AXL is a key regulator of inherent and chemotherapy-induced invasion and predicts a poor clinical outcome in early-stage colon cancer

PURPOSE

Despite the use of 5-fluorouracil (5-FU)-based adjuvant treatments, a large proportion of patients with high-risk stage II/III colorectal cancer will relapse. Thus, novel therapeutic strategies are needed for early-stage colorectal cancer. Residual micrometastatic disease from the primary tumor is a major cause of patient relapse.

EXPERIMENTAL DESIGN

To model colorectal cancer tumor cell invasion/metastasis, we have generated invasive (KRASMT/KRASWT/+chr3/p53-null) colorectal cancer cell subpopulations. Receptor tyrosine kinase (RTK) screens were used to identify novel proteins that underpin the migratory/invasive phenotype. Migration/invasion was assessed using the XCELLigence system. Tumors from patients with early-stage colorectal cancer (N = 336) were examined for AXL expression.

RESULTS

Invasive colorectal cancer cell subpopulations showed a transition from an epithelial-to-mesenchymal like phenotype with significant increases in migration, invasion, colony-forming ability, and an attenuation of EGF receptor (EGFR)/HER2 autocrine signaling. RTK arrays showed significant increases in AXL levels in all invasive sublines. Importantly, 5-FU treatment resulted in significantly increased migration and invasion, and targeting AXL using pharmacologic inhibition or RNA interference (RNAi) approaches suppressed basal and 5-FU-induced migration and invasion. Significantly, high AXL mRNA and protein expression were found to be associated with poor overall survival in early-stage colorectal cancer tissues.

CONCLUSIONS

We have identified AXL as a poor prognostic marker and important mediator of cell migration/invasiveness in colorectal cancer. These findings provide support for the further investigation of AXL as a novel prognostic biomarker and therapeutic target in colorectal cancer, in particular in the adjuvant disease in which EGFR/VEGF-targeted therapies have failed.

Identification of an acetylation-dependant Ku70/FLIP complex that regulates FLIP expression and HDAC inhibitor-induced apoptosis

FLIP is a potential anti-cancer therapeutic target that inhibits apoptosis by blocking caspase 8 activation by death receptors. We report a novel interaction between FLIP and the DNA repair protein Ku70 that regulates FLIP protein stability by inhibiting its polyubiquitination. Furthermore, we found that the histone deacetylase (HDAC) inhibitor Vorinostat (SAHA) enhances the acetylation of Ku70, thereby disrupting the FLIP/Ku70 complex and triggering FLIP polyubiquitination and degradation by the proteasome. Using in vitro and in vivo colorectal cancer models, we further demonstrated that SAHA-induced apoptosis is dependant on FLIP downregulation and caspase 8 activation. In addition, an HDAC6-specific inhibitor Tubacin recapitulated the effects of SAHA, suggesting that HDAC6 is a key regulator of Ku70 acetylation and FLIP protein stability. Thus, HDAC inhibitors with anti-HDAC6 activity act as efficient post-transcriptional suppressors of FLIP expression and may, therefore, effectively act as 'FLIP inhibitors'.

Guidelines on the standards for the training of specialised health professionals dealing with breast cancer

According to EUSOMA position paper 'The requirements of a specialist breast unit', each breast unit should have a core team made up of health professionals who have undergone specialist training in breast cancer. In this paper, on behalf of EUSOMA, authors have identified the standards of training in breast cancer, to harmonise and foster breast care training in Europe. The aim of this paper is to contribute to the increase in the level of care in a breast unit, as the input of qualified health professionals increases the quality of breast cancer patient care.

