Bleeding complications in patients with squamous cell carcinoma of the head and neck

Emergency Management and Nursing Considerations of Carotid Blowout Syndrome

INTRODUCTION

Carotid blowout syndrome is a rare but fatal complication often witnessed secondary to treating patients with head and neck cancer. It occurs when damage and necrosis lead to the carotid artery wall rupture. The symptoms encountered in these patients range from asymptomatic to cardiac arrest. Here, we present 5 cases of carotid blowout syndrome in the emergency department.

CASE PRESENTATIONS

Patients demonstrated symptoms ranging from subtle bleeding to hemodynamic instability, highlighting the diverse nature of carotid blowout syndrome in this population. Notably, while all patients had a history of radiotherapy, some had additional risk factors for carotid blowout syndrome, including prior surgery (n = 2), malnutrition (n = 3), and tracheostomies (n = 2). Definitive diagnoses were established through clinical evaluation and computed tomography angiography. Immediate interventions included bleeding control, resuscitation, and consultations with relevant specialties. Four patients underwent interventional radiology procedures, and 1 patient received otolaryngology care. While 2 patients recovered completely, 1 died in the emergency department, and 1 in the intensive care unit. One patient's clinical course was complicated by a stroke.

CONCLUSION

The approach to the carotid blowout syndrome patient includes complex steps that proceed in a multidisciplinary manner, starting from triage until discharge. Emergency nurses play crucial roles at every stage. They should be aware of carotid blowout syndrome when evaluating patients with head and neck cancer presenting with bleeding. When treating these patients, emergency nurses should be ready for airway interventions, bleeding control, and massive transfusion protocol. In this context, the multifaceted approaches made by nurses contribute significantly to carotid blowout syndrome management in the emergency department.

The impact of trans-arterial embolization on the result of chemoradiotherapy in oral cavity cancer

Objectives: Evaluation of the hemostatic effect of trans-arterial embolization on patients with advanced oral cavity cancer who had bleeding complications while undergoing definitive concurrent chemoradiotherapy (CCRT). Additionally, assess the effect of trans-arterial embolization on treatment response following concurrent chemoradiotherapy, as well as overall survival (OS) and progression-free survival (PFS) in the group of patients following the intervention. Method: From September 2018-June 2021, a retrospective descriptive study was conducted on 16 patients with inoperable, locally advanced oral cavity cancer who received definitive concurrent chemoradiotherapy, experienced acute bleeding complications, and received selective intravascular intervention with various embolization materials at Vietnam National Cancer Hospital. Results: After selective embolization, 16/16 patients ceased bleeding; 1 patient re-bled for the second time after 3 weeks. The average duration of chemoradiotherapy interruption due to intervention was 6.7 days. After CCRT, 15/16 (93.75%) patients achieved a response, with 9/16 (56.25%) patients achieving a complete response. The median OS was 14 months (range, 3-26 months), and the median PFS was 10 months (range, 3-20 months). There were no significant complications, particularly neurological side effects. ConclusionsTumor bleeding is a common and serious complication of CCRT treatment in patients with locally advanced oral cavity cancer. Embolization is a safe and effective method of controlling acute bleeding that has no adverse effect on the outcome of definitive concurrent chemoradiotherapy.

Reduction of Blood Loss by Means of the Cavitron Ultrasonic Surgical Aspirator for Thoracoscopic Salvage Anatomic Lung Resections

