Oncologic Emergencies
This oncologic emergency results from rapid destruction of malignant cells, leading to hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia.
A. SIADH
B. Tumor lysis syndrome
C. Disseminated intravascular coagulation
D. Hypercalcemia of malignancy
B. Tumor lysis syndrome
Remember, 3 hypers: hyperkalemia, hyperphosphatemia, hyperuricemia
1 hypo: hypocalcemia due to excess phosphorus binding calcium
Which electrolyte abnormality is particularly associated with cisplatin therapy?
A. Hypercalcemia
B. Hypomagnesemia
C. Hypernatremia
D. Hyperphosphatemia
B. Hypomagnesemia
Hallmark electrolyte disturbance, caused by direct injury to the renal tubules reducing reabsorption
Which of the following is a key targeted therapy used as first-line treatment for many patients with HER2-positive metastatic breast cancer?
A. Rituximab
B. Trastuzumab
C. Cetuximab
D. Bevacizumab
B. Trastuzumab
Trastuzumab is a monoclonal antibody targeting the HER2 receptor and is a foundational therapy for HER2-positive breast cancer.
A patient with high-grade lymphoma is starting chemotherapy. Before treatment, the pharmacist identifies a uric acid of 13 mg/dL, potassium of 5.8 mEq/L, phosphorus of 6.2 mg/dL, and elevated creatinine. Which intervention should the pharmacist prioritize?
A. Recommend allopurinol alone and proceed with chemotherapy
B. Recommend rasburicase and aggressive TLS monitoring/supportive management
C. Recommend calcium supplementation only
D. Recommend withholding all hydration to prevent fluid overload
B. Recommend rasburicase and aggressive TLS monitoring/supportive management
Rasburicase rapidly converts uric acid to allantoin and is particularly useful when significant hyperuricemia is already present
Which pharmacogenomic deficiency is associated with an increased risk of severe or potentially fatal toxicity from 5-fluorouracil (5-FU) and capecitabine?
A. TPMT deficiency
B. UGT1A1 deficiency
C. DPYD deficiency
D. CYP2C19 deficiency
C. DPYD deficiency
The DPYD gene encodes dihydropyrimidine dehydrogenase (DPD), the primary enzyme responsible for metabolizing 5-FU and its prodrugs. Reduced DPD activity can cause excessive exposure and severe mucositis, diarrhea, neutropenia, neurotoxicity, and potentially fatal toxicity.
A patient receiving intensive chemotherapy has a temperature of 38.5°C (101.3°F) and ANC of 300 cells/mm³. This requires prompt empiric antibacterial therapy.
A. Tumor lysis syndrome
B. Febrile neutropenia
C. Cytokine release syndrome
D. Sepsis secondary to mucositis
B. Febrile neutropenia
Definition: single oral temperature ≥38.3°C or ≥38.0°C sustained for at least 1 hour with ANC <500 cells/mm³ or expected to fall below 500
Which medication can be administered with high-dose methotrexate to rescue normal cells and reduce toxicity?
A. Mesna
B. Leucovorin
C. Dexrazoxane
D. Amifostine
B. Leucovorin
Leucovorin is a reduced folate that can rescue normal cells from methotrexate toxicity by bypassing inhibition of dihydrofolate reductase. High-dose methotrexate therapy therefore requires appropriate leucovorin rescue and monitoring of methotrexate concentrations
Which of the following agents is a commonly used component of initial therapy for a newly diagnosed patient with multiple myeloma who is eligible for treatment?
A. Bortezomib
B. Rituximab
C. Osimertinib
D. Tamoxifen
A. Bortezomib
Bortezomib, a proteasome inhibitor, is an important component of frontline multiple myeloma therapy. Modern induction regimens commonly incorporate a proteasome inhibitor, immunomodulatory agent, corticosteroid, and often an anti-CD38 monoclonal antibody, depending on patient and transplant eligibility
A 45-year-old patient is receiving her 2nd cycle of chemotherapy. She reports nausea at home the day after her last cycle of chemotherapy administration and asked if she could get anything prior to her chemo that would help prevent the delayed nausea at home. Which is best for this patient?
