A review in the treatment of oncologic emergencies

LncRNA ZFAS1 regulates ATIC transcription and promotes the proliferation and migration of hepatocellular carcinoma through the PI3K/AKT signaling pathway

PURPOSE

Long noncoding RNAs (lncRNAs) exert a significant influence on various cancer-related processes through their intricate interactions with RNAs. Among these, lncRNA ZFAS1 has been implicated in oncogenic roles in multiple cancer types. Nevertheless, the intricate biological significance and underlying mechanism of ZFAS1 in the initiation and progression of hepatocellular carcinoma (HCC) remain largely unexplored.

METHODS

Analysis of The Cancer Genome Atlas Program (TCGA) database revealed a notable upregulation of lncRNA ZFAS1 in HCC tissues. To explore its function, we investigated colony formation and performed CCK-8 assays to gauge cellular proliferation and wound healing, Transwell assays to assess cellular migration, and an in vivo study employing a nude mouse model to scrutinize tumor growth and metastasis. Luciferase reporter assay was used to confirm the implicated interactions. Rescue experiments were conducted to unravel the plausible mechanism underlying the activation of the PI3K/AKT pathway by lncRNAs ZFAS1 and ATIC.

RESULTS

ZFAS1 and ATIC were significantly upregulated in the HCC tissues and cells. ZFAS1 knockdown inhibited cell proliferation and migration. We observed a direct interaction between the lncRNA ZFAS1 and ATIC. ATIC knockdown also suppressed cell proliferation and migration. SC79, an activator of AKT, partially restores the effects of lncRNA ZFAS1/ATIC knockdown on cell proliferation and migration. Knockdown of lncRNA ZFAS1/ATIC inhibited tumor growth and lung metastasis in vivo.

CONCLUSION

Overall, lncRNA ZFAS1 regulates ATIC transcription and contributes to the growth and migration of HCC cells through the PI3K/AKT signaling pathway.

Prognostic Importance of Lactate and Blood Gas Parameters in Predicting Mortality in Patients with Critical Malignancies

Background

The aim of the present study was to detect the prognostic importance of lactate and other blood gas parameters for mortality prediction in patients with critical malignancies referring to the emergency service. The general condition of patients with malignancy who have referred to the emergency department should be evaluated and it should be shown that they are not in any oncological emergency. It is a highly significant predictor of mortality after sepsis and shock in hyperlactatemia accompanying metabolic acidosis. It is significantly used for treatment monitoring.

Methods

This study was planned prospective and observational study. The patients enrolled were divided into two groups including survivor and non-survivor depending on 30-day mortality. The primary outcome of the study was determined as following the mortality within 30 days.

Results

The mean lactate level was 1.9 (1.4-2.5) mmol/L in the survivor group, and 2.6 (1.9-4.4) mmol/L in the non-survivor group; a significant difference was obtained between both groups (p<0.001). When the cut-off value of the lactate was determined as >2.95 mmol/L in order to differentiate the survivors from non-survivors, the sensitivity and specificity were detected as 35.0% and 86.1%, respectively. It was detected by the multivariate regression analysis that lactate predicts the 30-day mortality with a higher significance level in patients with critical malignancies.

Conclusions

It was concluded that lactate is a good predictor and may be used safely in predicting 30-day mortality in patients with any critical malignancy referring to the emergency department.

Review of Hematological and Oncological Emergencies

Patients with hematological malignancies, both treated and untreated, or solid tumors undergoing treatment are at risk of life-threatening complications, which may present in the emergency department (ED). Such emergencies are diverse in etiology and often require prompt treatment. Traditional complications, such as febrile neutropenia, have had recent guideline updates, which incorporate new evidence and a new validated risk stratification tool. In addition, newer approaches to treatment, such as chimeric antigen receptor (CAR) T-cell therapy, are becoming more widely available and have unique associated toxicities. This review discusses the management of the following hematological and oncological emergencies likely to be encountered in the ED: febrile neutropenia, CAR T-cell toxicities, differentiation syndrome, tumor lysis syndrome, hypercalcemia of malignancy, and hyponatremia.

The Oncological Emergency of Intestinal Obstruction: ED Recognition and Treatment Outcomes

OBJECTIVES

Gastrointestinal complications, like blockage, are among the most common oncological emergencies. We investigated whether individuals with cancer presenting at the emergency department (ED) with intestinal obstruction were triaged accurately, and we further evaluated the triage decisions' effect on their ED treatment outcomes.

DATA SOURCES

A retrospective review was completed on all available records of adult cancer patients who were admitted with intestinal obstruction to a tertiary referral hospital. Over 3 years, 46 cancer patients were admitted from the ED with a provisional diagnosis of intestinal obstruction, confirmed by radiological examination. More than half the patients were undertriaged, which often resulted in these patients experiencing a series of risky time delays in the ED. Patients were significantly delayed in reaching five treatment outcomes: first assessment with a physician, initiation of treatment, decision to admit, length of ED stay, and length of hospital stay.

