Anthracycline Specific Treatment

Answer 11

 Apply cold compresses
 DMSO (dimethyl sulfoxide)
 Dexrazoxane (Totect®)
- Don’t press the area and don’t give dexrazoxane and DMSO together

Question 12

Mechlorethamine Specific Treatment

Answer 12

Apply cold packs

Give sodium thiosulfate

Question 13

Vinca Alkaloid Specific Treatment

Answer 13

Apply cold pack

Give hyaluronidase

Question 14

What cancers are typically associated with hypercalcemia?

Answer 14

Breast, multiple myeloma and lung cancers

Question 15

**Corrected Calcium Formula

Answer 15

measured calcium + 0.8*(4-albumin)

Question 16

Normal Calcium Level

Answer 16

8.5-10.5 mg/dL

Question 17

Normal Bone Remodeling

Answer 17

 Resorption : Osteoclasts remove bone mineral and matrix, creating an erosion cavity
 Reversal: Mononuclear cells prepare bone surface for new osteoblasts to begin building bone
 Formation: Osteoblasts synthesize a matrix to replace resorbed bone with new bone
 Resting : A prolonged resting period follows until a new remodeling cycle begins

Question 18

How long does bone remodeling take?

Answer 18

 Bone remodeling for every bone in our body takes 10 years.
 It takes approximately 120 days for one specific area to go through all 4 phases

Question 19

Define Osteolytic Hypercalemia Malignancy (HCM)

Answer 19

 Metastatic tumor cells release factors that directly stimulate osteoclast activity
 Osteoclastic activity releases growth factors that stimulate tumor-cell growth
 Bone resorption releases calcium from the skeleton, increasing the flow of calcium through the extracellular space, resulting in elevated serum calcium

Question 20

Define Humoral Hypercalcemia

Answer 20

 Kidney increases reabsorption of calcium and loss of phosphate via the urine

Question 21

Signs and Symptoms of Hypercalcemia

Answer 21

GI: constipation N/V
Renal: polyuria, polydipsea
Nuerologic: lethargy/confusion
Cardiac: Shortened QT interval

Question 22

Treatment of Hypercalcemia

Answer 22

1. Hydration +/- diuretics
2. Bisphosphonate (zolendronic acid, pamidronate)
3. Denosumab
4. Calcitonin
5. Corticosteroids

Question 23

Zolendronic Acid Dose and Infusion time

Answer 23

Renal dose adjusted

Infusion time is >15 minutes

Question 24

Pamidronate Infusion Time

Answer 24

> 2 hours due to renal toxicity

Question 25

Bisphosphonates Onset and MOA

Answer 25

Onset: 48 hours
MOA: inhibit osteoclast recruitement, induces osteoclast apoptosis, and inhibits osteoclast activity

Question 26

Bisphosphonates AE

Answer 26

Acute renal failure (check SCr)
Osteonecrosis of the Jac
HypoPh and hypoK

Question 27

Calcitonin Use, MOA, AE

Answer 27

Rapid reduction of calcium
MOA: inhibit clast bone resorption and increase renal excretion of Ca
AE: tachyphylaxis
Salmon calcitonin is preferred

Question 28

Denosumab Use

Answer 28

Used after bisphosphonate failure

Question 29

Corticosteroids Use and Onset

Answer 29

Onset 3-5 days

Limited use due to AE