Supportive Care

Question 1

What is tumor lysis syndrome?

Answer 1

result of massive breakdown of tumor cells; intracellular content is released faster than the body can eliminate them

Question 2

When does TLS happen?

Answer 2

spontaneously OR result of treatment

Question 3

What are risk factors for TLS?

Answer 3

Bulky, chemosensitive disease
Lymphoproliferative malignancy (blood cancer)
Elevated WBCs
High serum urate
Elevated LDH
Volume depletion
Renal insufficiency
Acidic urine pH

Question 4

What electrolyte imbalances are the result of TLS?

Answer 4

Hyperkalemia
Hyperuricemia
Hyperphosphatemia
Hypocalcemia

Question 5

What is the most important intervention for TLS?

Answer 5

Hydration; ~2-3 L/m2/day
Loop diuretics can be added after volume replacement

Question 6

Which agent is given prior to chemo to prevent hyperuricemia?

Answer 6

Allopurinol

Question 7

Which agent breaks down uric acid into a soluble form and can be used to treat hyperuricemia?

Answer 7

Rasburicase

Question 8

What is the result of hyperkalemia?

Answer 8

arrhythmias
neuromuscular abnormalities

Question 9

What is given for mild hyperkalemia (no arrhythmias)?

Answer 9

Sodium Polystyrene Sulfonate (KAYEXALATE)

Question 10

What is given for severe hyperkalemia (EKG changes)?

Answer 10

Regular Insulin+ dextrose

Question 11

What is a local allergic reaction (red blotches along vein) without pain?

Answer 11

flare reaction

Question 12

What is an agent capable of causing tightness, achiness, and phlebitis (inflammation of vein)?

Answer 12

irritant

Question 13

What is an agent that is known to produce severe tissue damage and/or necrosis when infiltrated?

Answer 13

vesicant

Question 14

What is the administration of solution/ medication into tissue surrounding an IV?

Answer 14

infiltration

Question 15

What is the administration of a vesicant into surrounding tissues?

Answer 15

extravasation

Question 16

Why is extravasation a medical emergency?

Answer 16

blistering and sloughing off of tissue begins 1-2 weeks after injury; tissue necrosis follows

Question 17

What agents have the highest vesicant potential?

Answer 17

Daunorubicin
Doxorubicin
Epirubicin
Idarubicin
Vinblastine
Vincristine
Vinorelbine

Question 18

What is treatment of vinca alkaloid extravasion?

Answer 18

Apply warm compress around area QID for 48-72 hours;
Antidote: hyaluronidase injections x 1 day

Question 19

What is treatment of anthracycline (rubucin) extravasation?

Answer 19

Apply cool compress around area QID for 48-72 hours;
Antidote: dimethyl sulfoxide topically QID x 14 days OR
IV Dexrazoxane

Question 20

Where is IV Dexrazoxane administered?

Answer 20

large vein other than one affected by extravasation

Question 21

Why does Dexrazoxane have 2 different brand names?

Answer 21

ZINECARD- anthracycline-induced cardiotoxicity
TOTECT- anthracycline extravasation

Question 22

What is myelosuppression?

Answer 22

decreased production of cells made by bone marrow

Question 23

What is the result of myelosuppression?

Answer 23

neutropenia (decreased WBC)
anemia (decreased RBC)
thrombocytopenia (decreased platelets)

Question 24

What is considered neutropenic?

Answer 24

ANC < 1000

Question 25

What is considered absolutely neutropenic?

Answer 25

ANC < 100

Question 26

What is a normal ANC (neutrophil count)?

Answer 26

ANC = 2000-5000

Question 27

What is considered febrile neutropenic?

Answer 27

neutropenic AND oral temperature > 38.3C (101F) or multiple oral temperatures >38C (100.5F) over 1 hour

Question 28

What medications should NOT be used when febrile neutropenia is suspected/ present?

Answer 28

Tylenol NSAIDs Steroids

Question 29

What medications can be used for pain with febrile neutropenia?

Answer 29

opioids

Question 30

What medications can be given after chemo to reduce the incidence, magnitude, and length of neutropenia?

Answer 30

Colony Stimulating Factors (CSFs)

Question 31

When are CSFs used to prevent neutropenia?