CONCLUSION

The application of triage in practice was inconsistent, inaccurate, and had a significant negative impact on patient treatment outcomes.

IMPLICATIONS FOR NURSING PRACTICE

The study results indicated the need to critically analyze current triage training and policies to increase their effectiveness. Improvement strategies are identified in the literature, and several are discussed. Involving triage nurses in this work is essential.

Therapeutics for paediatric oncological emergencies

Background

With advancements in the field of oncology, cancer survival rates have improved dramatically but modern cancer treatments also come with an increasing number of disease and treatment-associated complications. This article provides an updated narrative review on the pathophysiology, clinical presentations and latest management strategies for common paediatric oncological emergencies.

Methods

An extensive PubMed^® search of all human studies in the English literature was performed in Clinical Queries for different oncology syndromes and conditions using the following Medical Subject Headings: “tumour lysis syndrome”, “hyperleukocytosis”, “disseminated intravascular coagulation”, “superior mediastinal syndrome”, “superior vena cava syndrome”, “sepsis”, “severe inflammatory response syndrome”, “acute respiratory distress syndrome”, “posterior reversible encephalopathy syndrome” and “reversible posterior leukoencephalopathy syndrome”. Categories were limited to clinical trials and reviews for ages from birth to 18 years.

Results

The general description, presentation and management of these oncologic emergencies are systematically described. Early recognition along with prompt and proactive treatment can reduce the chances of potential complications and improve the clinical outcomes, thereby improving not only survival rates in oncology patients but also their clinical outcomes and quality of life.

Conclusions

Oncologic emergencies are associated with significant mortality and morbidity. Healthcare professionals involved with the care of oncology patients must be vigilant of these emergencies.

Clinical characteristics and therapeutic outcomes of mediastinal neuroblastoma with intraspinal extension: a retrospective study

BACKGROUND

Mediastinal neuroblastoma (NB) can invade the spinal canal and result in spinal cord compression. Some patients go on to develop severe spinal deformities after decompression of the spinal cord. The optimal therapeutic strategy for mediastinal NB with intraspinal extension is still unclear. Our study is to assess the therapeutic strategies for such patients.

METHODS

A total of 77 patients suffered mediastinal tumors with intraspinal extension between March 2015 and Aug 2019 were enrolled in the study. According to the primary therapy, NB were classified into 4 groups: chemotherapy, video-assisted thoracoscopic surgery (VATS)/thoracotomy, neurosurgical decompression, and a combined thoracic-neurosurgical approach. Clinical features, including patient demographics, neurologic recovery and survival rate, were assessed.

RESULTS

Among the 77 patients suffered mediastinal tumors with intraspinal extension, neurological symptoms were present in 44 patients. Neurological deficits improved in 76.5% of patients who underwent neurosurgical intervention and 50% of the other patients (P=0.094). Compression manifestations of ≤4 weeks duration showed an improved outcome compared to a longer compression time, with complete recovery of neurological function in 60% of patients versus 28.6% for patients with a longer symptom duration (P=0.04). NB constituted 49.4% of the 77 patients. An overall survival rate of 90.0%±9.5% was achieved for patients in the combined thoracic-neurosurgical group, 59.5%±15.0% in the thoracotomy group, 40.0%±29.7% in laminectomy group, and 37.0%±20.2% in the chemotherapy group. Complete regression of the tumor was demonstrated in 80% of combined group, which was greater than that of patients in the other groups (P=0.001).

CONCLUSIONS

Neurological recovery was correlated with the type of initial treatment and the duration of neurological symptoms. Mediastinal NB with intraspinal extension can be effectively managed with a combined neurosurgical and thoracic surgical approach.

Cancer related emergencies with the chief complaint of pain: Incidence, ED recognition, and quality of care

BACKGROUND

Pain is the most common reason for cancer-related emergency department (ED) visits and a precursor of the urgency of oncological emergencies.

PURPOSE

To identify the incidence of oncological emergencies with the chief complaint of pain and evaluate ED recognition and quality of care in managing the associated emergency.

METHODS

This was a retrospective observational study of cancer patients presented to three EDs during the four-year study period.

RESULTS

The study's sample consisted of 252 patients admitted with oncological emergencies with a chief complaint of pain. Some oncological emergencies were more likely to be prioritized appropriately, such as febrile neutropenia and increased intracranial pressure. However, most patients with spinal cord compression and cardiac tamponade were more likely to be triaged to less urgent triage categories. Timeliness of ED care was suboptimal for most patients, particularly among those assigned to less urgent triage categories. Indicators for the low quality of care extended beyond ED with multiple adverse events in the hospital.

CONCLUSION

Triage nurses are expected to use the oncological emergencies' prevalent symptoms to allocate the patients to high triage urgency accurately. Patient waiting to be seen expected to be reassessed periodically to ensure waiting remain safe. Hospitals can adopt or establish pathways, protocols, or standardized order sets to fast-track patients with oncological emergencies. The health information system should be available to monitor and improve the delivered care continuously.

