Exam 2 - Oncologic Emergencies Part 1

Question 1

List the metabolic oncologic emergencies? (3)

Answer 1

hypercalcemia of malignancy, syndrome of inappropriate antidiuretic hormone (SIADH), tumor lysis syndrome (TLS)

Question 2

List the hematologic metabolic emergencies? (2)

Answer 2

febrile neutropenia, hyperviscosity syndrome

Question 3

List the structural oncologic emergencies? (3)

Answer 3

spinal cord compression, pericardial effusion, superior vena cava syndrome (SVCS)

Question 4

Describe the incidence of hypercalcemia of malignancy?

Answer 4

occurs approximately in 30% of cancer patients, more common in stage IV

Question 5

Define hypercalcemia?

Answer 5

corrected calcium level of >/=10.5 mg/dL

Question 6

Define mild hypercalcemia?

Answer 6

10.5-11.9

Question 7

Define moderate hypercalcemia?

Answer 7

12-13.9

Question 8

Define severe hypercalcemia?

Answer 8

14+

Question 9

What is the formula for corrected calcium?

Answer 9

0.8 x (4 - albumin) + serum calcium

Question 10

List the clinical manifestations of hypercalcemia of malignancy?

Answer 10

renal, GI, neurologic, cardiac

Question 11

Describe the humoral mechanism of hypercalcemia?

Answer 11

increased parathyroid hormone-related peptide (PTHrP) causes increased renal tubular reabsorption of calcium which increases phosphorus excretion; hypercalcemia and hypophosphatemia

Question 12

Which cancers have higher rates of humoral mechanism of hypercalcemia?

Answer 12

squamous cell carcinomas

Question 13

Describe the bone invasion mechanism of hypercalcemia?

Answer 13

local osteolytic activity that leads to secretion of calcium

Question 14

Which cancers have higher rates of bone invasion of hypercalcemia?

Answer 14

multiple myelomas, metastatic breast cancer

Question 15

Describe the rare causes mechanism of hypercalcemia?

Answer 15

increased calcitriol production or ectopic PTH production

Question 16

Which cancers have higher rates of rare causes of hypercalcemia?

Answer 16

Hodgin’s lymphoma and patients with Hx of head/neck irradiation and chronic lithium therapy

Question 17

What is used for increasing calcium secretion when treating hypercalcemia of malignancy?

Answer 17

IV fluids; normal saline 1-2 L bolus followed by 200-500 mL/hr

Question 18

What can be added on to increase calcium secretion when treating hypercalcemia of malignancy?

Answer 18

furosemide 20-40 mg for those with volume overload

Question 19

List drugs used for reducing bone resorption when treating hypercalcemia of malignancy? (4)

Answer 19

pamidronate, zoledronate, denosumab, calcitonin

Question 20

What is the MOA of bisphosphonates?

Answer 20

inhibits osteoclast activity

Question 21

What is the MOA of denosumab?

Answer 21

binds to RANKL to inhibit interaction with RANK and prevent osteoclast formation

Question 22

What is the MOA of calcitonin?

Answer 22

directly inhibits osteoclastic bone resorption and increases excretion of calcium, phosphate, sodium, magnesium, and potassium

Question 23

What is the dosing for pamidronate with a corrected calcium of 12-13.5 mg/dL?

Answer 23

60-90 mg IV over 2-24 hrs

Question 24

What is the dosing for pamidronate with a corrected calcium of >13.5 mg/dL?

Answer 24

90 mg IV over 2-24 hrs

Question 25

What are the AEs of pamidronate?

Answer 25

bone fractures, musculoskeletal pain, flu-like symptoms, osteonecrosis of the jaw

Question 26

What is the dosing for zoledronic acid with a corrected calcium of 12+ mg/dL?

Answer 26

4 mg IV qw

Question 27

What are the AEs of zoledronic acid?

Answer 27

hypophosphatemia/calcemia/magnesemia/kalemia, nausea, anemia, infusion site reactions

Question 28

What is the dosing for denosumab?

Answer 28

120 mg SC qw

Question 29

What are the AEs of denosumab?

Answer 29

bone fractures, musculoskeletal pain, osteonecrosis of the jaw, increased infection risk, hypophosphatemia/calcemia, HA

Question 30

Which medication can be used in renal impairment when treating hypercalcemia of malignancy?

Answer 30

denosumab

Question 31

What is the dosing for calcitonin?

Answer 31

4-8 U/kg IM/SC q12 hrs

Question 32

What are the AEs of calcitonin?

Answer 32

hypocalcemia, facial flushing

Question 33

What is a clinical pearl for calcitonin?

Answer 33

limit therapy to 24-48 hrs due to tachyphylaxis

Question 34

What are other interventions for treating hypercalcemia of malignancy? (2)

Answer 34

glucocorticoids, dialysis

Question 35

Define tumor lysis syndrome (TLS)?

Answer 35

a condition caused by a number of cancer cells lysing in a short period of time and contents of these cells being released into the peripheral bloodstream

Question 36

Describe the incidence of tumor lysis syndrome?

Answer 36

more common in non-solid tumors, highest risk in patients with elevated baseline uric acid/nephropathy/hypotension/LV dysfunction

Question 37

Explain the Cairo-Bishop definition for laboratory tumor lysis syndrome?

Answer 37

2 or more of the following abnormalities within 3 days before or 7 days after initiation of treatment: hyperkalemia (6+ mEq/L), hyperuricemia (8+ mEq/L), hyperphosphatemia (4.5+ mg/dL), hypocalcemia (7 mg/dL or less); or 25% increase/decrease for all, respectively

Question 38

Explain the Cairo-Bishop definition for clinical tumor lysis syndrome?

Answer 38

presence of laboratory tumor lysis plus at least one of the following: acute kidney injury, seizures/neuromuscular irritability, cardiac arrhythmia

Question 39

What is used for the treatment of tumor lysis syndrome? (3)

Answer 39

laboratory monitoring q4-6 hrs, fluids (normal saline 150-300 mL/hr), uric acid lowering medications

Question 40

What is treatment for low risk tumor lysis syndrome patients?

Answer 40

monitoring