Small cell lung cancer
The scenario: newly diagnosed extensive-stage disease, not yet treated, with a liver filling with metastases. Why we push to treat in the hospital, and what this patient can expect that a patient in 2016 could not.
alive at 5 years, extensive stage
median survival, limited stage
median survival after relapse
What changed, in months of median survival
The trials behind each bar
| Trial | Setting | What was added | Median survival | Hazard ratio |
|---|---|---|---|---|
| IMpower133 2018 | Extensive, first line | Atezolizumab to carboplatin + etoposide | 12.3 vs 10.3 mo | 0.70 |
| CASPIAN 2019 | Extensive, first line | Durvalumab to platinum + etoposide | 13.0 vs 10.3 mo | 0.73 |
| IMforte 2025 | Extensive, maintenance | Lurbinectedin to atezolizumab | 13.2 vs 10.6 mo | 0.73 |
| DeLLphi-304 2025 | Extensive, second line | Tarlatamab instead of chemotherapy | 13.6 vs 8.3 mo | 0.60 |
| ADRIATIC 2024 | Limited, after chemoradiation | Durvalumab consolidation | 55.9 vs 33.4 mo | 0.73 |
| DeLLphi-305 Sept 2026 | Extensive, maintenance | Tarlatamab to durvalumab | Survival benefit announced by press release. Numbers not yet presented. | |
Name check: IMpower is the lung program. IMvigor is the same company's bladder program. Easy to swap at the bedside.
Adding it up: how long does extensive-stage disease live now?
No treatment
Historical series. With organ compromise or fast-moving symptoms, start in the hospital.
2016
Platinum + etoposide, then topotecan. About 2% alive at 5 years.
2026, the patient who reaches every step
Induction, maintenance, then tarlatamab at relapse. This is the best case. The first-line median alone is 12 to 13 months.
Medians from different trials cannot be added, so tell the patient "can reach", not "will live".
Tarlatamab in five lines
What it is
A bispecific antibody. One arm grabs DLL3 on the tumor cell, the other grabs CD3 on a T cell, and the T cell kills what it touches. DLL3 is on most small cell tumors and almost no normal tissue.
How it is given
1 mg on day 1, 10 mg on days 8 and 15, then 10 mg every 2 weeks. Approved for second line since November 2025. Since September 2026 the first two doses need 6 to 8 hours of monitoring, not an overnight stay.
What you will be called for
Cytokine release in just over half, almost always in cycle 1: fever, sometimes mild hypotension. Confusion or word-finding trouble in about 1 in 10. Night float needs to know the patient got it.
Who actually benefits
In a US real-world cohort, patients who were up and about (ECOG 0 to 1) lived a median of 13.4 months. Those at ECOG 2 or worse lived 3.2. Retrospective data, but the message holds: protect function during first line.
Also on the horizon: ifinatamab deruxtecan, an antibody-drug conjugate against B7-H3, shrank tumors in 48% of pretreated patients in a phase 2 study. Its FDA application was withdrawn on September 25, 2026 pending the phase 3 trial.
The last brain MRI was two months ago. Why repeat it?
1. Two months is a long time in this disease
Small cell can double in weeks. Brain metastases are present in 10 to 20% at diagnosis and in more than half of patients by two years.
2. The result changes the order of treatment
Symptomatic brain metastases: steroids and radiation first. Small and silent: systemic therapy first, then re-image.
3. Surveillance needs a day-zero image
Preventive brain radiation did not beat MRI surveillance in a randomized trial (11.6 vs 13.7 months). If you follow with MRI every 3 to 4 months, you need a baseline to compare against.
4. Every future confusion gets compared to it
SIADH, opioids, liver failure, later neurotoxic drugs. When confusion comes, the first question is whether something in the brain is new.
Applying it at the bedside
- Poor performance status from the cancer itself is a reason to treat small cell, not to hold. Response rates to platinum plus etoposide are 60 to 70%, and symptoms can improve quickly.