A. Dolasetron
B. Granisetron
C. Ondansetron
D. Palonosetron
D. Palonosetron
Palonosetron is the only second-generation agent, and it is distinguished by a much longer half-life (~40 hours) and higher receptor-binding affinity, which give it superior efficacy specifically against delayed CINV
A patient with acute lymphoblastic leukemia is being considered for treatment with 6-mercaptopurine (6-MP). Which pharmacogenomic result would indicate an increased risk of severe myelosuppression with standard dosing?
A. CYP2D6 ultrarapid metabolizer
B. TPMT poor metabolizer
C. UGT1A1 ultrarapid metabolizer
D. DPYD normal metabolizer
B. TPMT poor metabolizer
TPMT helps metabolize thiopurines such as 6-MP and azathioprine. Patients with TPMT poor-metabolizer phenotypes have increased exposure to active thiopurine metabolites and are at substantially increased risk of severe, potentially life-threatening myelosuppression.
A patient with metastatic cancer develops severe back pain, leg weakness, and bowel/bladder dysfunction. What oncologic emergency should be suspected?
A. Spinal cord compression
B. Tumor lysis syndrome
C. SVC syndrome
D. Malignant hypercalcemia
A. Spinal cord compression
Metastatic cancer can compress the spinal cord, causing back pain, weakness, sensory changes, and bowel/bladder dysfunction. This requires urgent evaluation and treatment to prevent permanent neurologic damage
A patient receiving irinotecan develops severe delayed diarrhea. Which medication is commonly used for treatment?
A. Loperamide
B. Diphenhydramine
C. Ondansetron
D. Atropine
A. Loperamide
Rationale: Irinotecan has two diarrhea patterns:
Which of the following is an appropriate first-line treatment option for a patient with newly diagnosed chronic-phase chronic myeloid leukemia (CML)?
A. Imatinib
B. Rituximab
C. Azacitidine
D. Venetoclax
A. Imatinib
Imatinib is a BCR-ABL tyrosine kinase inhibitor (TKI) that specifically targets the abnormal tyrosine kinase produced by the BCR::ABL1 fusion gene associated with the Philadelphia chromosome
Per NCCN guidelines, choice of TKI depends on risk stratification. Think "nibs" for newly-diagnosed CML.
A patient receiving pembrolizumab presents with 8–10 watery bowel movements per day, abdominal cramping, and blood in the stool. Infectious studies are negative. The pharmacist recognizes this as likely grade 3 immune-mediated colitis. What is the most appropriate pharmacist recommendation?
A. Continue pembrolizumab and start loperamide
B. Hold pembrolizumab and initiate systemic corticosteroid therapy
C. Administer filgrastim
D. Start mesna and continue pembrolizumab
B. Hold pembrolizumab and initiate systemic corticosteroid therapy
presentation is concerning for severe immune-related colitis associated with checkpoint inhibitor therapy.
The pharmacist should recommend:
A patient with metastatic colorectal cancer is scheduled to receive an irinotecan-containing regimen. Genetic testing reveals the patient is *UGT1A1*28/28. Which toxicity is the patient at increased risk for, particularly with higher irinotecan doses?
A. Cardiotoxicity
B. Hemorrhagic cystitis
C. Severe neutropenia
D. Ototoxicity
C. Severe neutropenia
Irinotecan is converted to its active metabolite SN-38, which is inactivated primarily through glucuronidation by UGT1A1.
The *UGT1A1*28/28 genotype is associated with reduced UGT1A1 expression and decreased SN-38 glucuronidation, increasing exposure and the risk of severe neutropenia.
A patient with multiple myeloma develops confusion, constipation, polyuria, and markedly elevated serum calcium. What is the most likely diagnosis?
A. SIADH
B. Tumor lysis syndrome
C. Hypercalcemia of malignancy
D. Acute kidney injury from cisplatin
C. Hypercalcemia of malignancy
Hypercalcemia can cause classic symptoms of constipation, polyuria, confusion, weakness, and dehydration.
Treatment commonly involves IV fluids plus an antiresorptive agent such as a bisphosphonate or denosumab
Which of the following medications may be used to reduce the risk of anthracycline-induced cardiotoxicity in selected patients receiving doxorubicin?
