MCQ Quiz: Oncologic Emergencies

Oncologic emergencies are acute, life-threatening conditions that can develop as a direct result of cancer or as a complication of its treatment. Prompt recognition and rapid, evidence-based intervention are critical to improving patient outcomes and preventing mortality. For pharmacists, a thorough understanding of the pathophysiology and management of these emergencies is essential. This quiz is designed for PharmD students to test their knowledge on the pharmacotherapy of common oncologic emergencies, including febrile neutropenia, tumor lysis syndrome (TLS), hypercalcemia of malignancy, and spinal cord compression, reinforcing the pharmacist’s vital role in supportive care for cancer patients.

1. A patient with acute lymphoblastic leukemia develops hyperkalemia, hyperphosphatemia, and acute renal failure after starting chemotherapy. This clinical picture is most consistent with:

  • a) Febrile neutropenia
  • b) Hypercalcemia of malignancy
  • c) Tumor Lysis Syndrome (TLS)
  • d) Spinal cord compression

Answer: c) Tumor Lysis Syndrome (TLS)

2. Which laboratory finding is characteristic of Tumor Lysis Syndrome (TLS)?

  • a) Hypercalcemia
  • b) Hypophosphatemia
  • c) Hypokalemia
  • d) Hyperuricemia

Answer: d) Hyperuricemia

3. Allopurinol is used for TLS prophylaxis because it works by:

  • a) Directly breaking down existing uric acid.
  • b) Increasing the renal excretion of uric acid.
  • c) Inhibiting xanthine oxidase, thereby preventing the formation of new uric acid.
  • d) Alkalinizing the urine.

Answer: c) Inhibiting xanthine oxidase, thereby preventing the formation of new uric acid.

4. A patient at high risk for TLS has a baseline uric acid of 10 mg/dL. Which agent is preferred for management because it converts existing uric acid into a more soluble compound?

  • a) Allopurinol
  • b) Febuxostat
  • c) Rasburicase
  • d) Sevelamer

Answer: c) Rasburicase

5. Neutropenia is defined as an Absolute Neutrophil Count (ANC) below what level?

  • a) < 2,000 cells/mm³
  • b) < 1,500 cells/mm³
  • c) < 1,000 cells/mm³
  • d) < 500 cells/mm³ (or < 1,000 cells/mm³ with a predicted decline to < 500)

Answer: d) < 500 cells/mm³ (or < 1,000 cells/mm³ with a predicted decline to < 500)

6. A patient with chemotherapy-induced neutropenia develops a single oral temperature of 38.3°C (101°F). This constitutes:

  • a) A normal reaction.
  • b) An oncologic emergency known as febrile neutropenia.
  • c) Tumor lysis syndrome.
  • d) A delayed chemotherapy hypersensitivity reaction.

Answer: b) An oncologic emergency known as febrile neutropenia.

7. What is the cornerstone of initial management for a high-risk patient with febrile neutropenia?

  • a) Waiting for blood culture results before starting treatment.
  • b) Administering oral antibiotics at home.
  • c) Immediate administration of empiric, broad-spectrum intravenous antibiotics with anti-pseudomonal activity.
  • d) Starting prophylactic G-CSF therapy.

Answer: c) Immediate administration of empiric, broad-spectrum intravenous antibiotics with anti-pseudomonal activity.

8. Which of the following is an appropriate first-line monotherapy agent for empiric treatment of high-risk febrile neutropenia?

  • a) Vancomycin
  • b) Ceftriaxone
  • c) Cefepime
  • d) Doxycycline

Answer: c) Cefepime

9. In the management of febrile neutropenia, vancomycin should be added to the initial empiric regimen only if which of the following is present?

  • a) The patient has a low-grade fever.
  • b) The patient has a high white blood cell count.
  • c) There is clinical suspicion of a catheter-related infection, severe mucositis, or hemodynamic instability.
  • d) Vancomycin should always be used first-line for all patients.

Answer: c) There is clinical suspicion of a catheter-related infection, severe mucositis, or hemodynamic instability.

10. What is the most common cause of hypercalcemia of malignancy in patients with solid tumors?

  • a) Overproduction of parathyroid hormone (PTH).
  • b) Secretion of parathyroid hormone-related protein (PTHrP) by tumor cells.
  • c) Increased dietary calcium intake.
  • d) Decreased renal excretion of calcium.

Answer: b) Secretion of parathyroid hormone-related protein (PTHrP) by tumor cells.

11. The initial and most critical step in managing severe, symptomatic hypercalcemia of malignancy is:

  • a) Starting oral bisphosphonates.
  • b) Administering calcitonin.
  • c) Aggressive intravenous hydration with normal saline.
  • d) Initiating hemodialysis.