- High bilirubin from liver metastases. Carboplatin is cleared by the kidney and keeps its dose. Etoposide has no formal liver dose rule, but a high bilirubin raises the free, active drug. Many reduce cycle 1 and go back up as bilirubin falls. Set the number with oncology pharmacy.
- Immunotherapy can join at cycle 2. Cycle 1 in the hospital is chemotherapy. The checkpoint inhibitor is added once the patient is an outpatient.
- Growth factor after cycle 1, tumor lysis labs every day, and a goals-of-care conversation in the same admission. These run in parallel with treatment, not after it.
Check yourself: two patients on durvalumab, our usual checkpoint inhibitor. One finished chemoradiation for limited-stage disease. The other finished 4 cycles of carboplatin and etoposide for extensive-stage disease. How long does each stay on it?
Limited stage: up to 24 months, then stop (ADRIATIC). Extensive stage: until progression or intolerance, no end date (CASPIAN). Same drug and dose. What changes is the stopping rule: a fixed course when the goal is cure, open-ended when the goal is control.
Lurbinectedin maintenance (IMforte) was tested with atezolizumab, not durvalumab. The durvalumab-based option is tarlatamab (DeLLphi-305), positive by press release and not yet approved.
Sources
Sources. Trial data retrieved from PubMed unless marked.
- Horn L, et al. IMpower133. N Engl J Med 2018. PMID 30280641
- Paz-Ares L, et al. CASPIAN. Lancet 2019. PMID 31590988
- Cheng Y, et al. ADRIATIC. N Engl J Med 2024. PMID 39268857
- Paz-Ares L, et al. IMforte. Lancet 2025. PMID 40473449
- Mountzios G, et al. DeLLphi-304. N Engl J Med 2025. PMID 40454646
- Petrelli F, et al. A decade of progress in small-cell lung cancer. Eur J Clin Pharmacol 2026. doi:10.1007/s00228-026-04119-2
- Barsouk AA, et al. Real-world tarlatamab outcomes by performance status. Clin Lung Cancer 2026. doi:10.1016/j.cllc.2026.07.001
- Mountzios G, et al. Patient-reported outcomes in DeLLphi-304. Lung Cancer 2026. doi:10.1016/j.lungcan.2026.109581
- Zambrano Iglesias MI, et al. Decoding small cell lung cancer. Cancers 2026. doi:10.3390/cancers18132173
- Takahashi T, et al. Prophylactic cranial irradiation vs observation. Lancet Oncol 2017. PMID 28343976
- Tarlatamab (Imdelltra) prescribing information, DailyMed (web). Label
- Etoposide prescribing information, DailyMed (web). Label
- AstraZeneca press release, DeLLphi-305, September 8, 2026 (web). Link
- CancerNetwork, ifinatamab deruxtecan application withdrawn, October 1, 2026 (web). Link
Pancreatic adenocarcinoma
Two common scenarios: a tumor labeled locally advanced on neoadjuvant chemotherapy, and a new head mass with liver lesions and no biopsy yet. What makes a tumor unresectable, what second line looks like after June 2026, and why every patient gets a germline test.
What changed in metastatic disease, in months of median survival
What is new in second line: RASolute 302
The drug
More than 90% of pancreatic cancers are driven by a mutant KRAS. Daraxonrasib is a once-daily pill that blocks RAS in its active state, across mutation types (G12D, G12V, G12R and others), which is why it is not limited to the rare G12C.
The trial
500 patients after one prior line, daraxonrasib vs chemotherapy of the physician's choice. Survival 13.2 vs 6.7 months (hazard ratio 0.40). Progression-free survival 7.2 vs 3.6 months. Stopped for side effects: 1.2% vs 11.2%. ASCO 2026 plenary, NEJM, FDA approved August 26, 2026.
What to watch for on the wards
Rash in most patients, mouth sores and diarrhea in more than half. Skin prevention starts on day 1: steroid cream, moisturizer, sunscreen. It is a pill, so a patient with an outlet obstruction or a tube on suction is not absorbing it.
What is still open
First-line and adjuvant trials are enrolling (RASolute 303 and 304). First line is still chemotherapy for patients who can take a combination. The approval also covers patients who cannot.
