34 Oncologic Emergencies

Preet Paul Singh

QUESTIONS

Each of the numbered items below is followed by lettered answers. Select the ONE lettered answer that is BEST in each case unless instructed otherwise.

Questions 34.1–3 A 48-year-old White man presents with a history of progressive facial swelling, fullness in the head and shortness of breath for 1 month. He has a 40 pack-year smoking history. On examination, the patient has venous distention of the neck and chest wall. Laboratory test results revealed normal blood counts, basic metabolic profile, and liver functions. Computed tomography (CT) scan revealed an 8 × 6-cm lung mass with multiple liver lesions.

Question 34.1 What is the most likely cause of his condition?

A. Small cell lung cancer

B. Hodgkin lymphoma

C. Diffuse large B-cell lymphoma

D. Superior vena cava (SVC) thrombosis

Question 34.2 Biopsy was performed and showed small cell lung cancer. Which is the best initial modality of treatment for this patient?

A. Surgery

B. Radiation therapy

C. Chemotherapy

D. SVC stent

Question 34.3 What is the most likely location for the primary tumor?

A. Peripheral left lung

B. Peripheral right lung

C. Central left lung

D. Central right lung

Question 34.4 Which among the following is the earliest fundoscopic sign for increased intracranial pressure?

A. Papilledema with blurring of the disc margins

B. Foster–Kennedy syndrome

C. Disc hemorrhage

D. Absence of venous pulsations within the center of the optic disc

Questions 34.5–6 A 57-year-old man presents with severe back pain and bilateral leg weakness for 3 days. Magnetic resonance imaging (MRI) of the spine reveals metastatic lesion at T10 vertebral body with significant cord compression.

Question 34.5 Which of the following are most likely primary cancers in this patient?

A. Lung cancer and breast cancer

B. Lung cancer and lymphoma

C. Colon cancer and lymphoma

D. Colon cancer and prostate cancer

Question 34.6 What is the most appropriate initial therapy for this patient with malignant spinal cord compression?

A. Chemotherapy

B. Radiation therapy

C. Strontium-89

D. Dexamethasone

Question 34.7 In patients with increased intracranial pressure, which of the following signs indicates midbrain dysfunction?

A. Midsize pupils unresponsive to light

B. Coma

C. Absence of oculocephalic reflex

D. Ataxic breathing

Question 34.8 Which of the following laboratory abnormalities are associated with tumor lysis syndrome? (Select two correct responses)

A. Hypokalemia

B. Hypophosphatemia

C. Hypocalcemia

D. Hyperuricemia

Question 34.9 A 28-year-old man presents with newly diagnosed acute myeloid leukemia. He has a white cell count of 140,000/mm³, glucose of 96 mg/dL, sodium of 138 mEq/L, potassium of 4 mEq/L, creatinine of 1.1 mg/dL, blood urea nitrogen (BUN) of 15 mg/dL, uric acid of 4.8 mg/dL, albumin of 5.2 g/dL, and calcium of 10.2 mg/dL. He is started on induction chemotherapy, aggressive intravenous fluids and allopurinol. Twelve hours later, the patient developed cardiac arrest not responsive to cardiopulmonary resuscitation and died. What is the most likely cause of his death?

A. Leukostasis

B. Severe hyperkalemia

C. Pulmonary embolism

D. Chemotherapy-induced cardiac arrhythmia

Questions 34.10–11 A 40-year-old woman presents with fever and headache 3 days after receiving chemotherapy. Her blood pressure is 130/85 and heart rate 101. Laboratory tests revealed hemoglobin of 8.5 g/dL, WBC of 11,500/mm³, platelets of 69,000/mm³, sodium of 142 mEq/L, potassium of 4.3 mEq/L, bicarbonate of 24 mEq/L, BUN of 44 mg/dL, creatinine of 1.8 mg/dL, albumin of 3.8 g/dL, total bilirubin 2.4 mg/dL, and direct bilirubin 0.3 mg/dL. Her prothrombin time and partial thromboplastin time were normal. Peripheral blood smear showed several fragmented red blood cells and helmet cells. Direct Coombs test is negative.

Question 34.10 What is the most likely diagnosis?

A. Disseminated intravascular coagulopathy

B. Malignant hypertension

C. Brain metastases

D. Hemolytic uremic syndrome

Question 34.11 Which of the following chemotherapy drugs are implicated in the etiology of this syndrome? (Select two correct responses)

A. Paclitaxel

B. Mitomycin

C. Gemcitabine

D. Pemetrexed

Question 34.12 A 63-year-old man with metastatic squamous cell carcinoma of the lung presents with constipation and nausea for 3 days. Laboratory tests revealed hemoglobin of 13.5 g/dL, WBC of 12,500/mm³, platelets of 155,000/mm³, sodium of 146 mEq/L, potassium of 4.8 mEq/L, bicarbonate of 28 mEq/L, BUN of 44 mg/dL, creatinine of 1.7 mg/dL, albumin of 2.8 g/dL, and calcium of 13.1 mg/dL. What is the most appropriate therapy, in addition to intravenous fluids?

A. Gallium nitrate

B. Furosemide

C. Bisphosphonates

D. Calcitonin

Question 34.13 Denosumab is approved for prevention of skeletal-related events in patients with bone metastases from solid tumors. Which of the following describes the mechanism of action of denosumab?

A. Inhibits osteoclasts by binding RANKL (receptor activator of nuclear factor-κΒ ligand) to prevent RANKL activation by RANK.

B. Inhibits active form of vitamin D, 1,25-dihydroxyvitamin D and prevents intestinal calcium absorption

C. Activates osteoblasts by binding RANKL (receptor activator of nuclear factor-κΒ ligand)

D. Impede protein prenylation and bone resorption by osteoclasts by inhibiting the mevalonate pathway.

Question 34.14 Which of the following findings are required for diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH)? (Select two correct responses)

A. Decreased effective serum osmolality (<275 mOsm/kg of water)

B. Inappropriate urinary concentration: Urine osmolality >100 mOsm/kg of water with normal renal function

C. Clinical evidence of hypovolemia (orthostasis, tachycardia, decreased skin turgor, dry mucous membranes)

D. Urine sodium <10 mmol/L in the face of normal salt and water intake

Question 34.15 Rasburicase, indicated for treatment of hyperuricemia, is a recombinant version of which of the following enzymes involved in purine metabolism?

A. Xanthine oxidase

B. Urate oxidase

C. Guanase

D. Hypoxanthine phosphoribosyltransferase

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