A. Mesna
B. Dexrazoxane
C. Leucovorin
D. Amifostine
B. Dexrazoxane
Cardioprotective agent used in selected patients receiving anthracyclines such as doxorubicin. It helps reduce anthracycline-associated cardiac injury, in part by chelating iron and reducing free-radical formation.
A fit 45-year-old adult is newly diagnosed with acute myeloid leukemia (AML). Which of the following combination therapies is recommended?
A. Azacitidine + venetoclax
B. Cytarabine + daunorubicin (7+3)
C. R-CHOP
D. Hydroxyurea + all-trans retinoic acid (ATRA)
B. Cytarabine + daunorubicin (7+3)
First-line therapy for acute myelogenous leukemia involves 7+3 therapy which consists of daunorubicin plus cytarabine.
An 18-year-old patient with osteosarcoma receives high-dose methotrexate. At 42 hours, the methotrexate concentration is 14 µmol/L, and serum creatinine has increased by 60% from baseline, indicating delayed methotrexate clearance with acute kidney injury. The patient is receiving scheduled leucovorin.
What is the most appropriate pharmacist intervention regarding rescue therapy?
A. Continue the current leucovorin dose and reassess the methotrexate level in 24 hours
B. Discontinue leucovorin permanently and initiate hemodialysis
C. Administer glucarpidase and hold leucovorin for 2 hours before and 2 hours after glucarpidase administration
D. Administer glucarpidase and continue leucovorin on current schedule
C. Administer glucarpidase and hold leucovorin for 2 hours before and 2 hours after glucarpidase administration
The patient has delayed methotrexate elimination accompanied by acute kidney injury, placing her at high risk for severe methotrexate toxicity. Glucarpidase rapidly breaks down circulating methotrexate into inactive metabolites and should be administered promptly when clinically indicated. Leucovorin should be temporarily withheld around glucarpidase administration because glucarpidase can also metabolize leucovorin, potentially reducing its protective effect.
A man of Mediterranean ancestry with newly diagnosed Burkitt lymphoma, uric acid 13 mg/dL, and acute kidney injury is about to receive rasburicase for tumor lysis syndrome. Deficiency of THIS enzyme is an absolute contraindication because a by-product of rasburicase's reaction causes hemolysis and methemoglobinemia.
A. Thiopurine methyltransferase (TPMT)
B. Dihydropyrimidine dehydrogenase (DPD)
C. Glucose-6-phosphate dehydrogenase (G6PD)
D. UDP-glucuronosyltransferase 1A1 (UGT1A1)
C. Glucose-6-phosphate dehydrogenase (G6PD)
Rasburicase (recombinant urate oxidase) converts uric acid to allantoin, generating hydrogen peroxide as a by-product. In G6PD-deficient red cells — which cannot regenerate NADPH to detoxify oxidative stress — this precipitates hemolytic anemia and methemoglobinemia. The FDA label lists G6PD deficiency as a contraindication
A patient with newly diagnosed acute promyelocytic leukemia presents with significant bleeding. Laboratory studies show prolonged PT and aPTT, markedly elevated D-dimer, low fibrinogen, and thrombocytopenia. Which of the following complications is most likely responsible?
A. Tumor lysis syndrome
B. Leukostasis
C. Disseminated intravascular coagulation (DIC)
D. Hyperviscosity syndrome
C. Disseminated intravascular coagulation (DIC)
APL is strongly associated with DIC and severe coagulopathy, which can lead to life-threatening bleeding. Laboratory pattern includes low fibrinogen, elevated D-dimer, prolonged PT/aPTT, and thrombocytopenia.
Drug to start immediately in APL? ____
A 58-year-old patient with relapsed diffuse large B-cell lymphoma develops fever of 39.2°C (102.6°F), hypotension requiring norepinephrine, and hypoxia requiring high-flow oxygen 8 hours after receiving CAR-T cell therapy. Infectious workup is pending. Several hours later, the patient becomes confused, has difficulty naming objects, and cannot follow simple commands.
Which of the following is the most appropriate interpretation and initial management?
