Oncology and Hypercalcemia Management Quiz

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Questions and Answers

Which of the following is a possible cause of hypercalcemia of malignancy?

Lytic bone destruction

PTHrP production

1,25-dihydroxyvit D/calcitriol production

All of the above (correct)

Which type of cancer is most strongly associated with PTHrP production?

Lung Cancer - Small Cell

Lung Cancer - Squamous Cell (correct)

Myeloma

Breast Cancer

What is the most effective short-term management option for hypercalcemia of malignancy?

Calcitonin

Bisphosphonates

IV hydration (correct)

Steroids

Which of the following drugs is an Anti-HER2 therapy used in breast cancer treatment?

Trastuzumab (A) Signup and view all the answers

Which of the following medications has a rapid onset of action (4-6 hours) but can lead to tachyphylaxis within 48 hours, making it suitable as a bridge to bisphosphonates?

Calcitonin (D) Signup and view all the answers

What is the main difference in endocrine therapy for pre-menopausal and post-menopausal women with breast cancer?

Post-menopausal women receive aromatase inhibitors, while pre-menopausal women receive tamoxifen. (A) Signup and view all the answers

What is the maximum effect timeframe for bisphosphonates in treating hypercalcemia of malignancy?

4-7 days (C) Signup and view all the answers

Steroids are primarily used in hypercalcemia of malignancy to address which of the following?

Treating bone metastases pain and flare (B) Signup and view all the answers

Which of the following is NOT considered a recommended surveillance method for breast cancer patients?

Surveillance blood work (A), Surveillance CT scans (B) Signup and view all the answers

Which of the following is a lifestyle modification recommended to reduce breast cancer mortality?

Regular physical activity (A) Signup and view all the answers

Which of the following factors is NOT a consideration for outpatient management of febrile neutropenia?

Presence of comorbidities (D) Signup and view all the answers

In the outpatient management of febrile neutropenia, which of the following antibiotics is NOT recommended for patients with a penicillin allergy?

Amoxicillin/clavulanate (D) Signup and view all the answers

Which of the following is a common side effect associated with endocrine therapy?

Bone loss (D) Signup and view all the answers

What type of drug is an Antibody Drug Conjugate (ADC)?

An antibody tagged with chemotherapy (C) Signup and view all the answers

Which of the following drugs is NOT an example of an aromatase inhibitor?

Tamoxifen (A) Signup and view all the answers

Which of the following drugs is an example of an Anthracycline?

Doxorubicin (A) Signup and view all the answers

What is the maximum recommended daily dosage of loperamide for managing diarrhea related to chemotherapy?

16 mg (C) Signup and view all the answers

Which of the following is a common side effect of chemotherapy that can often be managed with aggressive loperamide regimen?

Diarrhea (C) Signup and view all the answers

Which of the following chemotherapy drugs is often associated with rash as a side effect?

5FU/Cape (B) Signup and view all the answers

What is the recommended treatment for oral ulcers caused by mucositis?

Viscous Lidocaine (D) Signup and view all the answers

What type of chemotherapy drug is often implicated in causing alopecia (hair loss)?

Taxanes (B) Signup and view all the answers

Which of the following is a side effect of chemotherapy that can potentially be permanent?

Neuropathy (C) Signup and view all the answers

Which of the following medications is commonly used for managing mucositis?

Magic Mouthwash (D) Signup and view all the answers

What is the recommended approach for managing diarrhea caused by chemotherapy?

Aggressive loperamide regimen (B) Signup and view all the answers

Which of the following is a potential treatment option for localized prostate cancer?

Radical prostatectomy (D) Signup and view all the answers

What is the main purpose of a bone scan in the context of prostate cancer?

To detect the presence of bone metastases (B) Signup and view all the answers

What is the significance of a high Gleason score in a prostate cancer diagnosis?

It indicates a higher likelihood of the cancer spreading (D) Signup and view all the answers

Which of the following is a characteristic of castrate-resistant prostate cancer?