Localized CT-guided irradiation inhibits neurogenesis in specific regions of the adult mouse brain

Radiation is used in the study of neurogenesis in the adult mouse both as a model for patients undergoing radiation therapy for CNS malignancies and as a tool to interrupt neurogenesis. We describe the use of a dedicated CT-guided precision device to irradiate specific sub-regions of the adult mouse brain. Improved CT visualization was accomplished with intrathecal injection of iodinated contrast agent, which enhances the lateral ventricles. T2-weighted MRI images were also used for target localization. Visualization of delivered beams (10 Gy) in tissue was accomplished with immunohistochemical staining for the protein γ-H2AX, a marker of DNA double-strand breaks. γ-H2AX stains showed that the lateral ventricle wall could be targeted with an accuracy of 0.19 mm (n = 10). In the hippocampus, γ-H2AX staining showed that the dentate gyrus can be irradiated unilaterally with a localized arc treatment. This resulted in a significant decrease of proliferative neural progenitor cells as measured by Ki-67 staining (P < 0.001) while leaving the contralateral side intact. Two months after localized irradiation, neurogenesis was significantly inhibited in the irradiated region as seen with EdU/NeuN double labeling (P < 0.001). Localized radiation in the rodent brain is a promising new tool for the study of neurogenesis.

The needs of relative visiting adult critical care units as perceived by relatives and nurses. Part I

This was a descriptive study, aimed at identifying the needs of relatives while they were visiting adult critical care units. A convenience sample of 24 critical care units participated, involving 351 critical care nurses and 255 visiting relatives. Using an adaptation of Molter's Critical Care Family Needs Inventory, the objectives of the study were: To compare (in ranking order) relatives' perceptions of how important their needs were with how important critical care nurses perceived them to be. To identify how satisfied relatives were with how their needs were met, while visiting the unit. To compare who relatives perceived to be the most appropriate person to fulfill each of their needs, with who nurses assessed to be the most appropriate person to fulfill the relatives needs. Relatives highlighted the importance of re-assurance and their need for sufficient information about their family member. Critical care nurses were only moderately accurate in assessing how important relatives' needs were, according to the findings from this relatives' group. Relatives were 'satisfied' with how the majority of their needs had been met. Only 10 of the 30 needs were considered to have been met to 'very satisfactory' level by at least 60% of the sample group. Nurses were identified by relatives as being the most appropriate person to fulfil 19 out of the 30 needs. Whereas nurses perceived themselves to be the most appropriate people to fulfill 25 of the 30 needs for relatives. The implications for clinical practice are also discussed.

Vagal dysfunction in irritable bowel syndrome assessed by rectal distension and baroreceptor sensitivity

Autonomic nervous system dysfunction has been implicated in the pathophysiology of irritable bowel syndrome (IBS). This study characterized the autonomic response to rectal distension in IBS using baroreceptor sensitivity (BRS), a measure of autonomic function. Rectal bag pressure, discomfort, pain, ECG, blood pressure and BRS were continuously measured before, during and after rectal distension in 98 healthy volunteers (34 +/- 12 years old, 52 females) and 39 IBS patients (39 +/- 11 years old, 35 females). In comparison with the healthy volunteers, IBS patients experienced significantly more discomfort (69 +/- 2.2% vs 56 +/- 3.6%; P < 0.05), but not pain (9 +/- 1.4% vs 6 +/- 2.4%; ns) with rectal distension despite similar distension pressures (51 +/- 1.4 vs 54 +/- 2.4 mmHg; ns) and volumes (394 +/- 10.9 vs 398 +/- 21.5 mL; ns). With rectal distension, heart rate increased in both healthy volunteers (66 +/- 1 to 71 +/- 1 bpm; P < 0.05) and IBS patients (66 +/- 2 to 74 +/- 3 bpm; P < 0.05). Systolic blood pressure also increased in both healthy volunteers (121 +/- 2 to 143 +/- 2 mmHg; P < 0.05) and patients (126 +/- 3 to 153 +/- 4 mmHg (P < 0.05) as did diastolic blood pressure, 66 +/- 2 to 80 +/- 2 mmHg (P < 0.05), compared with 68 +/- 3 to 84 +/- 3 mmHg (P < 0.05) in IBS patients. The systolic blood pressure increase observed in IBS patients was greater than that seen in healthy volunteers and remained elevated in the post distension period (139 +/- 3 mmHg vs 129 +/- 2 mmHg; P < 0.05). IBS patients had lower BRS (7.85 +/- 0.4 ms mmHg(-1)) compared with healthy volunteers (9.4 +/- 0.3; P < 0.05) at rest and throughout rectal distension. Greater systolic blood pressure response to rectal distension and associated diminished BRS suggests a compromise of the autonomic nervous system in IBS patients.