A. Grade 4 CRS; administer tocilizumab and corticosteroids, while continuing evaluation for infection; the neurologic findings represent ICANS and warrant corticosteroids
B. Grade 2 CRS with uncomplicated delirium; administer acetaminophen and IV fluids and observe for progression
C. Grade 4 ICANS without CRS; administer tocilizumab as first-line therapy because ICANS is primarily driven by IL-6
D. Septic shock without CRS/ICANS; defer immunosuppressive therapy until cultures are definitively positive
A. Grade 4 CRS; administer tocilizumab and corticosteroids, while continuing evaluation for infection; the neurologic findings represent ICANS and warrant corticosteroids
CRS following CAR-T therapy, characterized by fever, hypotension requiring a vasopressor, and hypoxia requiring high-flow oxygen. Based on ASTCT grading, vasopressor requirement plus significant oxygen support is consistent with severe (grade 4) CRS. Corticosteroids are the mainstay of treatment for clinically significant ICANS
A patient with metastatic colorectal cancer has molecular testing showing a BRAF V600E mutation and has not previously received systemic therapy for metastatic disease. Which targeted therapy is specifically associated with treatment of BRAF V600E–mutated metastatic colorectal cancer?
A. Encorafenib + cetuximab
B. Osimertinib + cetuximab
C. Trastuzumab + pertuzumab
D. Ibrutinib + rituximab
A. Encorafenib + cetuximab
The combination of encorafenib, a BRAF inhibitor, with cetuximab, an EGFR inhibitor, is an established targeted approach for BRAF V600E–mutated metastatic colorectal cancer. The EGFR blockade helps address feedback pathway activation that can limit BRAF inhibitor activity in colorectal cancer.
A 55-year-old woman with node-positive breast cancer is starting curative-intent docetaxel/doxorubicin/cyclophosphamide (TAC), a regimen with a febrile neutropenia risk >20%. The oncologist asks the pharmacist whether primary G-CSF prophylaxis is indicated, which agent to use, and when it should be administered.
Which recommendation is most appropriate?
A. Primary G-CSF prophylaxis is indicated; administer pegfilgrastim approximately 24 hours after completion of chemotherapy.
B. G-CSF prophylaxis is not indicated unless the patient develops febrile neutropenia; administer filgrastim during chemotherapy if neutropenia occurs.
C. Primary G-CSF prophylaxis is indicated; administer pegfilgrastim immediately before the TAC infusion on day 1.
D. Primary G-CSF prophylaxis is indicated; administer pegfilgrastim 7 days before chemotherapy to increase the baseline neutrophil count.
A. Primary G-CSF prophylaxis is indicated; administer pegfilgrastim approximately 24 hours after completion of chemotherapy.
TAC regimen has a high (>20%) risk of febrile neutropenia, so primary prophylaxis with a G-CSF is recommended.
Pegfilgrastim is a long-acting G-CSF commonly used for primary prophylaxis. It is generally administered at least 24 hours after completion of cytotoxic chemotherapy rather than on the same day.
This gene bioactivates tamoxifen to endoxifen, and for a postmenopausal woman with resected ER+/HER2– breast cancer whose genotype predicts a POOR METABOLIZER phenotype, the 2018 CPIC guideline names THIS as the preferred management step."
A. Continue standard tamoxifen 20 mg/day and add a strong CYP2D6 inhibitor to boost levels
B. Switch to an aromatase inhibitor (or, if AI is not an option, consider increasing tamoxifen to 40 mg/day) and avoid strong CYP2D6 inhibitors
C. Reduce tamoxifen to 10 mg/day to prevent toxicity
D.Discontinue all endocrine therapy
B. Switch to an aromatase inhibitor (or, if AI is not an option, consider increasing tamoxifen to 40 mg/day) and avoid strong CYP2D6 inhibitors
Tamoxifen is a prodrug converted to its most potent antiestrogenic metabolite, endoxifen, chiefly by CYP2D6. No-function and decreased-function alleles (e.g., *3, *4, *5, *6 [no function]; *10, *41 [decreased function]) lower endoxifen exposure and are associated with reduced efficacy.