Resectable or not: it is about the vessels
The radiologist reports how much of each vessel's circumference the tumor touches. Half the circle is the line. Veins can be resected and rebuilt. The celiac axis and the superior mesenteric artery generally cannot.
Three questions, in order
- Anatomy. Which vessels, how many degrees, can the vein be reconstructed?
- Biology. CA 19-9 above about 500 or bulky regional nodes raise the risk of hidden spread. They do not prove it. Nodes outside the surgical field count as metastatic.
- Condition. Can this patient survive a Whipple and then chemotherapy?
Before you repeat a label from an outside chart, find the scan report and the tissue result that support it.
| Category | Arteries (celiac, superior mesenteric, hepatic) | Veins (portal, superior mesenteric) | Usual first step |
|---|---|---|---|
| Resectable | No contact | No contact, or 180° or less with a smooth contour | Surgery, or chemotherapy first |
| Borderline | Superior mesenteric or celiac contact of 180° or less. Hepatic artery contact that can be reconstructed. | More than 180°, or irregular or thrombosed, but reconstructible | Chemotherapy first, then re-stage |
| Locally advanced | Superior mesenteric or celiac encased more than 180°. Aortic involvement. | Occluded or involved with no way to reconstruct | Chemotherapy. Surgery only in selected responders. |
| Metastatic | Liver, peritoneum, lung, or nodes beyond the surgical field. Vessels no longer matter. | Systemic therapy | |
Summary of the NCCN and international consensus definitions. The exact wording differs slightly between head and body or tail tumors.
Germline testing: for every patient, at diagnosis
Guidelines have recommended germline testing for all patients with pancreatic adenocarcinoma since 2019, with no filter for age or family history. Half of the carriers have no family history that would have flagged them.
It picks the chemotherapy
BRCA1, BRCA2 and PALB2 tumors cannot repair platinum damage. These patients should get a platinum first line (FOLFIRINOX, or gemcitabine + cisplatin), not gemcitabine + nab-paclitaxel.
It opens maintenance
A germline BRCA mutation is the entry ticket for olaparib maintenance. See POLO below.
It protects the family
Each first-degree relative has a 50% chance of carrying it. That means breast MRI, risk-reducing surgery, prostate and pancreas surveillance for people who are still healthy. The patient may not live long enough for a second chance to send the test.
Send tumor sequencing too. It finds the KRAS mutation, the 1% with mismatch-repair deficiency who respond to immunotherapy, and the rare KRAS wild-type tumor carrying a targetable fusion such as NRG1 or NTRK.
POLO: when and how I use a PARP inhibitor
The trial
3,315 patients screened, 7.5% had a germline BRCA mutation. Those whose metastatic disease had not progressed after at least 16 weeks of first-line platinum were randomized to olaparib 300 mg twice daily or placebo.
Progression-free survival 7.4 vs 3.8 months (hazard ratio 0.53). Overall survival was not different: 19.0 vs 19.2 months. At 3 years, 34% vs 18% were alive.
All four boxes must be ticked
- Germline BRCA1 or BRCA2 mutation
- Metastatic disease
- At least 16 weeks of platinum chemotherapy
- No progression on that platinum
Then olaparib replaces chemotherapy as maintenance. What the patient gains is time off FOLFIRINOX with disease control, not a proven longer life. If the tumor grew through platinum, a PARP inhibitor will not work either: the resistance mechanisms overlap.
Name check: POLO is the pancreas trial. The SOLO trials tested the same drug in ovarian cancer. Rucaparib has phase 2 data that extend the same idea to PALB2 and to somatic BRCA mutations.
