exam 2 lecture 6 bone modifying agents

Question 1

what percent of cancer causes hypercalcemia? what are the most common tumor types that cause these bony metastases? Non malignant causes?

Answer 1

20-30% of all cancer patients. (has decreased due to bisphosphonate use)

lung and breast are most common

non malignant cause- renal failure, hyperparathyroidism

Question 2

What are the types of HCM (hypercalcemia)

Answer 2

1. humoral (80% of cases) caused by PTHrP (parathyroid hormone).
2. local osteolytic hypercalcemia
3. 1, 25 OH secreting lymphomas

Question 3

signs an symptoms of HCM (include levels)

Answer 3

mild- asymptomatic (maybe polyuria/polydipsia)
10-12

moderate
12-14
dehydration, lethargy, confusion

severe >14
renal failure, cardiac issues

Question 4

Corrected calcium calculation

Answer 4

Serum calcium + 0.8 (4 - serum albumin)

Question 5

tx of mild HCM

Answer 5

fluids/hydration

Question 6

tx of moderate HCM

Answer 6

Hydration, 200-400 mk/hr NS
bisphosphonate use (zolindronic acid/ pamidronate)
loop diuretics for patients who develop fluid overload

Question 7

severe HCM tx

Answer 7

> 14
HYDRATION HYDRATION HYDRATION (NS)

Bisphosphonates

calcitonin after bisphosphonates

Question 8

treatment of treatment refractory HCM

Answer 8

Denosumab

Question 9

chronic HCM management

Answer 9

zoledronic acid
pamidronate

Question 10

bisphosphonates MOA

Answer 10

inhibit osteoclast activity
increase mineralization
decrease bone resorption

Question 11

what are cancer with affinity to bone

Answer 11

Prostate (most common)
breast
myeloma
lung
kidney

Question 12

diagnosis of SRE (skeletal related events

Answer 12

symptoms of bony pain/tenderness

bone scan

Question 13

risk factors for fractures

Answer 13

smoking
FH
history of fracture
age

Question 14

treatment of bone metastases

Answer 14

radiation
chemo
IV bone modifying agents (RANK L inhibitors and bisphosphonates)

Question 15

what to know about radiation therapy in bone metastases

Answer 15

85% response rate. Pain relief within 1-2 weeks. If no relief after 6 weeks, unlikely to see benefit

Question 16

What are the bisphosphonates used for skeletal related events? WHat to keep in mind?

Answer 16

Pamidronate and zoledronic acid

ALWAYS dose ADJUST FOR RENAL DOSING

we prefer zoledronic acid because it is quicker to give

Question 17

do we dose adjust zoledronic acid and pamidronate for HCM? WHat about for skeletal related events

Answer 17

NO ADJUSTMENT FOR HCM

ADJUST FOR SRE

Question 18

WHat type of drug is denosumab? What is it used for?

Answer 18

RANK-L drug

Use 1- bone metastases from solid tumors (drug name is xgeva)

Use 2- osteopenia for women at high risk for fracture and receiving aromatase inhibitor for breast cancer and men receiving ADT (drug name prolia)

Question 19

What to do before denosumab initiation

Answer 19

correct hypocalcemia
no renal adjustment needed (this may be why we pick it over bisphosphonate)
Calcium and vit D supplement (same with bisphosphonate)

Question 20

side effects of bisphosphonate

Answer 20

osteonecrosis of jaw

Question 21

compare renal dysfunction of zolendronic acid, pamidronate and denosumab?
hypocalcemia?

Answer 21

renal-Zolendronic acid> Pamidronate>denosumab (not renally eliminated)

hypocalcemia- denosumab>zoledronic acid

Question 22

How does TLS happen

Answer 22

tumor lysis syndrome is a massive release of intracellular contents into blood stream that overwhelms homeostasis. Serious and life threatenig.

Question 23

What type of cancers do we see TLS in? What are the risk factors?

Answer 23

associated with aggressive hematologic malignancies, but also in solid tumors.

tumor specific risk favtors- high tumor burden, high tumor grade, rapid cell turnover

Patient specific- age, renal impairement

Question 24

how does TLS present

Answer 24

Hyperkalemia
hyperuremia (AKI)
hyperphosphatemia
hypocalcemia

they cause acute renal failure

Question 25

How to prevent TLS

Answer 25

Identify high risk pts monitor electrolytes aggressive hydration Control hyperuricemia it is an oncologic emergency

Question 26

prophylaxis of TLS

Answer 26

monitoril hydration allopurinol (for low and moderate risk) (rasburicase for high risk)

Question 27

Difference between allopurinol and rasburicase

Answer 27

when TLS occurs, allopurnol does not facilitate breakdown of uric acid, but stops manufacturing of more uric acid rasburicase can decrease existing uric acid

Question 28

rasburicase limitation?

Answer 28

rasburicase EXPENSIVE CI in pregnant and breast feeding

Question 29

what is MSCC

Answer 29

malignant spinal cord compression. It is an oncologic emergency. Early diagnosis and treatment is ESSENTIAL to prevent paralysis

Question 30

What is the most common cause of MSCC? symptoms?

Answer 30

Prostate most common Pain, motor deficit, sensory deficit

Question 31

MSCC diagnosis

Answer 31

MRI of spine

Question 32

MSCC treatment

Answer 32

STEROIDS IMMEDIATELY (dexamethasone) surgery (needs pt to be good performance status) radiotherapy If pt has good PS, surgery immediately, if not, radiation therapy use bisphosphonates after surgery

Question 33

What is SVC?

Answer 33

superior vena cava syndrome. SVC gradually compressed by tumors it is also an oncolytic emergency

Question 34

signs and symptoms of SVC

Answer 34

facial and arm edema, capillary formation, hypotension

Question 35

SVC syndrome treatment

Answer 35

use some type of stent to maintain breathing while we do biopsy to figure out what we are dealing with alleviation of symptoms- elevation of head, steroids, diuretics depending on severity, we can do radiation, chemo, anticoag

Question 36

malignant pleural effusion (MPE) common cancer? symptoms?

Answer 36

lung, breast, lymphoma symptoms 1. pleural effusion- accumulation of fluid in pleural space ranges from no symptoms to acute respiratory distress (dyspnea most seen symptom)

Question 37

MPE management

Answer 37

Thoracentesis (drain fluid) and send to lab for analysis thoracentesis minimizies acute symptoms temporarily, but fluid re accumulates within 30 days pleurodesis- activates cascade leading to adhesion of pleural layers. pleural catheters- used to drain fluid frequently. Might cause infection.