It is no longer responsive to therapies that lower androgen levels (B) Signup and view all the answers

What is the role of a digital rectal examination in the workup of prostate cancer?

To assess the size and consistency of the prostate gland (A) Signup and view all the answers

Which of the following is a common side effect associated with Androgen Deprivation Therapy (ADT) for prostate cancer?

Hot flashes (A) Signup and view all the answers

Which of the following statements about PARP inhibitors in prostate cancer treatment is accurate?

They may be used as a front-line treatment for metastatic prostate cancer (D) Signup and view all the answers

Which of the following is a treatment option specifically aimed at shutting down androgen production in prostate cancer?

CYP17 inhibitor (A) Signup and view all the answers

Which type of lung cancer is NOT associated with hypercalcemia?

Adenocarcinoma (A), Hypertrophic Osteoarthropathy (C) Signup and view all the answers

What is the most appropriate next step in the diagnostic workup for a patient with a suspected lung cancer based on a CT scan finding?

Perform a PET/CT scan to evaluate for tumor spread and mediastinal involvement (A) Signup and view all the answers

Which of the following is a typical profile of a patient with an EGFR-positive adenocarcinoma?

Elderly, Female, Asian, Non-smoker (B) Signup and view all the answers

What is the role of molecular testing in lung cancer management?

To provide information about the tumor's genetic alterations and potential targets for therapy (D) Signup and view all the answers

Which of the following is NOT a valid method for obtaining a tissue sample for lung cancer diagnosis?

Pleural effusion analysis (B) Signup and view all the answers

What is the significance of a malignant pleural effusion in a patient with NSCLC?

It is an indicator of a disease that is not curable (A) Signup and view all the answers

In a patient with a suspected paraneoplastic syndrome, what should the physician order?

A serum and CSF antibody panel (D) Signup and view all the answers

Which of the following is NOT a common symptom associated with hypertrophic osteoarthropathy seen in lung cancer patients?

Hypercalcemia (D) Signup and view all the answers

What is the initial service to consult when a patient presents with a lung nodule, even if the stage is not yet determined?

Thoracic Surgery (C) Signup and view all the answers

What is the definitive treatment for a patient with stage 1 lung cancer who is fit for surgery?

Surgery (D) Signup and view all the answers

What is the best service to consult for a patient with stage 3 lung cancer who is not a surgical candidate?

Medical Oncology (A) Signup and view all the answers

Which of the following is NOT a standard treatment for a patient with resectable stage 2 or 3 lung cancer?

Radiation Therapy alone (D) Signup and view all the answers

What is the most common treatment approach for a patient with resectable stage 2 or 3 lung cancer?

Neoadjuvant chemotherapy followed by surgery (C) Signup and view all the answers

What is the role of immunotherapy in the treatment of stage 3 lung cancer?

It is used in conjunction with chemotherapy (C) Signup and view all the answers

What is the significance of EGFR+ in the treatment of lung cancer?

Patients with EGFR+ are more likely to benefit from targeted therapy (B) Signup and view all the answers

What is the definition of 'unresectable' stage 3 lung cancer?

All of the above (D) Signup and view all the answers

Study Notes

Oncology & Palliative Care

Topics covered include oncologic emergencies, screening and prevention, common solid tumour sites, systemic toxicities, and palliative care.
Specific tumour sites discussed include breast, lung, colorectal, prostate, other GI cancers (e.g., gastroesophageal, HCC, pancreatic), genitourinary cancers (e.g., testes, bladder, renal cell), and gynecologic cancers (e.g., endometrial, cervical, ovarian).
Oncologic emergencies involve conditions like febrile neutropenia, hypercalcemia, TLS (tumor lysis syndrome), SVC syndrome (superior vena cava syndrome), MBO (malignant bowel obstruction), and brain mets/leptomeningeal disease.
Importance of palliative care is emphasized in the management of patients with advanced cancer.

Overview (RC Objectives)

Important concepts (RC Objectives) regarding oncology and palliative care are outlined.
Key concepts mentioned include oncologic emergencies, screening & prevention, common solid cancers, and palliative care.
Important topics are stated without repetition of the information from previous sections.
Details on cancers are not given but the categories are listed.