The trials behind each bar
| Trial | Line | Comparison | Median survival | Hazard ratio |
|---|---|---|---|---|
| PRODIGE 4 2011 | First | FOLFIRINOX vs gemcitabine | 11.1 vs 6.8 mo | 0.57 |
| MPACT 2013 | First | Gemcitabine + nab-paclitaxel vs gemcitabine | 8.5 vs 6.7 mo | 0.72 |
| NAPOLI-3 2023 | First | NALIRIFOX vs gemcitabine + nab-paclitaxel | 11.1 vs 9.2 mo | 0.83 |
| NAPOLI-1 2016 | Second | Liposomal irinotecan + 5-FU vs 5-FU | 6.1 vs 4.2 mo | 0.67 |
| RASolute 302 2026 | Second | Daraxonrasib vs chemotherapy | 13.2 vs 6.7 mo | 0.40 |
| POLO 2019 | Maintenance | Olaparib vs placebo, germline BRCA | 19.0 vs 19.2 mo | 0.83, not significant |
Check yourself: the outside chart says "locally advanced pancreatic adenocarcinoma on neoadjuvant chemotherapy." The only pathology you can find reads "suspicious for adenocarcinoma" and the liver lesions grew bacteria. Name three things you cannot yet state as fact.
That the diagnosis is tissue-proven. That the stage is locally advanced and not metastatic (the liver lesions are abscesses on one biopsy, which does not clear the others). That the treatment intent is curative. Each of these changes what you tell the patient and what the next oncologist does.
Sources
Sources. Trial data retrieved from PubMed unless marked.
- O'Reilly EM, Wolpin BM, et al. Daraxonrasib or chemotherapy in previously treated metastatic pancreatic cancer (RASolute 302). N Engl J Med 2026. doi:10.1056/NEJMoa2605555
- Golan T, et al. POLO. N Engl J Med 2019. doi:10.1056/NEJMoa1903387
- Kindler HL, et al. POLO overall survival. J Clin Oncol 2022. doi:10.1200/JCO.21.01604
- Conroy T, et al. FOLFIRINOX vs gemcitabine. N Engl J Med 2011. PMID 21561347
- Von Hoff DD, et al. MPACT. N Engl J Med 2013. doi:10.1056/NEJMoa1304369
- Wainberg ZA, et al. NAPOLI-3. Lancet 2023. doi:10.1016/S0140-6736(23)01366-1
- Wang-Gillam A, et al. NAPOLI-1. Lancet 2016. PMID 26615328
- Daraxonrasib (Rasonque) approval summary with indication and safety, August 2026 (web). Link
- Dana-Farber Cancer Institute, FDA approval of daraxonrasib, 2026 (web). Link
- The ASCO Post, RASolute 302 plenary report, June 10, 2026 (web). Link
Tumor lysis and rasburicase
The question from rounds: is rasburicase given before tumor lysis happens, and at what dose? This tab follows the 2025 New England Journal of Medicine review, plus a 2026 BMJ study on outcomes.
What a dying tumor cell releases
Potassium up
Kills first. Arrhythmia. Urgent above 6.5 or with ECG changes.
Phosphate up
Or up 25%. Now the main cause of kidney injury.
Uric acid up
Or up 25%. The one we can treat best.
Calcium down
Corrected for albumin. Tetany, seizures, long QT.
Tumor lysis syndrome needs two laboratory criteria plus one clinical criterion in the same 24 hours, from 3 days before to 7 days after treatment. Clinical criteria: kidney injury (creatinine 1.5 times the upper limit, a rise of 0.3 mg/dL, or urine under 0.5 mL/kg per hour for 6 hours), arrhythmia or sudden death, seizure.
Who is most at risk
The classic list
- Acute myeloid or lymphoblastic leukemia on intensive induction
- Burkitt lymphoma
- Advanced aggressive lymphoma
- CLL with bulky nodes or high counts starting venetoclax
Clues in any patient
- High uric acid, high white count, high LDH, older age
- Kidney function already reduced
- Any patient sick enough to start treatment in the hospital deserves a baseline set of labs
Tumor lysis has been reported in tumors called low risk. Steroids alone can trigger it in lymphoma.
Before the first dose
Labs and drugs
Uric acid, potassium, phosphate, creatinine, LDH. Stop what hurts the kidney: anti-inflammatories, ACE inhibitors and ARBs, contrast if avoidable.
Fluids
Start 24 to 48 hours before treatment. 1 to 3 liters per m² a day, usually normal saline, aiming for urine of 2 mL/kg per hour. Fluid overload is linked to ICU transfers and deaths, so measure output and adjust.
