Lecture 3: Oncology Supportive Care

Tumor Lysis Syndrome

-occurs as a result of massive ___ of tumor cells

breakdown

Tumor Lysis Syndrome (TLS)

-can occur __ or as a result of __

-usually presents within 1-5 days of treatment

spontaneously, treatment

Tumor Lysis Syndrome (TLS)

-destroyed cells release their intracellular content (acidic things + electrolytes) faster than the body can eliminate them

-most common oncologic ____

emergency

TLS Risk Factors

1. ___ disease (tumors ≥ 10cm in diameter)

2. lymphoproliferative malignancy (___ cancers)

bulky, blood

TLS Risk Factors

3. ___ chemotherapy regimen

4. elevated __ ___ __ count

intensive, white blood cell

TLS Risk Factors

5. high serum __ level

6. elevated __

urate, LDH

TLS Risk Factors

7. presence of __ depletion

8. pre-existing ___ insufficiency

9. concentrated ___ urine pH

volume, renal, acidic

TLS Presentation- Cell Lysis results in:

-HYPER____

-HYPER____

-HYPER____

-HYPO____

kalemia, uricemia, phosphatemia, calcemia

What is single most important intervention for TLS?

hydration

Hydration

-single most important intervention for TLS

-facilitates excretion of excess ___

-goal is about 2-3 L/m2/day

-loop diuretics can be added ____ volume has been replaced

electrolytes, after

Hyperkalemia

-most concerning metabolic abnormality as a result of TLS

-usually occurs first (~12-48 hours)

-can cause cardiac ____ and ___ abnormalities

arrhythmias, neuromuscular

Mild Hyperkalemia is < ___mEq/L

6.5

Mild Hyperkalemia Treatment

-__ ___ ___ (Kayexalate) (drink that pulls K from blood → intestines)

sodium polystyrene sulfonate

Severe Hyperkalemia is ≥ ___mEq/L and/or ___ changes

6.5, EKG

Severe Hyperkalemia Treatment

-___ ___ + ___

-albuterol

-IV calcium gluconate

-aggressive diuresis

-sodium bicarbonate

regular insulin, dextrose

Hyperphosphatemia treatment

-phosphate binders (___ ___)

-restrict dietary phosphate intake to 800-1000 mg/day

aluminum hydroxide

Hypocalcemia treatment

-usually will correct itself (once phosphorus is corrected)

-reserve treatment for ____ patients

-give IV ___ ___ if patient has tetany (twitching) or arrhythmia

symptomatic, calcium gluconate

2 drugs for hyperuricemia?

allopurinol, rasburicase

Allopurinol

-does not correct pre-existing hyperuricemia

-only used to ____ TLS (can be started before chemo course for this purpose)

prevent

Rasburicase

-oxidizes/breaks down uric acid to allantoin, a substance 5-10 timore more soluble than uric acid

-this is med you would give as part of ____ for TLS

treatment

____ ____: local allergic reaction without pain, usually accompanied by red blotches along the vein

flare reaction

____: agent capable of causing achiness, tightness, and phlebitis at the injection site or along the vein

irritant

____: agent that is known to produce severe tissue damage and/or necrosis when infiltrated

vesicant

____: inadvertent administration of a solution or medication into the tissue surrounding an IV catheter

infiltration

____: inadvertent administration of a vesicant into the tissue surrounding an IV catheter

extravasation

Extravasation

-produces severe and progressive tissue injury

-blistering and sloughing of tissue begins __-__ weeks after injury

-followed by tissue ____

-surgical debridement, skin grafting, and flap placement may be necessary

-medical emergency

1-2, necrosis

First thing you should do to treat extravasation?

turn chemo off

Agents with highest vesicant potential

-____ (end in "rubicin')

-___ ____ (start with "vin")