Answer 31

chemo regimen associated with >/= 20% incidence of febrile neutropenia

Question 32

When should CSFs be started to prevent febrile neutropenia?

Answer 32

24-72 hours after chemo competed

Question 33

Granulocyte CSF

Answer 33

Filgrastim (NEUPOGEN)

Question 34

Pegylated CSF

Answer 34

Pegfilgrastim (NEULASTA)

Question 35

When would we treat for febrile neutropenia?

Answer 35

< 20% incidence of febrile neutropenia but patient gets it anyway; would prevet every time after indecent

Question 36

When should CSFs not be given?

Answer 36

During chemo/ radiation

Question 37

What are the side effects of CSFs?

Answer 37

Bone pain (means its working) injection site reaction fever

Question 38

What is mucositis?

Answer 38

ranges from mild inflammation and erythema to bleeding ulcerations in oral cavity

Question 39

What is the prevalence of mucositis?

Answer 39

75% of those receiving chemo Nearly all patients receiving chemo + radiation of head and neck

Question 40

What are risk factors for mucositis?

Answer 40

Chemo containing alkylating agents or Topoisomerase II inhibitors; Radiation to head/ neck; Poor dentation; Tobacco use; Alcohol use

Question 41

What are the complications of mucositis?

Answer 41

Decreased oral intake--> malnutrition; Infection; N/V; Pain; Dose delay/ reduction--> negative tx outcome

Question 42

What is mucositis closely related to?

Answer 42

neutropenia

Question 43

When does mucositis usually occur?

Answer 43

5-7 days after start of chemo/ radiation

Question 44

How is mucositis prevented?

Answer 44

Dental assessment prior to tx; Oral hygiene; Ice (cryotherapy) for 30 mines before, during, and after chemo

Question 45

What are treatment options for mucositis?

Answer 45

Topical lidocaine, magic mouthwash Opioids Parenteral Controlled Analgesia (PCA) TPN/ feeding tube

Question 46

What is an indication of poor prognosis (50% die within 30 days)?

Answer 46

hypercalcemia of malignancy

Question 47

What clinical presentations are common for hypercalcemia of malignancy?

Answer 47

polyuria and polydipsia (body trying to flush out calcium)

Question 48

What types of cancer are associated with local osteolytic hypercalcemia?

Answer 48

hormonal cancers like to goto bone and turn them into dust

Question 49

What type of hypercalcemia of malignancy is most common?

Answer 49

Humoral hypercalcemia

Question 50

Why do we need to correct calcium lab values?

Answer 50

calcium is usually bound to albumin in the blood; low albumin does not mean low calcium

Question 51

What is the corrected calcium equation?

Answer 51

Measured calcium + [0.8 x (4 -albumin level)]

Question 52

How is hypercalcemia treated?

Answer 52

Hydration with normal saline +/- furosemide 1st line meds 2nd line meds

Question 53

What are the 1st line meds for hypercalcemia?

Answer 53

Bisphosphonates (Zoledronic Acid, Pamidronate) RANKL inhibitor (Denosumab)

Question 54

What is the mechanism of Bisphosphonates?

Answer 54

"stun" osteoclasts to prevent bone degradation

Question 55

What rare but serious side effect is associated with bisphosphonates, usually with long-term use?

Answer 55

osteonecrosis of the jaw (ONJ)

Question 56

What is the mechanism of RANKL inhibitors?

Answer 56

destroys osteoclasts

Question 57

When are RANKL inhibitors typically used?

Answer 57

hypercalcemia refractory to bisphosphonates

Question 58

What side effect is related to the mechanism of RANKL inhibitors?

Answer 58

severe hypocalcemia

Question 59

What is the 2nd line tx of hypercalcemia, usually for emergency treatment?

Answer 59

Calcitonin

Question 60

How does calcitonin work to treat hypercalcemia?

Answer 60

drives calcium intracellularly

Question 61

What problems are seen with calcitonin?

Answer 61

transient (short) response duration and tachyphylaxis (less effective over time)

Question 62

What are the goals of hypercalcemia therapy?

Answer 62

restore mental functioning so patient can make tx decisions; NOT to restore normal calcium