Oncological Emergencies Flashcards
Hypercalcaemia of malignancy is a medical emergency. What is the corrected calcium level that classifies hypercalcaemia?
1 - >1.5 mmol/L
2 - >2 mmol/L
3 - >2.6 mmol/L
4 - >4 mmol/L
3 - >2.6 mmol/L
What % of patients with solid tumours experience hypercalcaemia of malignancy?
1 - 1-2%
2 - 12-20%
3 - 20-30%
4 - 50-70%
3 - 20-30%
Most common cause of hypercalcaemia
Malignancy with metastasis typically cause hypercalcaemia by which of the following mechanisms?
1 - tumour stimulate osteoblasts to degrade bone and release Ca2+
2 - tumour stimulate osteoclasts to build bone but release Ca2+
3 - direct osteolysis of the bone by bone metastasis
4 - all of the above
3 - direct osteolysis of the bone by bone metastasis
Osteolysis causes release of Ca2+ into the blood stream
IL-1 and TNF-a in malignancy are also linked with stimulating osteoclast maturation and more breakdown
Some patients can develop hypercalcaemia, even in the absence of metastasis. What is the most common thing secreted by tumours that can cause hypercalcaemia?
1 - ace inhibitor
2 - calcitonin
3 - parathyroid hormone related peptide
4 - erythropoietin
3 - parathyroid hormone related peptide
Binds to PTH receptors and acts in the same way as PTH
Some patients can develop hypercalcaemia, even in the absence of metastasis. Tumours secrete parathyroid hormone related peptide (PHTP). This can then cause which of the following?
1 - increases Ca2+ absorption in GIT
2 - increases Ca2+ reabsorption in kidney
3 - increases Ca2+ release from bones
4 - all of the above
4 - all of the above
In bone PTHP binds to osteoblast, releases RANK and M-CSF that stimulates osteoclasts and breaks down bone, releasing Ca2+
All of the following cancers have been shown to increase parathyroid hormone related peptide (PHTP), causing hypercalcaemia, EXCEPT which one?
1 - squamous cell carcinoma
2 - breast cancer
3 - renal cancer
4 - colon cancer
5 - prostate cancers, melanoma
6 - neuroendocrine tumours
4 - colon cancer
In addition to boney metastasis and parathyroid hormone related peptide (PHTP) that can cause hypercalcaemia, overexpression of 1-alpha hydroxylase, the enzyme responsible for converting 25-hydroxyvitamin D to calcitriol leads to excessive production of calcitriol (the active form of vitamin D), resulting in increased intestinal absorption of calcium and increased osteoclast activity. Which malignancy is this common in?
1 - breast cancer
2 - lung cancer
3 - lymphomas
4 - ovarian cancer
3 - lymphomas
Hypercalcaemia is an increased level of Ca2+ in the plasma. Which of the following are acute affects on the body caused by hypercalcaemia?
1 - polydipsia (thirst in an attempt to dilute)
2 - polyuria (bodies attempt to remove Ca2+)
3 - abdominal pain
4 - all of the above
4 - all of the above
Which of the following is NOT a chronic effects of hypercalcaemia?
1 - diarrhoea
2 - musculoskeletal aches / weakness
3 - neurobehavioral symptoms
4 - renal calculi (kidney stones)
5 - osteoporosis (weak, painful, fragile bones)
6 - raised blood pressure
1 - diarrhoea
- typically causes constipation
Use the mnemonic:
- Bones = pain and osteoporotic bones
- Stones = renal calculi
- Abdominal Groans = constipation and pancreatitis
- Psychiatric Moans = confusion and hallucinations
If left untreated is hypercalcaemia dangerous?
- yes
Can cause coma and death
MEDICAL EMERGENCY
In a tumour, which of the following would be correct in the blood sample suggesting hypercalcaemia?
1 - high PTH and Ca2+
2 - low PTH and high Ca2+
3 - low PTH and Ca2+
4 - high PTH and low Ca2+
1 - high PTH and Ca2+
PTH as tumour releases this
Ca2+ as PTH causes this
If a patient presents with >3mmol/L of Ca2+ but is asymptomatic, do they need hospital admission all the time?
- No
May just need fluids, assessment and discharged
Which 2 of the following may we see on an ECG in a patient if they have suspected hypercalcaemia?
1 - shortened PT interval
2 - prolonged PR interval
3 - widened QT interval
4 - shortened QT interval
2 - prolonged PR interval
4 - shortened QT interval
If a patient presents with potential hypercalcaemia, all of the following should be stopped, EXCEPT which one?
