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Senior - Oncology > 6 - Oncologic Emergencies/pain Mgment > Flashcards

6 - Oncologic Emergencies/pain Mgment Flashcards

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1
Q

Oncologic emergencies types?

A

Local - Obstruction/pressure

Systemic - metabolic/hormonal complications

Iatrogenically - therapy/treatment complications

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2
Q

MC cause of elevated Ca?

A

Primary hyperparathyroidism

  • dont forget about cancer though
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3
Q

Cancer and hypercalcemia?

A

Seen w clinically evident cancer

23-30% have it
- associated w poor outcomes

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4
Q

MC cancers w high Ca?

A

Lung
Breast
MM

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5
Q

MC pathophysiology of malignancy-associated hypercalcemia?

A

Humoral hypercalcemia or malignancy

- HHM

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6
Q

What is HHM?

A

Secretions of PTHrP cause increased bone resorption

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7
Q

Pathophysiology of malignancy-associated hypercalcemia?

A

HHM

activation of osteoclast by cytokines released form cancer cells

Vitamin D secretion by cancer cells

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8
Q

Which cancers like to secrete cytokines to activate osteoclasts?

A

Breast

MM

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9
Q

What cancers like to secreted 1,25-OH2 vitamin D?

A

Lymphomas

Sarcoidosis/granulomatous dz

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10
Q

Types of hypercalcemia associated cancer?

A

Chart on slide 7

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11
Q

Explain HHM’s actions

A

Tumor secretes PTHrP
- not PTH but look alike/sound alike

This stimulates osteoclasts which increased calcium reabsorption

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12
Q

HHM is MClly associated w?

A 
SCC (lung, head, neck)
Renal
Bladder
Breast
Ovarian
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13
Q

Hypercalcemia s/s?

A

Classic:

  • Stones
  • Bones
  • Moans
  • Psychiatric groans

But ultimately based on level and rate or change

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14
Q

Early hypercalcemia s/s?

Not the classic signs

A 
Anorexia
Nausea
Fatigue
Constipation
Polyuria
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15
Q

Later hypercalcemia s/s?

A

Confusion
Psychosis
Tremor
Lethargy

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16
Q

If pt has low albumen the Ca labs will be?

A

Underestimated

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17
Q

Hypercalcemia of malignancy level?

A

> 12mg/dL is life threatening

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18
Q

Primary PTH labs have elevated PTH/elevated Ca, if they are low?

A

If low order PTHrp

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19
Q

Hypercalcemia pts need?

A

ECG - shortening of QT interval (whatever that is)

Serial Ca2++ labs

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20
Q

Tx for hypercalcemia?

A 
Treat the malignancy
But also:
- IV fluids
- IV furosemide (if hypervolemic)
- IV biphosphonates
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21
Q

Refractory hypercalcemia tx?

A

Calcitonin
Corticosteroids
Dialysis

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22
Q

2nd MC neurological complications of CA

A

Spinal cord compression

- usually 2/2 brain Mets

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23
Q

Other cancers that commonly cause spinal cord compression

A

Brain mets
Lung/breast/prostate
Renal
Lymphoma

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24
Q

What about cancer causes spinal cord compression?