Answer: c) Aggressive intravenous hydration with normal saline.

12. Which medication provides the most potent and sustained reduction in serum calcium but has a delayed onset of action (2-4 days)?

  • a) Furosemide
  • b) Calcitonin
  • c) Intravenous bisphosphonates (e.g., zoledronic acid)
  • d) Prednisone

Answer: c) Intravenous bisphosphonates (e.g., zoledronic acid)

13. A patient with metastatic lung cancer presents with new-onset back pain, leg weakness, and sensory loss. This is highly suspicious for which oncologic emergency?

  • a) Superior Vena Cava (SVC) syndrome
  • b) Malignant spinal cord compression
  • c) Hyperviscosity syndrome
  • d) Disseminated intravascular coagulation (DIC)

Answer: b) Malignant spinal cord compression

14. What is the immediate, first-line pharmacologic intervention for malignant spinal cord compression?

  • a) High-dose corticosteroids (e.g., dexamethasone) to reduce vasogenic edema.
  • b) Intravenous bisphosphonates.
  • c) Empiric broad-spectrum antibiotics.
  • d) Opioid analgesics for pain control alone.

Answer: a) High-dose corticosteroids (e.g., dexamethasone) to reduce vasogenic edema.

15. A patient with a large mediastinal mass presents with facial swelling, dyspnea, and distended neck veins. These are classic signs of:

  • a) Spinal cord compression
  • b) Tumor lysis syndrome
  • c) Superior Vena Cava (SVC) syndrome
  • d) Anaphylaxis

Answer: c) Superior Vena Cava (SVC) syndrome

16. The hypocalcemia seen in Tumor Lysis Syndrome is a direct result of:

  • a) Increased renal excretion of calcium.
  • b) Binding of calcium to phosphate, which is released in large amounts from lysed cells.
  • c) Decreased PTH secretion.
  • d) Poor dietary intake.

Answer: b) Binding of calcium to phosphate, which is released in large amounts from lysed cells.

17. Rasburicase is contraindicated in patients with which of the following conditions?

  • a) Gout
  • b) Hypertension
  • c) Diabetes
  • d) G6PD deficiency

Answer: d) G6PD deficiency

18. A patient is receiving an infusion of an anthracycline (e.g., doxorubicin). The nurse reports pain, swelling, and redness at the IV site, and there is no blood return. This is concerning for:

  • a) A mild infusion reaction.
  • b) Extravasation of a vesicant drug.
  • c) A local allergic reaction.
  • d) Phlebitis.

Answer: b) Extravasation of a vesicant drug.

19. Which of the following is a specific antidote for anthracycline extravasation?

  • a) Sodium thiosulfate
  • b) Hyaluronidase
  • c) Dexrazoxane (Totect®)
  • d) Phentolamine

Answer: c) Dexrazoxane (Totect®)

20. A patient with small cell lung cancer presents with hyponatremia, high urine osmolality, and euvolemia. This is characteristic of:

  • a) Diabetes insipidus
  • b) Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
  • c) Acute kidney injury
  • d) Hypercalcemia of malignancy

Answer: b) Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

21. A patient with febrile neutropenia is considered “low-risk” by their MASCC score. This patient may be a candidate for:

  • a) Inpatient treatment with IV combination antibiotics.
  • b) Outpatient management with an oral fluoroquinolone plus amoxicillin/clavulanate.
  • c) No antibiotic therapy.
  • d) Immediate hematopoietic stem cell transplant.

Answer: b) Outpatient management with an oral fluoroquinolone plus amoxicillin/clavulanate.

22. Which of the following cancers has the highest risk of causing Tumor Lysis Syndrome?

  • a) Low-grade prostate cancer
  • b) Early-stage breast cancer
  • c) High-grade lymphomas (e.g., Burkitt lymphoma) and acute leukemias
  • d) Colon cancer

Answer: c) High-grade lymphomas (e.g., Burkitt lymphoma) and acute leukemias

23. Calcitonin is useful in the acute management of severe hypercalcemia because:

  • a) It has a sustained effect lasting for several weeks.
  • b) It has a rapid onset of action (within hours) but a short duration of effect (tachyphylaxis).
  • c) It is the most potent calcium-lowering agent available.
  • d) It works by increasing bone resorption.

Answer: b) It has a rapid onset of action (within hours) but a short duration of effect (tachyphylaxis).

24. The primary treatment for the underlying cause of SVC syndrome and malignant spinal cord compression is typically:

  • a) Chemotherapy and/or radiation therapy directed at the tumor.
  • b) Long-term corticosteroid therapy.
  • c) Surgical removal of the entire tumor.
  • d) Palliative care alone.