Housekeeping

The presentation emphasizes the importance of high-yield topics for studying, specifically those relevant to screening, diagnosis, oncologic emergencies, and palliative care, to better prepare for the exam.
Common oral scenarios in oncology are discussed.
"Trial" questions that do not appear on subsequent exams are mentioned.

Oncologic Emergencies

Febrile neutropenia, hypercalcemia, TLS (tumor lysis syndrome), SVC syndrome, spinal cord compression, and brain mets/leptomeningeal disease are listed as oncologic emergencies.

MCQ1

A patient presents with a fever and low neutrophil count (ANC) after chemotherapy.
Key points in the question include fever 38.3C, ANC 0.9, prior low ANC, runny nose, and recent chemotherapy.
The best course of management involves admission, blood cultures, CXR, urinalysis, and broad-spectrum antibiotics (choice A) based on possible infection.

Febrile Neutropenia

Febrile neutropenia is a life-threatening condition.
Criteria for diagnosis include fever (≥38.3°C or ≥38°C for >1 hour) and an absolute neutrophil count (ANC) ≤1.0.
Standard workup includes blood cultures, urine culture, and CXR.
Additional imaging may be indicated.
Prompt broad-spectrum antibiotic administration is essential.

Outpatient Management of Febrile Neutropenia in Adults

Outpatient management is considered in non-severe cases if certain criteria are met.
These cases are primarily for the simple ED visit, including young age, no complications, solid tumors, and quick recovery.

Hypercalcemia of Malignancy

Etiology includes lytic bone destruction, PTHrP production, and 1,25-dihydroxyvitamin D production.
Management involves IV hydration, calcitonin, bisphosphonates, and treatment of the underlying malignancy.

Rapid Cellular Breakdown

Rapid cellular breakdown features of TLS, specifically include elevated potassium, phosphorus, uric acid, and calcium.
Diagnosis of TLS is determined if two or more of these blood test values are abnormal 7 days post-chemo.
Prophylactic measures for TLS involve fluid management.

Malignant Bowel Obstruction (MBO)

The presentation includes causes such as inttraluminal block, peritoneal disease, and extrinsic compression.
Interventions include consult general surgery (even if palliative), stenting, and diverting ileostomy/venting.
Non-pharmacological treatments include IV fluids, NG decompression, and octreotide.

SVC Syndrome

Thrombosis/fibrosis and malignancy (specifically non-small cell lung cancer) are listed as causes of SVC syndrome.
Symptom presentation involves facial and arm edema, distended neck and chest veins, dyspnea, and cough.
Management involves urgent stenting and steroids if stenting isn't an option.

Spinal Cord Compression

Etiology involves tumor pushing/metastases (Breast, Lung, Prostate, Multiple myeloma), leading to back pain (frequent initial sign), leg weakness, loss of sensation, urinary retention, and bowel incontinence.
Diagnosis includes MRI whole spine.
Management involves immediate consultation with spine surgery or radiation oncology (Rad Onc before Spine if you must choose one), steroids (dexamethasone).

Brain Mass/Leptomeningeal Disease

Intra-parenchymal lesions/meningeal disease block CSF flow are potential causes.
Symptoms include vertigo, ataxia, headaches, vision changes, and neurologic deficits.
Management involves immediate consult with neurosurgery and radiation oncology.

MCQ 1 (repeated) and Screening and Prevention

Screening for various cancers—including breast, lung, colon, HCC, and cervical—and cancer prevention are discussed.
The approach to solid tumour oncology, involving prevention, relevant biology, recognition, and diagnosis, early-stage management, metastatic management, and surveillance, is outlined.
Screening for asymptomatic conditions is distinguished from diagnosis.