-dactinomycin

-meclorethamine

-mitomycin C

anthracyclines, vinka alkaloids

Treatment decisions of extravasation is largely based on "____ ___" (bc this condition is rare and not easy to study)

theoretical optimism

Vinca Alkaloid Extravasation

-apply __ __ immediately, continue QID for 48-72 hours

-DO NOT apply a heating pad or dry heat ___ to the tissue

warm compress, directly

Vinca Alkaloid Extravasation

-antidote = ____ (Wydase)

hyaluronidase

is vinca alkaloid extravasation or anthracycline extravasation worse?

anthracycline

Anthracycline Extravasation

-apply ___ ___ immediately, continue for 48-72 hours

-DO NOT apply ice __ to the tissue

cool compress, directly

Anthracycline Extravasation

-historical antidote = ___ __ (but not preferred tx anymore)

dimethyl sulfoxide (DMSO)

____ (Totect) is FDA approved to treat anthracycline extravasation and is preferred over DMSO

dexrazoxane

Dexrazoxane (Totect)

-administered as an __ ___ over 2 hours into a large vein/extremity OTHER THAN the one affected by the ___

IV infusion, extravasation

remember chemotherapy destroys rapidly dividing cells, including __ __

blood cells

↓ WBCs = ___

neutropenia

↓ RBCs = ___

anemia

↓ platelets = ____

thrombocytopenia

Normal ANC = 2000-5000

Neutropenic ANC =

1000

Patient is considered absolutely neutropenic when ANC < __

100

Level of concern for neutropenia depends on:

-___ of neutropenia

-____ of neutropenia

-___ of neutrophil decline

degree, length, speed

ANC Calculation

ANC = ___ (%__ + %___)/100

WBC, neutrophils, bands

Cancer patients have blunted inflammatory responses, common signs of infections may be minimized/absent. The MOST IMPORTANT sign of infection in a neutropenic patient = ___

fever

Because we need to know if our cancer patient has a fever--they SHOULD NOT take tylenol, NSAIDs, chronic steroids, etc. Only option for relieving pain = ___

opioids

Fever

-single oral temp of >___°C

-multiple oral temps of >___°C persisting for over 1 hour

38.3, 38

Febrile neutropenia can be caused by gram __ or gram __ bacteria, so it is important we choose broad spectrum empiric antibiotic

positive, negative

Gram positive bacteria

-historically ___ common

-commonly found on the ___

-includes s. aureas, s. epiderimidis, and streptococcus

more, skin

Gram negative bacteria

-historically ___ common

-more __!

-includes psuedomonas sp., e coli, klebsiella sp., and enterobacter cloacae

less, deadly

Ideal properties of an empiric antimicrobial regimen for febrile neutropenia:

1. __ spectrum of coverage

2. bacteriocidal

3. anti-___ coverage

4. minimal resistance

broad, psuedomonal

Initial choice of therapy is usually an anti-psuedomonal ___-___ (ceftazidime, cefepime, pip/tazo, imipenem, meropenem)

beta lactam

Is single-agent therapy appropriate as a first choice in most febrile neutropenia patients?

yes

We use Colony Stimulating Factors to ___ febrile neutropenia

prevent

Colony Stimulating Factors

1) Granulocyte CSF (G-CSF) (___, ___)

2) Pegylated CSF (____, ____)

filgrastim, Neupogen, pegfilgrastim, Neulasta

When should we use CSFs to prevent febrile neutropenia?

-when chemo regimen is associated with ≥___% incidence of febrile neutropenia

20

When used to prevent febrile neutropenia, give CSFs 24-72 hours after chemotherapy is completed and continue until neutrophils have ___

recovered

CSFs should NOT be routinely used to __ febrile neutropenia (unless cases of sepsis or other life threatening complications)

treat

If patient develops febrile neutropenia during chemotherapy cycle without CSF prophylaxis, ___ CSF in all remaining cycles

add

CSF should NOT be given during ___ or ___ (bc it may actually worsen myelosuppression)

chemotherapy, radiation

CSF Adverse Effects

-___ ___!!!