Answer: a) Chemotherapy and/or radiation therapy directed at the tumor.

25. A patient receiving a taxane (e.g., paclitaxel) infusion develops dyspnea, hypotension, and angioedema. This is a medical emergency known as:

  • a) A delayed infusion reaction.
  • b) A hypersensitivity reaction (HSR).
  • c) Tumor lysis syndrome.
  • d) Extravasation.

Answer: b) A hypersensitivity reaction (HSR).

26. What is the role of a pharmacist in managing oncologic emergencies?

  • a) Recommending appropriate supportive care regimens (e.g., for TLS, FN).
  • b) Preparing and verifying doses of emergency medications (e.g., antibiotics, dexamethasone).
  • c) Counseling patients and providers on medication side effects and management.
  • d) All of the above.

Answer: d) All of the above.

27. For a febrile neutropenic patient who remains febrile after 4-7 days of broad-spectrum antibacterial therapy, what is the next appropriate step?

  • a) Discontinue all antibiotics.
  • b) Add empiric antifungal coverage (e.g., an echinocandin or voriconazole).
  • c) Switch to a narrower spectrum antibiotic.
  • d) Add prophylactic G-CSF.

Answer: b) Add empiric antifungal coverage (e.g., an echinocandin or voriconazole).

28. Why is it critical to use a special sample handling procedure (placing the sample on ice) when drawing blood to test for uric acid in a patient who has received rasburicase?

  • a) To prevent the blood from clotting.
  • b) Rasburicase will continue to break down uric acid in the sample tube, leading to a falsely low reading.
  • c) To keep the sample warm.
  • d) To accurately measure the potassium level.

Answer: b) Rasburicase will continue to break down uric acid in the sample tube, leading to a falsely low reading.

29. Denosumab can be used for hypercalcemia of malignancy, especially in patients refractory to bisphosphonates. It works by:

  • a) Increasing renal calcium excretion.
  • b) Inhibiting RANKL, thereby decreasing osteoclast function and bone resorption.
  • c) Binding directly to calcium in the bloodstream.
  • d) Increasing PTH levels.

Answer: b) Inhibiting RANKL, thereby decreasing osteoclast function and bone resorption.

30. The “nadir” refers to the lowest point that blood cell counts reach after chemotherapy. For most conventional chemotherapy agents, the nadir for neutrophils occurs approximately:

  • a) 1-3 days after chemotherapy.
  • b) 5-7 days after chemotherapy.
  • c) 10-14 days after chemotherapy.
  • d) 21-28 days after chemotherapy.

Answer: c) 10-14 days after chemotherapy.

31. The primary goal of managing SIADH in a cancer patient is:

  • a) Aggressive hydration with normal saline.
  • b) Fluid restriction and treating the underlying malignancy.
  • c) Administering desmopressin (DDAVP).
  • d) Prescribing high-dose diuretics.

Answer: b) Fluid restriction and treating the underlying malignancy.

32. Hyaluronidase is an antidote used for the extravasation of which class of chemotherapy agents?

  • a) Anthracyclines
  • b) Vinca alkaloids
  • c) Taxanes
  • d) Platinum agents

Answer: b) Vinca alkaloids

33. Besides malignancy, what is another common cause of Tumor Lysis Syndrome?

  • a) Aggressive treatment of certain viral infections.
  • b) Vigorous exercise.
  • c) Initiation of rituximab for non-malignant conditions, causing rapid B-cell lysis.
  • d) Dehydration.

Answer: c) Initiation of rituximab for non-malignant conditions, causing rapid B-cell lysis.

34. A patient with hypercalcemia has a corrected calcium level of 15.2 mg/dL and is confused. This is considered:

  • a) Mild hypercalcemia.
  • b) A normal calcium level.
  • c) Severe, symptomatic hypercalcemia requiring urgent treatment.
  • d) An error in the lab report.

Answer: c) Severe, symptomatic hypercalcemia requiring urgent treatment.

35. Prophylactic use of granulocyte colony-stimulating factors (G-CSFs) like filgrastim is recommended for patients receiving a chemotherapy regimen with a >20% risk of:

  • a) Nausea and vomiting
  • b) Febrile neutropenia
  • c) Alopecia
  • d) Anemia

Answer: b) Febrile neutropenia

36. A major risk factor for developing Tumor Lysis Syndrome is:

  • a) Low tumor burden.
  • b) A slow-growing, indolent tumor.
  • a) Pre-existing renal dysfunction.
  • d) Female gender.

Answer: a) Pre-existing renal dysfunction.