Screening for Breast Cancer (Update 2024)

Screening guidelines advise screening 50–74-year-old women with mammography every 2–3 years.
Women aged 40–49 should be informed about the benefits and harms. Screening is their personal choice.
Screening for breast cancer is outlined as women aged 50–74 should screen with mammography every 2–3 years

Breast Cancer Screening for 2S/Transgender/Nonbinary/Gender Diverse Patients

Specific guidelines for transgender women and other patients are discussed.
Recommendations for screening vary depending on whether a mastectomy was performed vs simple reduction mammoplasty.
Recommendations for hormone therapy and timing of screening are also outlined.

Screening for Lung Cancer

Screening criteria are age (55–74), smoking history (current or quit within 15 yrs), and ≥30 pack-years.
Annual low-dose CT screening is recommended.

Screening for Colorectal Cancer

Screening guidelines are for people aged 50–74, recommending either FIT q2 years or flex sigmoidoscopy q10 years.
For high risk individuals (family history, previous polyps/cancer), a colonoscopy at an earlier age or more frequent intervals is considered.

Screening for Hepatocellular Carcinoma (HCC)

Screening guidelines for cirrhosis vs. no cirrhosis with Hep B carrier are outlined.
Guidelines recommend ultrasound every 6 months for cirrhosis.
Guidelines recommend AFP every 6 months for no cirrhosis but with Hep B carrier.

Screening for Cervical Cancer

Screening guidelines are for patients aged 25–69 with a cervix: Cervical cytology q3 years (Pap smears); no screening required after 70 or 3 negative results over 10 years

Do Not Screen for These Cancers

Certain cancers are not routinely screened; examples include prostate, esophagus, skin, testes and ovaries, with exceptions for specific high-risk cases and possible exclusions.

Cancer Prevention—ETOH (Jan 2023)

Alcohol consumption at any level increases cancer risk.

Cancer Prevention—Smoking (Jul 2024)

Smoking is harmful.
Pharmacologic treatments include Varenicline, Bupropion, Nicotine Replacement Therapy(NRT), and Cytisine.
Non-pharmacologic treatments include behavioural interventions (brief health-worker counselling).

MCQ 2 (repeated)

Screening recommendations, considering factors like age, smoking history, family history, and recent diagnoses of HBV, are outlined.

Screening for Lung Cancer (repeated)

Screening criteria for lung cancer, including age (55–74), smoking history, and pack-years, and yearly low-dose CT screening, are outlined.

Prostate Cancer: Biology + Workup

Prostate cancer diagnosis depends on androgen, digital rectal examination (DRE), and PSA.
Gleason score is ascertained from prostate biopsies.
Useful imaging includes bone scans. The presentation of cancer usually appears in the setting of bone metastases.

Prostate Cancer: Management

Castrate-sensitive cancers respond to androgen deprivation therapy (ADT).
Localized prostate cancer management includes active surveillance, radical prostatectomy, and radiation therapy.

Testicular Cancer

Types of testicular cancer include seminoma and non-seminoma.
Diagnostic markers are β-hCG, AFP, and LDH. Localized cancer treatment includes surgery (orchiectomy), while metastatic cancer treatment includes chemotherapy (bleomycin).

MCQ 3 (repeated)

A patient with a history of reflux, abdominal pain, and suspicious peritoneal metastases requires an upper endoscopy.

Breast Cancer: Biology + Confirm Cancer

Estrogen-driven vs. HER2 cancer is a key differentiator.
Diagnosing breast cancer involves mammography, ultrasound, core needle biopsy (US-guided) markers such as ER, PR, and HER2.

Breast Cancer: Localized Management + Staging

Localized breast cancer treatments include mastectomy and lumpectomy, with lymph node treatment (SLNB/ALND).
Staging- based on pathology results determine stages 1, 2, or 3 with appropriate staging.

Breast Cancer: Systemic Therapy

Systemic therapy options for hormone-positive, HER2-positive, and triple-negative breast cancers are discussed.
Specific drugs for each subtype (e.g., Tamoxifen, Aromatase Inhibitors, Anthracyclines, Anti-HER2, Immunotherapy) and their side effects are noted.