Caring About Women and Cancer (CAWAC): a European survey of the perspectives and experiences of women with female cancers

This paper reports on the findings of the largest ever European survey of female patients' perceptions of their cancer treatment. It has provided clarification of what women consider important in relation to their management and has identified several areas where more research is needed. It has shown that women's knowledge about cancer before diagnosis is poor and the number undergoing regular screening could be improved. Women are not being adequately prepared and educated about what to expect from treatment and steps should be taken as a matter of urgency to redress this shortcoming. It was revealed that whilst families were the primary source of support to female cancer patients, women also derive considerable support from healthcare professionals, particularly senior doctors; more attention should be paid by specialists and nurses to developing psychological skills to cope with this. In this context, further research is needed into how support groups may best meet patient needs.

Targeting stromal cell sialylation reverses T cell-mediated immunosuppression in the tumor microenvironment

Immunosuppressive tumor microenvironments (TMEs) reduce the effectiveness of immune responses in cancer. Mesenchymal stromal cells (MSCs), precursors to cancer-associated fibroblasts (CAFs), promote tumor progression by enhancing immune cell suppression in colorectal cancer (CRC). Hyper-sialylation of glycans promotes immune evasion in cancer through binding of sialic acids to their receptors, Siglecs, expressed on immune cells, which results in inhibition of effector functions. The role of sialylation in shaping MSC/CAF immunosuppression in the TME is not well characterized. In this study, we show that tumor-conditioned stromal cells have increased sialyltransferase expression, α2,3/6-linked sialic acid, and Siglec ligands. Tumor-conditioned stromal cells and CAFs induce exhausted immunomodulatory CD8+ PD1+ and CD8+ Siglec-7+/Siglec-9+ T cell phenotypes. In vivo, targeting stromal cell sialylation reverses stromal cell-mediated immunosuppression, as shown by infiltration of CD25 and granzyme B-expressing CD8+ T cells in the tumor and draining lymph node. Targeting stromal cell sialylation may overcome immunosuppression in the CRC TME.

Assessing patients' needs and preferences in the management of advanced colorectal cancer

Clinical decision-making in advanced cancer is a highly complex process. Many factors are thought to influence this process arguably the most important of these is the patient's own preference. Studies show that most patients want to be fully informed as to their diagnosis and involved in clinical decision-making. However, the attitudes of healthcare workers often preclude patient involvement. Studies have also shown that acceptability of chemotherapy for minimal therapeutic gain differs markedly between patients depending on factors such as age, gender and family status. It is clearly impossible to make decisions about what is best for patients without involving them in the decision-making process. Indeed, it could be argued that active patient participation actually simplifies this process.

Organizational barriers in opioid use

Despite the fact that we have both the means and the knowledge to ameliorate most forms of pain effectively, a significant number of cancer patients still experience unacceptable levels of pain. This paper sets out to explore the nature of the various organizational barriers to effective pain management. There is ample evidence to demonstrate that both physicians and nurses lack knowledge regarding modern methods of pain control. This situation not only results in poor clinical decision making, but has also spawned a number of extraordinary myths and misconceptions about the use of opioids. Such myths and misconceptions often result in significant undermedication of the patient's pain. Problems can also exist with continuity of care--the patient may be seen by a number of different physicians across a number of different health care settings where no one person is willing to take responsibility for the overall management of the patient's pain. Further fragmentation can occur due to lack of communication between the hospital and the community care setting. This problem can be compounded by incomplete and inconsistent documentation of pain. An important and often overlooked problem relating to opioid use is the existence of bureaucratic regulations governing the supply, prescription and administration of opioids in many countries world wide. There appears to be a real fear that liberalizing many of these regulations will result in an increase in illicit drug use. This paper will conclude with a discussion on ways in which the above-mentioned organizational barriers can be overcome.