Allopurinol
The preferred first drug. It blocks new uric acid production. Reduce the dose in kidney disease. Febuxostat only for allopurinol allergy.
Then check labs every 6 to 12 hours for the first 24 to 72 hours. No bicarbonate: alkaline urine precipitates calcium phosphate.
Rasburicase: when, and how much
When to give it before treatment
A highly proliferative tumor (AML with white count over 50 thousand, ALL over 100 thousand, Burkitt, high-grade B or T-cell lymphoma) plus uric acid above 8 and creatinine above 1.5 times baseline or normal.
Also consider it when large fluid volumes are a problem: heart failure or chronic kidney disease.
When to give it later
As soon as uric acid passes 8 with one more abnormal value, or when it rises despite allopurinol. Do not wait for the creatinine.
In 1,276 adults with tumor lysis at 36 US hospitals, rasburicase within 12 hours was linked to less dialysis or death: 33% vs 42%, one event avoided for every 11 treated. Observational, but the best outcome data we have.
0.2 mg/kg or 3 mg?
The label says 0.2 mg/kg daily for up to 5 days. Prospective data show a single dose of 1.5 to 7.5 mg controls uric acid within 24 to 36 hours in most patients. 3 mg once is often enough for prophylaxis, with more doses only if needed. For established tumor lysis, US hospitals use 3 or 6 mg.
How much drug is the difference?
Three traps
G6PD deficiency
Rasburicase makes hydrogen peroxide. In G6PD deficiency that means hemolysis and methemoglobinemia. Contraindicated if known. Screen first in patients of Mediterranean or African ancestry.
The tube goes on ice
The enzyme keeps working in the tube and the lab reports a falsely low uric acid. Pre-cooled heparin tube, ice water, run within 4 hours.
Potassium that is not real
With a white count over 100 thousand, cells burst in the tube. A high potassium with normal phosphate and uric acid may be false. Get an ECG and repeat with a careful draw.
Two examples
Small cell lung cancer, liver full of tumor
LDH nearly three times normal says this tumor will lyse. Uric acid and creatinine are normal, so the main criterion is not met. But SIADH with a low sodium means the patient cannot take liters of saline. High risk plus no way to hydrate: that is the case for 3 mg before treatment. Then labs every 6 to 12 hours.
Relapsed T-cell lymphoma with chronic kidney disease
Uric acid low on allopurinol, so the main criterion is not met. The kidney limits how much fluid is safe, and that is the situation where rasburicase before treatment is a consideration.
Check yourself: Burkitt lymphoma, uric acid 4.1, creatinine 0.8, chemotherapy starts tomorrow. The night resident says "uric acid is normal, allopurinol is enough." Agree?
By this review, yes, with conditions. Uric acid is under 8, creatinine is normal, and the patient can take fluids, so prophylactic rasburicase is not required. The plan is allopurinol, fluids already running, labs every 6 to 12 hours, and 3 mg of rasburicase ordered as rescue the moment uric acid climbs. Some guidelines would give a dose up front to every Burkitt patient. Know that both approaches exist.
Sources
Both read in full.
- Bociek RG, Lunning M. Tumor Lysis Syndrome. N Engl J Med 2025;393:1104-16. doi:10.1056/NEJMra2300923
- Shenoy T, et al. Early treatment with rasburicase and risk of kidney replacement therapy and death in adults with tumour lysis syndrome: emulated target trial. BMJ 2026;394:e100040. doi:10.1136/bmj-2026-100040
Ifosfamide: inpatient or outpatient?
Ifosfamide with an anthracycline (doxorubicin in the AIM regimen, epirubicin in the Italian neoadjuvant regimen). It used to mean an admission every cycle. Today it depends on the patient and on what the team can monitor outside the hospital.
Then: always admitted. Now: it depends.