Breast Cancer: Surveillance

Annual clinical examination and mammography are recommended for breast cancer surveillance.
Lifestyle modifications, such as weight control, exercise, limited alcohol and tobacco use, and a healthy diet, are emphasized.

Breast Cancer Treatment Side Effects

Side effects of tamoxifen, aromatase inhibitors, anthracyclines, and anti-HER2 agents such as trastuzumab/pertuzumab are noted.

Lung Cancer: Biology

Important topics related to lung cancer biology (non-small cell vs. small cell) and their associated risk factors are presented.
Key topics include squamous cell, adenocarcinoma, rare(ish) cancers (neuroendocrine tumors, adenosquamous, sarcomatoid, large cell), rapid growth rates, non/small cell lung cancer.
Important considerations include knowing the workup for carcinoids and performing an Echo if there is suspicion of any.

Lung Cancer: Paraneoplastic Syndromes

Paraneoplastic syndromes, such as SIADH, Lambert-Eaton myasthenic syndrome (LEMS), encephalomyelitis, and others, related to lung cancer are discussed.

Lung Cancer: Workup

Staging in lung cancer, including CT of the chest, abdomen, and pelvis, and MRI brain, is discussed.
Molecular testing, including EGFR and PD-L1 testing, is emphasized.

NSCLC: Staging

Staging for NSCLC, including the different stages based on lymph node involvement and distant metastasis, is discussed.

Non-Small Cell Lung Cancer: Early Stage Management

Early-stage management of NSCLC, including surgery, radiation, concurrent chemoradiation, and immunotherapy, is outlined.

Non-Small Cell Lung Cancer: Metastatic Management

Metastatic NSCLC management details are presented concerning treatment based on EGFR or other mutation status, along with use of immunotherapy/chemotherapy.

Small Cell Lung Cancer: Workup & Management

Limited vs. extensive-stage management and treatment options are discussed (chemotherapy + immunotherapy).
Prophylactic brain radiation, now avoided as no survival benefit, is noted.

Lung Cancer: Note on Radiation Pneumonitis

Timing, location, and treatment for radiation-induced pneumonitis are described.

Colorectal Cancer: Workup

Diagnostic method involves a full colonoscopy and biopsy.
Staging involves CT of the chest, abdomen, and pelvis.
Markers, including carcinoembryonic antigen (CEA), are discussed.

Colorectal Cancer: Management

Treatment strategies for stages 1, 2, 3, and 4 (systemic therapy) and additional considerations are discussed.
Curable stage IV disease variants and eligibility for such treatments are addressed.

Colorectal Cancer: Stage 1-3 Surveillance

Surveillance guidelines for stages 1–3 colorectal cancer, including timelines for follow-up visits, CT-scanning, and colonoscopies, are presented.

Gastroesophageal Cancer: Biology

Cancer types (squamous cell, adenocarcinoma) and their common locations (upper/mid esophagus, distal esophagus, Barrett's esophagus) are discussed.
Risk factors for each cancer type (alcohol, smoking, GERD, obesity, and caustic injury) are listed.
Important lesion presentations (Leser-Trelat sign) are also highlighted in the context of other organ cancer presentations.

Systemic Therapy and Their Side Effects

Chemotherapy and immunotherapy are presented as important systemic treatments in oncology.

Systemic Therapy Toxicities Disclaimer

The difficulty in understanding side effects of new therapies is an important consideration when managing advanced cancer treatment.
The general internist must consult with the oncologist when in doubt or in need of clarification on toxicities. The general internist must consult with the oncologist/expert in any case of ambiguity in these important situations.

Chemotherapy Toxicities

A variety of chemotherapy drugs and associated toxicities (irrev. cardiomyopathy, secondary leukemias, diarrhea, mucositis, peripheral neuropathy, etc) are noted.
Important toxicities are emphasized in the context of the relevant cancer types.

