Hi ,

Welcome back to the Oncology Insights Newsletter which helps you learn oncology, and other nuggets, as you progress in your oncology career. 

Last time you learned about the importance of the rasburicase collection process, VTE risk, and why feeling dumb should be a goal

This week you'll learn about hiccups with dexamethasone, tumor lysis syndrome in testicular cancer, and why some patients with testicular cancer get 2 versions of cycle 1.

Have a great week!

Kelley

🧠 IPS (Insight, Pearl, Sundry)

Insight

Hiccups are the worst 😳

Did you know some patients receiving dexamethasone develop uncontrolled hiccups? And we use a LOT of dexamethasone in oncology.

The incidence isn’t well understood because it’s believed it goes largely unreported

Discontinuation of dexamethasone is effective at stopping the hiccups, but since most patients are taking it to prevent nausea and vomiting, we need to swap in something else, of which methylprednisolone is a good option

Patients on dexamethasone 12 and 8 mg can be converted to ~64 and 40 mg methylprednisolone, respectively

One study found this swap to be very effective with 85% of patients having complete resolution. Interestingly, and expectedly, most had recurrence if they were re-challenged (73.5%) so stick with methylprednisolone going forward.

Pearl

In the world of medical zebras 🦓 and horses 🐴, tumor lysis syndrome (TLS) in solid tumors is a zebra

Zebras are those rare diseases or surprising complications that stand out in a field of common diagnoses (🐴)

TLS is an expected complication (🐴) in various hematologic malignancies because of their rapid growth and sensitivity to chemotherapy causing tumor cells to die quickly and release their intracellular contents (eg, uric acid, potassium, phosphorus) - we expect TLS in these diseases

In the world of solid tumors, TLS is typically a zebra 🦓 because we don’t see it a lot

Testicular cancer is one exception

This disease has these 2 key features necessary to trigger TLS upon initiation of chemotherapy 👇

⏩ Highly proliferative

⏩ Sensitive to chemotherapy

It is mostly likely to occur at the start of treatment; although, it has been reported to occur spontaneously in patients prior to treatment initiation

Although TLS is not common in testicular cancer, it has been associated with a high mortality rate so don't let this zebra 🦓 sneak up on you when managing these patients!

Sundry

If oncology was always “by the book” it would make it a lot easier to learn

But it isn’t, and it’s not

One example of something you learn with experience is treating a newly diagnosed patient with testicular cancer and significant disease burden, such as being in multi-organ failure from an obstruction or compression, pulmonary dysfunction from bulky disease, large brain mets, etc

These patients need urgent chemo because they are clinically unstable and we know testicular cancer is very sensitive to chemo

Some of these patients may get a half cycle or a 50% dose reduction of chemo as “induction”. Then when they respond quickly and have significant decrease in tumor burden, they will undergo a second "cycle 1" for the full-dose treatment.

For those that receive a reduced dose as induction, they may require treatment with full-dose chemotherapy sooner than 3 weeks. Oftentimes, these patients will receive a 50% dose as induction, and then have a quick turnaround for cycle 1 10-14 days later.

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