Week 5 Flashcards
overviews of oncologic emergency categories
metabolic
*hypercalcemia of malignancy
*tumor lysis syndrome
hematologic
*febrile neutropenia
structureal
*spinal cord compression
Oncologic Emergency type
tumor lysis syndrome
Patho:
Clinical Presentation:
Risk factors:
Dx and workup:
Prevention:
Mgt/treatment plan:
Patho: occurs when large number of cancer cells die ithin a short period of time. cell contents are released into the blood. including dna, phosphate, potassium,-> leads to production of uric acid-> deposit in kidneys
Clinical Presentation:
Hyperkalemia (ecg abnomalities, cardiac arrest)
hypruricmemia(aki, crystal nephropathy)
hyperphosphatemia(ak, gi upset, ams)
hypocalcemia (ams, seizures, tetany)
Risk factors:
Cancer related: high proliferative, tumor bulk, circulating tumor cells, sensitivity to chemo
pt specific: elevated UA, nephropathy, hydration sttaus, hypotension, acidic uring, HF
Dx and workup:
lab TLS: >/2 or more of metabolic abnormalities w.in 3 days before or 7 days after initial trt.
*hyperkalemia>6
*hyperuricemia>8
hyperphosphatemia>4.5
*hypocalcemia</7
or 25% increase or decrease(calcium) from baseline
clinical tls: lab tls SS +
*aki
*seizures
*cardiac arrythmias
Prevention:
*hold causative agents
*hydration, avoid sodium bicarb
Mgt:
high risk: hydration, rasburicase, allopurinol
intermediate risk: hydration, allopurinol, consider rasburicase
low risk: observation, normal hydration, monitoring
mgt of TLS
allopurinol
moa:
indication:
dosing:
consideration:
mgt of TLS
allopurinol
moa: decreased formation of uric cid formation
indication: pt at risk for devloping tls. initiate 24 hrs before chemo
dosing: 300 mg po daily
consideration:
ddi
renal function
severe hypersensitivity
mgt of TLS
rasburicase
moa:
indication:
dosing:
consideration:
mgt of TLS
moa: reduce uric acif levels, wont inhibit uric acid formation
indication:preexsiting hyperuricemia
dosing: 1.5 mg or 3 mg
consideration:
leave blood samples on ice. heat can break down uric acid een more. put sample on ice,
refractory tls to rasburicase
use dialysis
rare
refractory volume overload, oligouria, and anuria
persistent hyperkalemia or hyperuricemia
hyperphosphatemia induced hypocalcemia
trt of hyperkalemia in tls
hydration- diuretics to optimize urine output
caclium chloride-stabilizes cardiac cell membrane
regular insulin: drives K intracellularly
sodium bicarb: drive K+ intracelularly by increasing ph
sodium polystyrene: promotes gi excretion of K
dialysis: removes K+ thorugh blood filtration
trt of hyperphosphatemia
first line: hydration
lmit dietary phosphate to 800-1000 mg/day
phophate binders: calcium acetate, calcium cabronate, aluminum hydroxide, lanthanum, sevelamer
last line dialysis
trt of hypocalcemia
resolves w. resolution of hyperphosphatemia
only trt symptomatic hyperphosphatemia to avoid overcorrection
Oncologic Emergency type
febrile neutropenia
Patho:
Clinical Presentation:
Risk factors:
Dx and workup:
Prevention:
Mgt/treatment plan:
Oncologic Emergency type
fever: single temp >38.3 OR temp>38C for over 1 hour AND ANC<500 or ANC<1000 and expected to drop to <500 in 48hrs
*often first and osmetimes only sign an immunocompromised pt has developed an infection
Patho:
Clinical Presentation:
Risk factors:
Dx and workup:
Low: anticipated <7 days
ntermediate: anticipated 7-10 days
high neutropenia >10 days
hx and physical, labs (cbc, renal function tests, lfts, electrolytes, microbe culture
Prevention:
low risk: none
intermediate: consider bacterial, funcal . use viral
high risk: use bacterial, consider fungal, and use viral
Mgt/treatment plan:
antimicrobials: levofloxcin and ciprofloxacin
pneumoccal: penecillin vk
antifungal: floconazole, posaconazole, voriconazole, micafungin, caspofungin
pneumocystisis: bactrim
viral: acyclovir
csf: Pegfilgastrim, filgastrim
Risk assessmen score: MASCC score
*high risk: <21
low risk>/21
low risk: outpt mgt-> oral abx
high risk pt: inpt mgt. broad spectrum iv abx
oral options for outpt management of febrile neutropenia
ciprofloxacin +augmentin
levofloxacin
moxifloxcain
ciprofloxacin +clindamycin
oraloptions not appropriate for pts on fluoro quinolones at time of diagnosis
pts w. N/V
in pt management of febrile neutropenia
iv therapy
monotherapy w. broad spectrum anti pseudamonal abx
cefepime
pip tazo
meropenem
imipenem
ceftazidime
double gram-coverage can be condisrd
mrsa coverage in febrile neutropenia
not covered unless specific indicaion
ex; catheter related infections
ssti
pneumonia
mucositis
fungal coverage in febrile neutropenia
fungal coverage added later on in course of febrile neutropenia..