1 - zoledronic acid
2 - indapamide
3 - Ca+2 and vit D supplements
4 - vitamin A
1 - zoledronic acid
This stops bone break down, all others contribute to increasing serum Ca2+
Fluids are important to give in hypercalcaemia. How much of 0.9% saline should be given over 24h?
1 - 500ml - 1L
2 - 1-2L
3 - 3-4L
4 - 6-7L
3 - 3-4L
Slower rehydration rates in elderly and heart failure
In addition to addressing Ca2+ in hypercalcaemia, which 2 of the following are likely and need correcting?
1 - hyperkalcaemia
2 - hypermagnesaemia
3 - hypomagnesaemia
4 - hypokalcaemia
3 - hypomagnesaemia
4 - hypokalcaemia
If a patients hypercalcaemia remains above 3 mmol/L, which of the following medications should be given?
1 - indapamide
2 - vitamin A
3 - zolendronic acid
4 - spironolactone
3 - zolendronic acid
Give 4mg over 15 mins
Avoid if Creatinine >400 µmol/L (unless benefit outweighs potential risk
Side effects: GI upset, flu like symptoms, exacerbation of metastatic bone pain.
Chronic use can cause osteonecrosis of the mandible
How long does it typically take zolendronic acids to reduce Ca2+ in hypercalcaemia?
1 - <12h
2 - <48h
3 - <72h
4 - <120h
2 - <48h
Do not give further bisphosphonates until at least 4 days after previous dose
If a patient has refractory hypercalcaemia/life-threatening symptoms, which of the following can be given?
1 - Calcitonin
2 - Denosumab
3 - Glucocorticoids
4 - Dialysis
5 - all of the above
5 - all of the above
What is the definition of hyponatraemia?
1 - <120 mmol/L
2 - <135 mmol/L
3 - <150 mmol/L
4 - <200 mmol/L
2 - <135 mmol/L
Normal range is 135-145 mmol?L
Which of the following are symptoms of hyponatraemia?
1 - stupor/coma
2 - anorexia
3 - lethargy/confusion
4 - tendon reflexes reduces
5 - limp muscles (weak)
6 - orthostatic hypotension
7 - seizures/headaches
8 - stomach cramping
9 - all of the above
9 - all of the above
Although there are a number of causes of hyponatraemia, which of the following is most common?
1 - chemotherapy (nausea and vomiting)
2 - small cell lung cancer
3 - brain metastases
4 - medications (opioids, tricyclic antidepressants, SSRIs, NSAIDs, antiepileptics)
2 - small cell lung cancer
Excess production of Antidiuretic hormone by the tumour leading to SIADH
Does syndrome of inappropriate antidiuretic hormone (SIADH) cause water retention or excretion?
- retention
Causes a dilution effect of the blood and Na+
Hyponatraemia must be corrected slowly to reduce the risk of what?
1 - AKI
2 - splenomegaly
3 - oligodendrocyte degeneration and CNSmyelinolysis
4 - DKA
3 - oligodendrocyte degeneration and CNSmyelinolysis
Osmotic demyelination
Severe neurological sequelae, may be permanent
Alcoholics & malnourished are particularly at risk
In syndrome of inappropriate antidiuretic hormone (SIADH) which of the following is correct?
1 - euvolaemic
2 - hypervolemic
3 - hypovolemic
1 - euvolaemic
In syndrome of inappropriate antidiuretic hormone (SIADH) which 2 of the following are correct?
1 - low plasma sodium (<135mmol/L)
2 - low plasma osmolality (<270mmol/kg)
3 - high plasma sodium (>145mmol/L)
4 - high plasma osmolality (<295mmol/kg)
1 - low plasma sodium (<135mmol/L)
2 - low plasma osmolality (<270mmol/kg)
ADH causes retention of DH2O, which dilutes everything
In syndrome of inappropriate antidiuretic hormone (SIADH) which 2 of the following are correct?
1 - low urine sodium
2 - low urine osmolality (<100mmol/kg)
3 - high urine sodium
4 - high urine osmolality (>100mmol/kg)
3 - high urine sodium
4 - high urine osmolality (>100mmol/kg)
In syndrome of inappropriate antidiuretic hormone (SIADH) there is an increase in fluid volume, which stretches the blood vessels. Does this cause an increase or decrease in aldosterone?
- decrease
Aldosterone is released during low BP
Aldosterone is reduced during high BP
Low aldosterone means less Na_ retained by kidneys that increases Na+ urine content