A

Local mass effect

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25
S/s of cancer related spinal cord compression?
Back pain - at level of tumor (80%) - worse w sneezing/cough/wt bearing/supine Neurological sxs - progressive weakness - sensory dysfunction - bowel/bladder dysfunction
26
DX for spinal cord compression?
MRI | - emergent if neurologic functions
27
Tx for spinal cord compression?
``` Immediate corticosteroids - dexmethasone Treat the malignancy Radiation Surgery Chemo ```
28
Surgery indications (spinal cord compression)
``` Ukn etiology Failure of radiation Radio-resistant tumor Pathologic fx Dislocation/unstable spine ```
29
Febrile neutropenia definition?
Fever > 100.4 sustained for greater than 1 hr Or Single temp of 101.0 - w absolute neutrophil count <1500 ANC
30
ANC is?
= WBC (total) x neutrophil (%)
31
S/S of febrile neutropenia?
Fever
32
HX/PE for febrile neutropenia?
Look for source of fever Maj will not have documented infection - still treat w empiric broad-spectrum abx after blood cxs are obtained
33
With febrile neutropenia s/s of infection may be?
Attenuated due to lack of an inflammatory reaction
34
Labs for febrile neutropenia?
``` CBC w diff CMP (creatine, LFT, electrolytes) UA/Urine culture Sputum culture Blood cultures Culture of suspicious sites ```
35
Imaging for febrile neutropenia?
CXR - infiltrates w/o neutrophils to make infiltrates CT - thickened bowel - neutropenic enterocolitis
36
Any pt w neutropenia and abdominal pain you should consider?
Neutropenic enterocolitis
37
Tx for febrile neutropenia
Broad spectrum coverage - gram +, Gram - >> anaerobes W/in 60 min of presentation Continue 48hrs past end of fever
38
Abx for febrile neutropenia?
- cefepime - carbapenem - piperacillin-tazobactam q
39
If abx fail w febrile neutropenia, consider?
Fungal - amphotericin B - itraconazole - caspofungin Contact ID
40
What is superior vena cava syndrome?
Obstruction of blood flow through the SVC
41
Superior vena cava syndrome is associated w?
MC - Lung cancer | 2nd MC - lymphoma
42
Etiology of superior vena cava?
``` Invasion/compression of SVC from - R lung - lymph nodes - mediastinal structures Thrombosis of blood in SVC ```
43
S/s of superior vena cava syndrome?
Dypsnea Facial swelling Neck/UE swelling “Congestion” sxs Worse when bending forward
44
What is plethora?
A lot of something | In this case, fluid causing facial swelling
45
Late signs fo super vena cava syndrome?
Thrombosis Tumor extension into cardiac Neurologic syndromes - venous congestion into brain - cerebral edema)
46
PE for SVCS?
Facial edema Venous dilation - distention in neck - distention in chest
47
Imaging for SVCS?
CXR - widening of superior mediastinum CT - chest w contrast
48
SVCS tx?
Treat the cancer - radiation - chemo - anticoagulation - balloon angioplasty + stent - thrombolysis
49
SVCS prognosis?
Depends on disease progression - slow = tolerated for years - rapid = rapidly fatal (days)
50
Rapid SVCS what kills you?
Increased ICP | Cerebral hemorrhage
51
What is tumor lysis syndrome?
MC occurs w tx of hematologic malignancies or rapidly proliferating tumor that is sensitive to chemo - usually the induction phase of chemo
52
Greatest risk for tumor lysis syndrome
ALL | Burkitt lymphoma
53
When does tumor lysis syndrome happen?
1-5 days after chemo
54
What is the pathogenesis of tumor lysis syndrome?
Effective tx kills malignant cells and leads to massive release of cellular material - nucleic acids - phosphorus - potassium
55
Conditions that arise from tumor lysis syndrome?
Hyperuricemia (catabolism of nucleic acids) - AKI Hyperphosphatemia Hypocalcemia Hyperkalemia
56
What causes the hyperphosphatemia w TLS?
- 2/2 hypocalcemia (P binds to CA)
57
S/s of hyperphosphatemia?
Tetany Seizures Arrhythmias Sudden death
58
S/s of hyperkalemia?
Arrhythmias | - Coexisting renal failure worsens this
59
Most important aspect of tumor lysis syndrome?
Recognition of risk and prevention is the most important step of management
60
Tx for TLS?
Aggressive hydration - before/after chemo Allopurinol - competitive inhibits xanthine oxidase Rasburicase (exogenous urate oxidase) - catalyzes the breakdown of uric acid levels Monitor K, P, Ca, sCr, and uric acid
61
When to refer TLS?
Refer to nephrology if: - urine output is low - sCr is elevated
62
How do allopurinol and rasburicase work?
In the purine catabolism progression - allopurinol blocks hypoxanthine and xanthine - urate oxidase enhances uric acid See slide 40 for a diagram (makes more sense)
63
Common failure of cancer tx?
Pain management - many pts have inadequate control - pain impact QOL (esp near death)
64
Prolonged survival (cancer tx) is associated w?
Chronic pain tx w opioids - honestly they are dying who cares if they are addicted
65
When prescribing opioids meds for cancer you need to?
Focus on education - pt education - family education - expectation management - risk/benefit
66
3 basic approaches to pain?
1. Modify the source 2. Alter perception of pain 3. Block transmission of pain
67
Complications of pain meds?
Constipation Decreased mental acuity Dependence (again who cares)
68
Order of pain management meds?
1st line - acetaminophen 2nd line - NSAIDS 3rd line - opioids 3rd line - neuropatic pain meds
69
Biphosphonates and NSAIDS are indicated for?
Metastatic bone lesions
70
Neuropathic pain meds?
Gabapentin TCA (amitriptyline) Pregabalin
71
Bottom line for pain management?
No pt should be denied pain control in the setting of cancer - it is a fundamental responsibility of the PA But dont be afraid to refer to pain/palliative care experts

Senior - Oncology (5 decks)

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