only add if have + fungal markers (beta d glucan..) positive fungal cultures, doesnt respond to initial therapy in 4-7 days
trt: fluconazole, voriconazole, itraconazole, isavuconazole, posaconazole, liposomal amphotericin b
duration of treatment for fbrile neutropenia
unidentified infection
*continue untik
**anc >500
and afebrile >/2 days
identified infection:
ssti 7-14 days
blood stream infction: Gram-, 10-14 days: gram+ 7-14 days
bacterial sinusitis:7-14 days
bacterial pneumonia: 7-14 days
fungal (candida=2 weeks: mold=12 weeks)
Oncologic Emergency type
hypercalcemia of malignancy
Patho:
Clinical Presentation:
Risk factors:
Dx and workup:
Prevention:
Mgt/treatment plan:
Oncologic Emergency type
Patho:
humoral hypercalcemia: mediated by systemic secretion of PTH hormone. 80% of all cases
osteolytic hypercalcemia: increase osteoclastic bone resorption
vitamin d secreting lymphoma
ectopic hyperparathyoidism<1% cases
Clinical Presentation:
mild hypercalcemia: corrcted calcium
neurologic lethargy, confusion, irratibility, muscle weakness, etc.
Risk factors:
Dx and workup:
Prevention:
Mgt/treatment plan:
symptomatic hypercalcemia is an oncologic emergency
primary goal: treat underlying malignancy
hold medicines that can potentially worsen hypercalcemia
- HYDRATION: saline +/- furosemide (increase calciuresis)
primary therapies: iv biphosphonates, rank-l inhibitors
secondary therapies: calcitonin, glucocorticoids
biphosphonates
agents: zolendreic acid
pamidronate
inhibt bone resorption
takes up to 7-days to see effects
AE:!! flu like symptoms (pppx w. tylenol)!!, fevers arthralgias , neohrotoxicity,
denosumab
rank-l inhibitor reduce osteoclast acitivity
efficacy: 9-10 days
used in hyprcalcemia refractory to biphosphonates. use in pts w.evere renal impairment
toxicity: severe hypocalcemia, hypophosphatemia
calcitonin
inhibits bone resportion
can cause tachyphylaxis
other agents for hypercalcemia of malignancy
glucocorticoids: inhibits osteoclastic bone resoprtin by decreasing cytokines:
calcimemmetics (cinacalcet: effective for PTH carcinoma or primary/secondary hyperparathyroididm
dialysis: severe hypercalcemia due to renal insufficiency
*unable to hydrate pt
forms of lung cancer
2 forms of lung cancer
Non small cel85%) cmall cell(15%
Non small cell
*squamous (30) *non squamous70%)
Nonsquamous (
a)large cell (10%)
b)adenocarcinoma
clinical presentation of lung cancer
Clinical presentation of lung cancer
*pulmonary symptoms: cough dyspnea, chest pain or disocmfort, w. Or w.o hemoptysis
Extrapullmonary: fatigue, weightloss, anorexia
Paraneoplastic syndromes: hypercalcemia and siadh
disseminated disease can cause additional symptoms
most effective prevention in lung cancer
Most efective prevention in lung cancer:
*avoid tobacco
*maintain healthy diet high in fruits and vegetables
*offer screening to high risk individuals
general treatment goals for NSCLC
Treatment goals for NSCLC
*stage 1-11: cure
Stage III-Iv: prolongation of survival
Treatment goals for SCLC
Limited stage: cure
Extensive stage: prolongation of survival
local NSCLC (stage 1-2) trt
Stage 1:curgery
Stage 2:
Surgery followed by adjuvant therapy
Platinum based chemo regimen for 4 cycles
Osimertinib (EGFR+) for up to 3 years
Atezolizumab (PD-L1>/1%)
Neoadjuvant (therapy b4 surgery to shrink tumor down to increase chances of complete tumor removal
Radiation therapy
Reserved for pts who cant get surgery
local advanced stage nsclc (stage 3 tretment
Local advanced stage NSCLC (stage3) treatment
Stage 3a
Neoadjuvant chemo+/-nivolimumab
Adjuvant osimertinib (EGFR+) OR atezolizumab (PDL1>/1%)
Concurrent chemoradiotherapy for non surgical candidates
Stage 3b-3c
Considered unresectable disease
Concurrent chemo radiaion
Immunotherapy to increase progression free and overall survival
neoadjuvant regimens for nsclc
Neoadjuvant regimens for nsclc
Cisplatin or carboplatin incombo w. Other agents that are non platinum agents
*** pemetrexid only for nonsquamous histology only