Other Systemic Therapy Toxicities

Important side effects from targeted therapies, e.g., anti-angiogenics/VEGF inhibitors, EGFR tyrosine kinase inhibitors (e.g., Osimertinib), and trastuzumab/rituximab, are listed.
Side effects from all therapies are emphasized, e.g. autoimmune phenomena, (influx of symptoms like cough, tachycardia, allergic reactions, etc), along with other details like renal/liver dysfunction, hemorrhagic cystitis.

The Terrible 2's: Heart and Lung

Toxicity for cardiac and pulmonary organs related to the use of specific chemo drugs, with a focus on reversibility and onset of symptoms is reviewed ,
Specific toxicities are noted, e.g. anthracycline-related cardiac toxicity (irreversible) or Doxorubicin, trastuzumab toxicity (reversible), or bleomycin toxicity (irrev.) for lung.

Immunotherapy Toxicity Management

Management of immunotherapy-related toxicities, including supportive care and specific medications (e.g., steroids, infliximab) for severe cases are discussed.
Important consideration for early interventions to manage toxicities, such as ensuring that cancer patients do not get too much chemo in one period, or that a therapy is discontinued if needed (especially in cases with extremely high-risk complications).

Common Chemo Side Effects: Nausea

Nausea is a very common side effect during and after chemotherapy.
Effective methods of management with anti-emetic medications (e.g., NK₁-receptor antagonists, 5HT3 antagonists, steroids) are discussed.

Higher Yield Systemic Therapy Names

Important drugs encountered throughout the lecture, including chemotherapy, antibody/anti-HER2, anti-hormonal/estrogens, androgen deprivation therapy (ADT), immunotherapy, and targeted therapies (EGFR) are listed.

BONUS Q1 2024 (and others)

Specific bonus questions throughout the lecture are answered/addressed.
The questions focus on appropriate responses to the clinical cases.

Palliative Care

Discusses the use of early palliative care consultation.
Early involvement, performance status, and pain management are included.
MAID and related legal issues are explained concisely and are also noted as related or unrelated to specific cases.

Palliative Performance Status

The palliative performance status scale is outlined as a numerical scoring system used to assess the physical function and quality of life of patients using a 0–5 range. A score of 0 represents full health, while a score of 5 represents death.
The scale's significance in guiding palliative care decisions and implications of avoiding chemotherapy in patients undergoing active treatment when there is likely low survival time are discussed.

Pain Control

Treatment options from non-opioid to opioids and adjuvants are covered along with opioid titration.
Important aspects for opioid rotation (e.g., conversion to oral morphine equivalent, calculating breakthrough doses, and possible need for caution with renal or hepatic impairment) are noted.

Symptom Management

Discusses approaches to various symptoms like dyspnea, nausea and vomiting, delirium, and cachexia.

Medical Assistance In Dying (MAID)

Legal criteria for MAID, which includes eligibility, grievous illness, and irreversibility, are described.

Self-study: Metastases Trivia

Details on lymph node and bone metastases from various cancers are provided.

Self-study: Stage IV Consolidation

Consolidation of stage IV cancer, including lung, colorectal, and testicular cancers, is outlined.

Self-Study: Cancer of Unknown Primary

Diagnostic approach, clinical features, and treatment strategies in patients with cancer of unknown origin are discussed.

Self-Study: Renal Cell Carcinoma

Important considerations in the presentation of this tumor including important paraneoplastic syndromes like hypercalcemia, hypertension, and polycythemia are outlined.

Chemo Side Effects: Diarrhea and Mucositis

Common chemotherapy side effects, diarrhea and mucositis, are covered as well as management strategies.

Infamous Chemo Side Effects

Common chemotherapy-related toxicities (alopecia, rash, neuropathy, myelosuppression) and their implications are noted

End-of-Life Tidbits

Important consideration related to end of life planning, palliative care involvement, and discontinuation of inappropriate treatments when the patient has poor prognosis.

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Description

Test your knowledge on the management of hypercalcemia in malignancy and its association with various cancers. This quiz covers key therapeutic approaches, drug classifications, and clinical considerations relevant to oncological care. Perfect for medical students and professionals aiming to deepen their understanding of cancer-related complications.