In centrally located lung tumors, salvage pulmonary resections pose challenges due to adhesions between the pulmonary parenchyma, chest wall, and hilum. This study aimed to investigate the surgical outcomes associated with Cavitron Ultrasonic Surgical Aspirator (CUSA) usage in thoracoscopic salvage pulmonary resections. Patients with centrally located advanced-stage lung tumors who underwent salvage anatomic resections following systemic or radiotherapy were included. They were categorized into CUSA and non-CUSA groups, and perioperative parameters and surgical outcomes were analyzed. Results: The study included 7 patients in the CUSA group and 15 in the non-CUSA group. Despite a longer median surgical time in the CUSA group (3.8 h vs. 6.0 h, p = 0.021), there was a significant reduction in blood loss (100 mL vs. 250 mL, p = 0.014). Multivariate analyses revealed that the use of CUSA and radiotherapy had opposing effects on blood loss (β: -296.7, 95% CI: -24.8 to -568.6, p = 0.034 and β: 282.9, 95% CI: 19.7 to 546.3, p = 0.037, respectively). In conclusion, while using CUSA in the salvage anatomic resection of centrally located lung cancer may result in a longer surgical time, it is crucial in minimizing blood loss during the procedure.

The coagulome of oral squamous cell carcinoma: examining the role and regulation of coagulation in oral cancers using a systems approach

PURPOSE OF REVIEW

Solid tumors often establish a locally hypercoagulant state that promotes vascular complications, such as venous thromboembolism (VTE). Oral squamous cell carcinoma (OSCC) is associated with a broad range of hemostatic complications. Although VTE rarely occurs in ambulatory patients with OSCC, the coagulation cascade is typically activated by surgical resection and local hemorrhage. We present the recent progress in the understanding of the role and regulation of coagulation in OSCC.

RECENT FINDINGS

Application of systems biology, using bulk tumor and single cell genomic analyses, unveiled the landscape of the tumor coagulome. Of all tumor types, OSCC express the highest mRNA levels of F3 and PLAU, the genes that encode the tissue factor (TF) and urokinase-type plasminogen activator (uPA), the key regulators of coagulation and fibrinolysis, respectively. It also brought to light the intimate and reciprocal regulation between coagulation/fibrinolysis and the tumor microenvironment (TME).

SUMMARY

OSCC have a specific coagulome, with consequences that likely extend beyond the vascular risk. We discuss the attractive possibility that biomarkers of the coagulation cascade might reflect some important characteristics of the TME, offering new opportunities to better understand the impact of surgical procedures, better predict their oncological outcome and improve current therapeutic approaches.

Risk factors for rebleeding and long-term outcomes in patients with head and neck cancer bleeding: a multicenter study

Background

Acute, catastrophic bleeding in patients with head and neck cancer (HNC) is challenging and also a burden for their families and frontline physicians. This study analyzed the risk factors for rebleeding and long-term outcomes in these patients with HNC.

Methods

Patients who presented to the emergency department (ED) with HNC bleeding were enrolled in this study (N = 231). Variables of patients with or without rebleeding were compared, and associated factors were investigated using Cox’s proportional hazard model.

Results

Of the 231 patients enrolled, 112 (48.5%) experienced a recurrent bleeding event. The cumulative rebleeding incidence rate was 23% at 30 days, 49% at 180 days, and 56% at 1 year. Multivariate Cox regression analyses demonstrated that overweight-to-obesity (HR = 0.52, 95% CI 0.28–0.98, p = 0.043), laryngeal cancer (hazard ratio [HR] = 2.13, 95% confidence interval [CI] 1.07–4.23, p = 0.031), chemoradiation (HR = 1.49, 95% CI 1.001–2.94, p = 0.049), and second primary cancer (HR = 1.75, 95% CI 1.13–2.70, p = 0.012) are significant independent predictors of rebleeding, and the prognostic factors for overall survival included underweight (HR = 1.89, 95% CI 1.22–2.93, p = 0.004), heart rate > 110 beats/min (HR = 1.58, 95% CI 1.04–2.39, p = 0.032), chemoradiation (HR = 2.31, 95% CI 1.18–4.52, p = 0.015), and local recurrence (HR = 1.74, 95% CI 1.14–2.67, p = 0.011).

Conclusions

Overweight-to-obesity is a protective factor, while laryngeal cancer, chemoradiation and a second primary cancer are risk factors for rebleeding in patients with HNC. Our results may assist physicians in risk stratification of patients with HNC bleeding.