-injection site reactions

-fever

bone pain

____ = mucosal damage occurring in the oral cavity, pharyngeal, and laryngeal regions

mucositis

Mucositis

-occurs in up to 75% of patients who receive chemotherapy

-occurs in nearly all patients who receive chemotherapy + radiation to the ___ or ___

head, neck

Mucositis Risk Factors

-chemotherapy regimens containing alkylating agents or topoisomerase II inhibitors (ie "blind and stupid" chemo)

-____ to head or neck

-poor ___/ill-fitting dentures

-___ use

-___ use

radiation, dentition, tobacco, alcohol

Mucositis Consequences

-decreased oral intake, which leads to risk of ___

-infection

-N/V

-usually very ___

malnutrition, painful

Should you reduce dose or delay chemo when patient experiences mucositis?

no

Mucositis

-usually begins to occur __-__ days after start of chemotherapy or radiation

-recovery is closely linked to recovery of ___

5-7, neutropenia

Mucositis Prevention

-___ assessment prior to therapy

-oral hygiene (brush with soft toothbrush, floss, bland rises without __)

dental, alcohol

Mucositis Prevention

-oral ___ (ice) for 30 min before, during, and after chemo (but may not be feasible for patients with long infusion time)

cryotherapy

Mucositis Treatment-Pain Management

-Topical therapy = ___ ___, ___ ___

magic mouthwash, lidocaine rinses

Mucositis Treatment-Pain Management

-Usually requires treatment with ___ (may require PCA, oral route often not feasible)

opioids

Mucositis Treatment

-Patient may need __ or __ __ (G tube or J tube)

TPN, feeding tube

___ of malignancy occurs in 10-30% of patients with cancer

hypercalcemia

Hypercalcemia of Malignancy Clinical Presentation

-lethargy

-confusion

-anorexia

-nausea

-constipation

-shortened QT interval

-____

-___

-___ failure (because calcium is precipitating)

polyuria, polydipsia, renal

Hypercalcemia of Malignancy

-poor ___ factor

-historically 50% of patients died within 30 days

-rates have improves with use of __

prognostic, bisphosphonates

What lab value is important for diagnosis of hypercalcemia?

corrected calcium

Corrected calcium = measured calcium + 0.8(4 - ___)

albumin

Mild hypercalcemia = calcium

12

Moderate hypercalcemia = calcium ___-___ mg/dL

12-14

Severe hypercalcemia = calcium >__mg/dL

14

Treatment of Hypercalcemia

-HYDRATION with ___ ___ +/- ___

normal saline, furosemide

Treatment of Hypercalcemia

-1st line meds: ____ ___, _____ ___

IV bisphosphonates, RANKL inhibitor

Treatment of Hypercalcemia

-2nd line meds: ____

calcitonin

IV bisphosphonates

-___ ___ (Zometa)

-____ (Aredia)

zoledronic acid, pamidronate

IV bisphosphonates adverse effects

-____

-osteonecrosis of ___ (ONJ)

nephrotoxicity, jaw

RANKL Inhibitor

-___

Denosumab

Denosumab

-rarely used

-powerful

-use for hypercalcemia ___ to bisphosphonates or in patient with severe ___ impairment

refractory, renal

Denosumab

-Monitor for severe ___

hypocalcemia

Calcitonin

-use if we need ___ onset!!

fast

Calcitonin

-lowers calcium concentration by about 1-2 mg/dL but response is ___

-limited to first 48 hours due to ___ (ie drug can suddenly stop working)

transient, tachyphylaxis

is the goal of treating hypercalcemia to return calcium to normal levels?

no

Goal of treating Hypercalcemia of Malignancy

-regain patient's ___ ___ to determine wishes for further treatment

-if further therapy is desired, must aggressively treat underlying cancer

mental functioning