Admit
- First cycle, to see how the patient handles it
- Low albumin, reduced kidney function or prior cisplatin (higher risk of encephalopathy)
- A heart that cannot take 3 liters of fluid a day
- Earlier confusion or blood in the urine on ifosfamide
- No caregiver at home, or far from the hospital
- No outpatient program built for it
Outpatient can work
- A prior cycle went well
- Up and about (ECOG 0 to 1), with a central line
- Normal kidney function and albumin
- Can drink 2 to 3 liters a day, with someone at home
- A structured program: portable pump with mesna, a daily visit for labs, urine dipstick and a neuro check, and a number to call at night
At Moffitt, 58 adults received doxorubicin + ifosfamide or ifosfamide + etoposide either way. Outpatient care saved 16 hospital days per patient, with the same readmission rate (18% vs 19%) and no hemorrhagic cystitis. Fred Hutchinson moves patients outpatient after one inpatient cycle without problems.
One drug in, three products out
Cross-links DNA strands at guanine. The cell cannot copy its DNA and dies. Ifosfamide itself is inactive until liver enzymes (CYP3A4) switch it on.
Filtered into urine, where it ulcerates the bladder lining: hemorrhagic cystitis. Mesna neutralizes it.
Causes encephalopathy in 10 to 30% and damages the proximal tubule. Ifosfamide makes far more of it than cyclophosphamide does. Mesna does nothing here.
The anthracycline works differently: it wedges into DNA and jams topoisomerase II. Its price is the heart, and that price is counted over a lifetime. See the next block.
Doxorubicin has a lifetime budget
Heart damage from doxorubicin depends on the total dose a person has ever received, from any regimen, in any year. Every cycle spends from the same account and nothing refills it. The usual ceiling is 450 to 550 mg/m², and lower in a heart that is already at risk.
Totals in mg/m². AIM gives 75 per cycle, so six cycles reach 450. Risk figures are from the doxorubicin label, which gives 6 to 20% at 500 mg/m². Orange marks the cycles past 300, where the label asks for closer monitoring.
Before you order the next cycle
- Add it up. Every anthracycline the patient ever had, in mg/m². CHOP x6 is 300. AC x4 is 240. Ask about childhood cancer. Write the total in the note.
- Find the last echo. High-risk heart (ejection fraction under 55%, heart disease, chest radiation): echo every two cycles. Everyone else: echo once the total passes 250.
- At 300 with more cycles planned, ask about dexrazoxane.
- Hold and call cardiology if the ejection fraction falls 10 points to below 50%, or the patient is newly short of breath or swollen.
Running total
Epirubicin is counted at 0.8 of doxorubicin. Older tables use 0.5 to 0.67. Use the factor your pharmacy uses.
What a cycle looks like
AIM as commonly written: doxorubicin 75 mg/m² and ifosfamide 10 g/m² per cycle, every 21 days. The epirubicin version gives epirubicin 60 mg/m² on days 1 and 2 and ifosfamide 3 g/m² on days 1 to 3. Always follow the signed treatment plan, not this strip.
What has to be watched, wherever it is given
- It runs for days. Three to four days of infusion with liters of fluid and a second drug (mesna) that must never be interrupted.
- The bladder. Urine is checked for blood before each dose. More than a trace of blood means hold and call.
- The brain. Sleepiness, confusion, hallucinations or a flapping tremor usually appear in the first 48 hours, sometimes later. It can be severe. When it reverses, it does so 1 to 3 days after ifosfamide is stopped.
- The kidney. The tubule starts leaking bicarbonate, phosphate, potassium and glucose. Daily chemistry catches it.
- The fluid. Three liters a day on top of an anthracycline, sometimes in a heart that is already borderline. Daily weight and strict intake and output.
Add febrile neutropenia in nearly half of patients in the trial that tested this combination, even with growth factor.
Mesna, properly understood
How it works
In blood it is inactive. The kidney reactivates it, so its sulfur group is free only in urine, where it binds acrolein. It protects the bladder without protecting the tumor.
Why it outlasts the ifosfamide
Mesna is cleared within an hour or two. Ifosfamide and acrolein keep arriving for many hours more. So mesna is given as 20% of the ifosfamide dose at 0, 4 and 8 hours, or as a continuous infusion that runs 12 to 24 hours past the last drop of ifosfamide.