Palliation of head and neck cancer: a review of the unique difficulties

Each year, there are 11 900 new diagnoses of head and neck cancers in the UK, with around 4000 deaths. Survival rates are higher for those diagnosed earlier, however, patients are often diagnosed later, with 20% palliative at the time of diagnosis. There is a scarcity of head and neck cancer palliative care literature available. This review article aims to discuss the unique challenges of head and neck cancer palliation. It specifically focusses on the challenges of pain management, airway obstruction, dysphagia, haemorrhage and the psychology of palliative head and neck cancer management. This article explores the advantages and disadvantages of many of the different treatment options available. It is hoped that this article will highlight the unique difficulties encountered by patients with head and neck cancer towards the end of their life and offer insights and suggestions to improve patients' quality of life in their final weeks and months.

In-Hospital and Long-Term Outcomes in Patients with Head and Neck Cancer Bleeding

Background and Objectives: The purpose of the present study was to elucidate the in-hospital and long-term outcomes of patients with head and neck cancer (HNC) bleeding and to analyze the risk factors for mortality. Materials and Methods: We included patients who presented to the emergency department (ED) with HNC bleeding. Variables of patients who survived and died were compared and associated factors were investigated by logistic regression and Cox’s proportional hazard model. Results: A total of 125 patients were enrolled in the present study. Fifty-nine (52.8%) patients experienced a recurrent bleeding event. The in-hospital mortality rate was 16%. The overall survival at 1, 3 and 5 years was 48%, 41% and 34%, respectively. The median survival time was 9.2 months. Multivariate logistic regression analyses revealed that risk factors for in-hospital mortality were inotropic support (OR = 10.41; Cl 1.81–59.84; p = 0.009), hypopharyngeal cancer (OR = 4.32; Cl 1.29–14.46; p = 0.018), and M stage (OR = 5.90; Cl 1.07–32.70; p = 0.042). Multivariate Cox regression analyses indicate that heart rate >110 (beats/min) (HR = 2.02; Cl 1.16–3.51; p = 0.013), inotropic support (HR = 3.25; Cl 1.20–8.82; p = 0.021), and hypopharygneal cancer (HR = 2.22; Cl 1.21–4.06; p = 0.010) were all significant independent predictors of poorer overall survival. Conclusions: HNC bleeding commonly represents the advanced disease stage. Recognition of associated factors aids in the risk stratification of patients with HNC bleeding.

Molecular Landscape of the Coagulome of Oral Squamous Cell Carcinoma

BACKGROUND

Hemostatic complications, ranging from thromboembolism to bleeding, are a significant source of morbidity and mortality in cancer patients. The tumor coagulome represents the multiple genes and proteins that locally contribute to the equilibrium between coagulation and fibrinolysis. We aimed to study the coagulome of Oral Squamous Cell Carcinoma (OSCC) and examine its link to the tumor microenvironment (TME).

METHODS

We used data from bulk tumor DNA/RNA-seq (The Cancer Genome Atlas), single-cell RNA-seq data and OSCC cells in culture.

RESULTS

Among all tumor types, OSCC was identified as the tumor with the highest mRNA expression levels of F3 (Tissue Factor, TF) and PLAU (urokinase type-plasminogen activator, uPA). Great inter- and intra-tumor heterogeneity were observed. Single-cell analyses showed the coexistence of subpopulations of pro-coagulant and pro-fibrinolytic cancer cells within individual tumors. Interestingly, OSCC with high F3 expressed higher levels of the key immune checkpoint molecules CD274/PD-L1, PDCD1LG2/PD-L2 and CD80, especially in tumor dendritic cells. In vitro studies confirmed the particularity of the OSCC coagulome and suggested that thrombin exerts indirect effects on OSCC cells.

CONCLUSIONS

OSCC presents a specific coagulome. Further studies examining a possible negative modulation of the tumor's adaptive immune response by the coagulation process are warranted.