EMERALD: Emergency visit audit of patients treated under medical oncology in a tertiary cancer center: Logical steps to decrease the burden

Background:

We are a tertiary care cancer center and have approximately 1000–1500 emergency visits by cancer patients undergoing treatment under the adult medical oncology unit each month. However, due to the lack of a systematic audit, we are unable to plan steps toward the improvement in quality of emergency services, and hence the audit was planned.

Methods:

All emergency visits under the adult medical oncology department in the month of July 2015 were audited. The cause of visit, the demographic details, cancer details, and chemotherapy status were obtained from the electronic medical records. The emergency visits were classified as avoidable or unavoidable. Descriptive statistics were performed. Reasons for avoidable emergency visits were sought.

Results:

Out of 1199 visits, 1168 visits were classifiable. Six hundred and ninety-six visits were classified as unavoidable (59.6%, 95% CI: 56.7–62.4), 386 visits were classified as probably avoidable visit (33.0%, 95% CI: 30.4–35.8) whereas the remaining 86 (7.4%, 95% CI: 6.0–9.01) were classified as absolutely avoidable. Two hundred and ninety-seven visits happened on weekends (25.6%) and 138 visits converted into an inpatient admission (11.9%). The factors associated with avoidable visits were curative intention of treatment (odds ratio - 2.49), discontinued chemotherapy status (risk ratio [RR] - 8.28), and private category file status (RR – 1.89).

Conclusion:

A proportion of visits to emergency services can be curtailed. Approximately one-fourth of patients are seen on weekends, and only about one-tenth of patients get admitted.

Oncological Emergencies from Pathophysiology and Diagnosis to Treatment: A Narrative Review

Oncological emergencies are defined as any acute possible morbid or life-threatening events in patients with cancer either because of the malignancy or because of their treatment. These events may occur at any time during malignancy, from symptoms present to end-stage disease. The aim of this study is the review of urgent conditions results from cancer or cancer treatment side effects that need to be addressed immediately. In this study, a comprehensive and in-depth narrative review was carried out by searching the databases of PubMed, Scopus, Science Direct, Google Scholar with the keywords of "cancer, emergency, metabolic emergency, neutropenic fever" along with the words, "tumor lysis syndrome, chemotherapeutic emergency, diagnosis, treatment " in last two decades. Patients suffering from cancer mostly face the challenges that we are classified in different categories, including metabolic, hematologic, cardiovascular, neurologic, respiratory, infectious, and chemotherapeutic emergencies. These patients mostly complain of headaches, nausea, pain, and fever. In conclusion, knowledge of oncology emergencies and palliative care as part of a team approach is critical for treating cancer patients. In this light, it is pivotal for physicians to focus on the early detection of oncological emergencies. Moreover, training programs for cancer patients help them to timely recognize and report the oncologic emergency symptoms, leading to avoid deleterious consequences and unnecessary healthcare costs as well as improve the quality of life in these patients.

LncRNA CSMD1-1 promotes the progression of Hepatocellular Carcinoma by activating MYC signaling

Emerging evidence suggests that long non-coding RNAs (lncRNA) play critical roles in the development and progression of diverse cancers including hepatocellular carcinoma (HCC), but the underlying molecular mechanisms of lncRNAs that are involved in hepatocarcinogenesis have not been fully explored.

Methods: In this study, we profiled lncRNA expression in 127 pairs of HCC and nontumor liver tissues (a Discovery Cohort) using a custom microarray. The expression and clinical significance of lncCSMD1-1 were then validated with qRT-PCR and COX regression analysis in a Validation Cohort (n=260) and two External Validation Cohorts (n=92 and n=124, respectively). In vitro and in vivo assays were performed to explore the biological effects of lncCSMD1-1 on HCC cells. The interaction of lncCSMD1-1 with MYC was identified by RNA pull-down and RNA immunoprecipitation. The role of LncCSMD1-1 in the degradation of MYC protein was also investigated.

Results: With microarray, we identified a highly upregulated lncRNA, lncCSMD1-1, which was associated with tumor progression and poor prognosis in the Discovery Cohort, and validated in another 3 HCC cohorts. Consistently, ectopic expression of lncCSMD1-1 notably promotes cell proliferation, migration, invasion, tumor growth and metastasis of HCC cells in in vitro and in vivo experiments. Gene expression profiling on HCC cells and gene sets enrichment analysis indicated that the MYC target gene set was significantly enriched in HCC cells overexpressing lncCSMD1-1, and lncCSMD1-1 was found to directly bind to MYC protein in the nucleus of HCC cells, which resulted in the elevation of MYC protein. Mechanistically, lncCSMD1-1 interacted with MYC protein to block its ubiquitin-proteasome degradation pathway, leading to activation of its downstream target genes.

Conclusion: lncCSMD1-1 is upregulated in HCC and promotes progression of HCC by activating the MYC signaling pathway. These results provide the evidence that lncCSMD1-1 may serve as a novel prognostic marker and potential therapeutic target for HCC.