A comparison of autonomic function in patients with inflammatory bowel disease and in healthy controls

We evaluated autonomic function, symptoms and psychological parameters in patients with ulcerative colitis (UC), Crohn's disease (CD) and matched controls to assess whether UC patients have greater basal sympathetic autonomic activity. Outpatients with UC (n = 15), CD (n = 13) and healthy controls (n = 28) underwent spectral analysis of heart rate variability to assess cardiac autonomic function, a methacholine challenge to assess cholinergic pulmonary responsiveness, and questionnaires assessing disease severity, anxiety and depression. UC but not CD patients had greater sympathetic activity than controls with increased absolute (6600 vs 5884; P = 0.04) and relative (62.8%vs 54.8%; P = 0.02) low frequency areas. This was not because of increased overall autonomic nervous system (ANS) activation and was independent of disease activity. In UC patients, trait (personality-related) anxiety correlated strongly with disease symptoms (R = 0.84; P < 0.001) and quality of life (R = -0.81; P < 0.001) while situational (state) anxiety did not. In CD patients, ANS measures were similar to controls and disease activity was unrelated to psychological measures. Cholinergic pulmonary responsiveness was normal in both UC and CD patients. UC patients have an increased sympathetic ANS activity which is independent of symptom severity. In these patients symptom severity is strongly associated with measures of personality related (but not current) anxiety.

Advances in supportive care

A range of distressing symptoms, such as nausea and vomiting, dyspnoea and pain, which invariably impair quality of life, may develop in cancer patients as a result of their disease and treatment. The side-effects of cancer treatments place additional burdens on the patient. Patients indicate that they find nausea and vomiting and fatigue to be the most distressing symptoms. The burden of distressing symptoms and the side-effects of cancer treatments may be so great for some patients that they make a decision not to continue with treatment. Developing better methods of managing these complaints is critical for improving both quality of life and treatment outcome. Over the past two decades there have been dramatic advances in supportive care. The most significant advances have occurred in the general approach to symptom management and in the development of new pharmacological agents. Advances have also occurred in non-pharmacological approaches to supportive care and it is now acknowledged that interventions such as patient education and complementary therapies have an important role to play in ameliorating distressing symptoms.

Body site matters: an evaluation and application of a novel histological methodology on the quantification of mucous cells in the skin of Atlantic salmon, Salmo salar L

Mucous cell size and distribution were investigated in the skin of five salmon using a novel stereology-based methodology: one (48 cm) fish to test 15 tissue treatment combinations on measures of cell area and density on the dorsolateral region and, using the most suitable treatment, we mapped mucous cell differences between body regions on four (52 cm) salmon, comprising a male and a female on each of two diets. The section site, decalcification, embedding medium and plane of sectioning all impacted significantly on mucous cell size, whereas mucous cell density is more robust. There were highly significant differences in both mucosal density and mean mucous cell size depending on body site: the dorsolateral skin of the four salmon had significantly denser (about 8% of skin area) and larger (mean about 160 μm(2)) mucous cells, whereas the lowest mean density (about 4%) and smallest mean area (115 μm(2)) were found on the head. We found that 100 random measurements may be sufficient to distinguish differences >7 μm(2) in mean mucous cell areas. The results further suggest that salmon exhibit a dynamic repeatable pattern of mucous cell development influenced by sex, diet and possibly strain and season.

Treatment choices in advanced cancer: issues and perspectives

Treatment choices are difficult in advanced cancer, a disease in which there is little chance of a cure and in which the aim of treatment is usually to achieve palliation. With the clinical evidence and quality-of-life instruments currently available, it may be difficult to decide whether the burdens of cytotoxic chemotherapy are outweighed by its benefits. However, in some cancers, such as advanced colorectal cancer, there is evidence to demonstrate that chemotherapy is justified, with overall benefit to the patient. There are, nevertheless, many factors to be considered in the selection of the best possible care for each patient. These include the availability of new treatments with improved tolerability profiles, resource implications, quality of life and survival benefits (and how to assess them), the willingness or otherwise of patients to undergo chemotherapy, and information and participation preferences among patients. The differing attitudes of health care professionals and groups of patients add to the complexity of this issue. Guidelines offer one way of promoting the consistent and optimal management of patients with advanced cancer; however, individual patient choice will always take precedence over guidelines which, by definition, are devised with common needs in mind.