37. Which of the following is a key component of managing chemotherapy extravasation?

  • a) Immediately applying a pressure dressing to the site.
  • b) Continuing the chemotherapy infusion at a slower rate.
  • c) Stopping the infusion immediately, leaving the catheter in place, and attempting to aspirate any residual drug.
  • d) Applying a heating pad to the site.

Answer: c) Stopping the infusion immediately, leaving the catheter in place, and attempting to aspirate any residual drug.

38. The MASCC (Multinational Association for Supportive Care in Cancer) score is used to:

  • a) Predict the risk of CINV.
  • b) Identify patients with febrile neutropenia who are at low risk for complications.
  • c) Grade the severity of mucositis.
  • d) Assess a patient’s performance status.

Answer: b) Identify patients with febrile neutropenia who are at low risk for complications.

39. A patient being treated for hypercalcemia with zoledronic acid should be monitored for which potential adverse effect?

  • a) Hypocalcemia
  • b) Acute kidney injury
  • c) Osteonecrosis of the jaw (with long-term use)
  • d) All of the above

Answer: d) All of the above

40. Why are loop diuretics like furosemide only used in the management of hypercalcemia after the patient is euvolemic?

  • a) They are ineffective in dehydrated patients.
  • b) Using them in a volume-depleted patient can worsen dehydration and renal dysfunction.
  • c) They cause a paradoxical increase in calcium levels.
  • d) They must be given with a bisphosphonate.

Answer: b) Using them in a volume-depleted patient can worsen dehydration and renal dysfunction.

41. The definitive treatment for malignant spinal cord compression to relieve pressure on the spinal cord is:

  • a) Long-term physical therapy.
  • b) A course of oral antibiotics.
  • c) Radiation therapy and/or surgery.
  • d) Intrathecal chemotherapy.

Answer: c) Radiation therapy and/or surgery.

42. A patient at intermediate risk for TLS is starting chemotherapy. What is an appropriate prophylactic strategy?

  • a) No prophylaxis is needed.
  • b) Rasburicase one week before chemotherapy.
  • c) IV hydration and oral allopurinol.
  • d) Hemodialysis.

Answer: c) IV hydration and oral allopurinol.

43. A patient has a central venous catheter and develops febrile neutropenia. Which empiric antibiotic provides good coverage for MRSA, a common cause of catheter-related infections?

  • a) Cefepime
  • b) Piperacillin-tazobactam
  • c) Meropenem
  • d) Vancomycin

Answer: d) Vancomycin

44. What is the primary management for a non-severe hypersensitivity reaction to a chemotherapy agent?

  • a) Immediately stopping the infusion and providing supportive care (e.g., antihistamines, corticosteroids).
  • b) Continuing the infusion at a faster rate.
  • c) Administering an antibiotic.
  • d) No intervention is needed.

Answer: a) Immediately stopping the infusion and providing supportive care (e.g., antihistamines, corticosteroids).

45. Which of the following is NOT a metabolic emergency in oncology?

  • a) Tumor lysis syndrome
  • b) SIADH
  • c) Hypercalcemia of malignancy
  • d) Febrile neutropenia

Answer: d) Febrile neutropenia

46. A patient receiving high-dose cytarabine is at risk for which neurologic toxicity?

  • a) Peripheral neuropathy
  • b) Cerebellar toxicity (e.g., ataxia, nystagmus)
  • c) Ototoxicity
  • d) Optic neuritis

Answer: b) Cerebellar toxicity (e.g., ataxia, nystagmus)

47. A patient with febrile neutropenia should be counseled to:

  • a) Go to a crowded public place.
  • b) Eat raw fruits and vegetables.
  • c) Seek immediate medical attention for any signs of fever.
  • d) Take ibuprofen for their fever before calling their doctor.

Answer: c) Seek immediate medical attention for any signs of fever.

48. Why is allopurinol ineffective for treating established, high levels of uric acid in TLS?

  • a) It only prevents the formation of new uric acid; it does not break down existing uric acid.
  • b) It is not absorbed orally.
  • c) It causes a hypersensitivity reaction in all cancer patients.
  • d) It is too expensive.

Answer: a) It only prevents the formation of new uric acid; it does not break down existing uric acid.

49. An oncologic emergency caused by the infiltration of leukemic cells into the microvasculature, leading to impaired blood flow, is known as:

  • a) Leukostasis
  • b) Anemia
  • c) Thrombocytopenia
  • d) Leukocytosis

Answer: a) Leukostasis

50. The most important initial assessment for a patient presenting with suspected febrile neutropenia is:

  • a) A full body MRI.
  • b) A detailed dietary history.
  • c) A thorough physical exam to identify a potential source of infection and vital signs assessment.
  • d) A test of their visual acuity.

Answer: c) A thorough physical exam to identify a potential source of infection and vital signs assessment.

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