Cancer therapy complications and supportive care: Viva

This is a boy on a high emetogenic induction regimen presenting three overlapping toxicities: the breakthrough chemotherapy-induced nausea and vomiting, the severe oral mucositis, and the febrile neutropenia. The structured oral runs from the antiemetic management through the mucositis, the fever and the neutropenia, and it ends with the dexrazoxane cardioprotection that protects the heart across the anthracycline exposure and into the survivorship. [1][9]

Opening: recognise the three toxicities

Examiner. The boy has vomited three times despite the ondansetron, his mouth is ulcerated and he cannot eat, and he has a fever of 38.7 with a neutrophil count of 120. What are the three problems, and why did the vomiting break through? [1]

Candidate. The three problems are the breakthrough chemotherapy-induced nausea and vomiting, the severe oral mucositis of the WHO grade 3 or 4, and the febrile neutropenia. The vomiting broke through because the cyclophosphamide above one gram per square metre is a high emetogenic agent, and the ondansetron alone is underpowered for the risk. The Dupuis guideline of the Pediatric Oncology Group of Ontario sets the standard that the high emetogenic regimen receives the three-drug combination of the 5-HT3 antagonist plus the dexamethasone plus the NK1 antagonist aprepitant, and the single agent fails. [1]