Two dipstick tricks
Mesna gives a false positive for ketones. And anthracycline turns urine red-orange for a day or two: the dipstick is negative for blood. That settles the color, not the patient.
If the patient becomes confused
Stop the ifosfamide. Keep the mesna and fluids running. Check sodium, creatinine, bicarbonate, albumin. Stop sedatives. Methylene blue 50 mg IV is used by many centers on weak evidence. Avoid it in G6PD deficiency and with serotonergic antidepressants.
Who gets encephalopathy: low albumin, reduced kidney function, prior cisplatin, bulky pelvic disease, and patients on other drugs that act on the brain. Look at the albumin before every cycle.
Urine pH: three drugs, three different answers
| Situation | Alkalinize? | Why |
|---|---|---|
| High-dose methotrexate | Yes, pH 7 or higher | Methotrexate crystallizes in acid urine. Mandatory before and during. |
| Tumor lysis | No | Alkaline urine precipitates calcium phosphate. Rasburicase made it unnecessary. |
| Ifosfamide | Not for the bladder | Mesna and urine flow protect the bladder, not pH. Watch serum bicarbonate instead: the damaged tubule wastes it, and a falling bicarbonate with glucose in the urine and a normal blood sugar is the tubule telling you it is injured. Some protocols add bicarbonate to the fluids to correct that acidosis. Check the order set. |
What the intern checks each day
Urine
Dipstick for blood before each dose. Output at least 100 mL an hour.
Mind
Orientation and a written sentence each shift. Ask the family if they seem different.
Chemistry
Sodium, potassium, bicarbonate, creatinine, phosphate, magnesium.
Volume
Weight, intake and output, lungs, legs. Hold home drugs that shift volume or glucose in urine.
Check yourself: day 3 of AIM. The nurse reports red urine and the patient is a little sleepy. What do you do in the next ten minutes?
Two separate questions, and the brain comes first. Brain: sleepiness on day 3 is ifosfamide encephalopathy until proven otherwise. Pause the ifosfamide, keep mesna and fluids running, check orientation and a written sentence, get a fingerstick glucose and chemistry, hold sedatives, call the attending. Bladder: dip the urine. Negative for blood is doxorubicin color. Positive means hold ifosfamide and call. A clean dipstick today does not close the question: cystitis can still appear later in the cycle. And a harmless answer to one question does not answer the other.
Sources
Sources. Trials retrieved from PubMed. Drug facts from FDA labeling and guideline monographs (web).
- Judson I, et al. Doxorubicin alone vs intensified doxorubicin + ifosfamide (EORTC 62012). Lancet Oncol 2014. PMID 24618336
- Gronchi A, et al. Epirubicin + ifosfamide vs histotype-tailored neoadjuvant chemotherapy. Lancet Oncol 2017. PMID 28499583
- Kim H, et al. Cancer therapy-related cardiac dysfunction and cardiovascular imaging, summarizing the 2022 European Society of Cardiology definitions and monitoring. J Cardiovasc Imaging 2024 (web). Article
- Feijen EAM, et al. Anthracycline equivalence ratios to doxorubicin for late-onset cardiotoxicity. JAMA Oncol 2019. doi:10.1001/jamaoncol.2018.6634
- Variability in anthracycline dose conversions and cardiotoxicity monitoring. Support Care Cancer 2026. doi:10.1007/s00520-026-10774-z
- Doxorubicin prescribing information, cardiomyopathy warning. Label text
- Seo M, et al. Feasibility and safety of ifosfamide-based regimens for sarcomas in the outpatient setting. JCO Oncol Pract 2026. doi:10.1200/OP-25-01196
- Cheng KK, et al. Safety evaluation of outpatient ifosfamide regimens in adult sarcoma patients. J Oncol Pharm Pract 2025. doi:10.1177/10781552251399903
- Ifosfamide prescribing information, boxed warnings. Label text
- Mesna prescribing information, dosing schedule. Label text
- eviQ (Cancer Institute NSW). Ifosfamide-induced encephalopathy. Guideline
- Cancer Care Ontario. Ifosfamide drug monograph. Monograph