Isolated anterior mediastinal tuberculosis in an immunocompetent patient

Background

The differential diagnosis of a mediastinal mass is a common challenge in clinical practice, with a wide range of differential diagnosis to be considered. One of the rarer causes is tuberculosis. Atypical presentations of tuberculosis are well documented in immunocompromised patients, but should also be considered in the immunocompetent.

Case presentation

This case outlines a previously healthy 22 year-old immunocompetent male presenting with worsening chest pain, positional dyspnea, dry cough and dysphagia. Chest x-ray showed evidence of an isolated anterior mediastinal mass, which was confirmed on computed tomography. A mediastinoscopy was diagnostic as histology revealed necrotizing granulomatous inflammation and the presence of acid-fast bacilli, indicating mediastinal tuberculosis.

Conclusion

Typically the underlying presentation of mediastinal tuberculosis is mediastinal lymphadenitis. This case was unusual in that we detected an isolated large anterior mediastinal mass accompanied by a relatively small burden of mediastinal lymphadenitis. Cases similar to this have been documented in immunosuppressed patients however in our case no evidence of immunosuppression was found. This case report emphasizes the importance that a detailed and logical pathway of investigation is pursued when encountering a mediastinal mass.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-016-0175-7) contains supplementary material, which is available to authorized users.

Nursing in Colorectal Cancer Initiative--the audit phase. Part 1. Development of the audit tool

This paper describes the structure of an audit study together with the two-phase development of an audit tool and methodology. The purpose of the study was to develop a tool that defines and measures best practice in colorectal cancer nursing, and identifies areas for development. The European Oncology Nursing Society (EONS) and AstraZeneca collaborated to develop the Nursing in Colorectal Cancer Initiative (NICCI). The initiative was funded through educational grants from AstraZeneca and led by EONS. It is a project with two components, education and audit. The purpose of the project is to provide a sound educational basis for nurses in the elements of colorectal cancer care, together with the tools to evaluate and develop practice. The education phase culminated in an educational manual that provides a core set of materials concerning the fundamental aspects of colorectal cancer, to foster a common understanding amongst nurses nationally and internationally. The education manual provided the referenced rationale for the definition of a set of hallmarks and standards of clinical practice. The audit tool was developed from the hallmarks and standards and is focused on the care of patients receiving cytotoxic chemotherapy for colorectal cancer. The audit methodology is based on the structure, process outcome triad, together with the TELER system of audit.

Nursing in Colorectal Cancer Initiative: the audit phase. Part 2. Content validity of the audit tool and implications of the standards set for clinical practice

This paper gives an account of the process of refining the content validity of an audit tool, which defines and measures best practice in colorectal cancer nursing and identifies areas for development. The European Oncology Nursing Society (EONS) and AstraZeneca collaborated to develop the Nursing in Colorectal Cancer Initiative (NICCI). The initiative was funded through educational grants from AstraZeneca and led by EONS. It is a project with two components, education and audit. The education component culminated in a manual that provides a core set of materials concerning fundamental aspects of colorectal cancer, to foster a common understanding amongst nurses at national and international levels. An audit tool was developed to measure standards of nursing care in relation to the delivery of cytotoxic chemotherapy to patients with advanced colorectal cancer. The content validity of the audit tool was established in three stages by expert panel review with revisions made to the content and organisation of the audit measures at each stage. The standards set by the NICCI Audit Project have key implications for multi-professional practice in colorectal cancer care.

The EONS core curriculum revision project

This paper provides an overview of the EONS (European Oncology Nursing Study) core curriculum revision project. The aim of this project was to revise the EONS core curriculum for a Post-Basic Course in Cancer Nursing, first published in 1989, so that it would better reflect patient and family need and contemporary cancer nursing practice. A further aim of the project was to address the educational needs of both adult and paediatric oncology nurses. To achieve these aims a core curriculum revision meeting was organized and attended by representatives from most of the EU Member States. A rough draft of the core curriculum was developed, circulated and subjected to further scrutiny and modification. Following approval of the final draft, the core curriculum was translated from English into the 10 other official EU languages and made available in both paper and electronic form. The updated core curriculum was launched during the ECCO-10 conference and has now been disseminated widely amongst European cancer nurses and the wider nursing and medical community.