Emergencies in Hematology and Oncology

Hematological Complications of Human Immunodeficiency Virus (HIV) Infection: An Update From an HIV-Endemic Setting

Medical professionals, particularly in regions with a high burden of human immunodeficiency virus (HIV), should be alert to the hematological complications of HIV, which may include cytopenias, malignancy, and coagulation disturbances. Patients may present with these conditions as the first manifestation of HIV infection. Hematological abnormalities are often multifactorial with opportunistic infections, drugs, malignancy, and HIV infection itself contributing to the clinical presentation, and the diagnosis should consider all these factors. Life-threatening hematological complications requiring urgent diagnosis and management include thrombotic thrombocytopenic purpura, superior mediastinal syndrome, spinal cord compression, and tumor lysis syndrome due to aggressive lymphoma. Antiretroviral therapy is the therapeutic backbone, including for patients with advanced HIV, in addition to specific therapy for the complication. This article reviews the impact of HIV on the hematological system and provides a clinical and diagnostic approach, including the role of a bone marrow biopsy, focusing on perspectives from sub-Saharan Africa.

Aggressive B-Cell Lymphoma with Metastatic Spinal Cord Compression: Treat the Patient, Not the Disease

INTRODUCTION

The management of metastatic spinal cord compression (mSCC) is a demanding task. The main challenges of mSCC include various manifestations and unpredictable outcomes with indiscriminate treatment recommendations. Because of attendant urgency with potentially devastating health consequences, the SCC is an emotionally disturbing experience whose management could take an impulsive rather than rational approach. The treatment strategy is particularly problematic when mSCC is caused by a malignant lymphoma with its protean attributes.

CASE REPORT

A 68-year-old female presented with generalized body pain and weight loss. Imaging studies revealed a vast bulk of the disease involving lymph nodes, spleen, visceral organs, musculature, marrow, and bones including vertebrae with extension into the spinal canal. A biopsy of the chest wall mass showed high-grade diffuse large B-cell lymphoma. A magnetic resonance imaging (MRI) of the spine demonstrated diffuse marrow replacement by the tumor of the thoracic and lumbar spine with compression of the cord. The prompt treatment with corticosteroids and immunochemotherapy (ICT) was recommended, but the patient elected to seek a second opinion. After two doses of radiation therapy, the patient's general condition rapidly deteriorated and she was hospitalized for systemic ICT. Despite the treatment, her condition continued to deteriorate, and she died 3 weeks after the presentation.

CONCLUSION

The presented case demonstrates some hitherto unaddressed challenges in evaluation and treatment of mSCC caused by aggressive non-Hodgkin lymphoma (LSSC). The case scrutinizes the role of MRI in uncommon clinical situations. The case has also exposed some ethical issues associated with the proper management of LSCC.

An updated narrative review on the management of the most common oncological and hematological emergencies

Oncological emergencies are defined as an acute life-threatening event in a patient with a tumor occurring as part of their complex treatment regimen or secondarily to their underlying malignancy. These events can occur at any time from the initial diagnosis of their cancer to end-stage disease. These oncological emergencies are broadly classified into four major categories; metabolic, structural, hematological and treatment-related causes; and can be encountered in any clinical setting, ranging from primary care physician and emergency department visits to a variety of subspecialty environments. This study aims to cover an in-depth review of the underlying pathogenesis, clinical presentation, and updated management protocol of most common emergencies belonging to the above-mentioned categories. An all-language literature search was conducted on 15th October 2021 and 10th March 2022, limited to 5 years on PubMed database using the following search strings: oncological emergencies, malignant spinal cord compression, febrile neutropenia, hyperviscosity syndrome, superior vena cava syndrome, immune related adverse events, tumor lysis syndrome, hypercalcemia of malignancy, corrected calcium, malignant pericardial effusion and chemotherapy extravasation.

The diagnosis and management of suspected lymphoma in general practice

With rapid advancements in diagnosis and treatment of malignancies, the gap between generalists and subspecialists continues to widen, particularly in cancers like lymphoma where the spectrum of disease varies from indolent to rapidly progressive. Prior to establishing with a hematologist/oncologist, patients must be accurately and comprehensively diagnosed and managed for lymphoma in the generalist setting. In the following manuscript, we review the common clinical presentations in which should raise concern for lymphoma. We summarize the literature regarding the role of laboratory studies including complete blood count and peripheral blood flow cytometry, the recommendations for lymph node sampling, the role and selection of imaging modalities, and ideal patient monitoring for high-risk clinical syndromes that may be encountered in lymphoma.

A Novel M6A-Related Genes Signature Can Impact the Immune Status and Predict the Prognosis and Drug Sensitivity of Lung Adenocarcinoma

Lung adenocarcinoma (LUAD) is a primary cause of cancer-related death around the world and has a poor outcome and high incidence. Treatment options are, however, restricted. One of the most critical factors in cancer and metastasis is the N6-methyladenine (m6A) alteration on RNA. This modification could alter gene expression and even function at numerous levels, such as the stability, translocation and translation of RNA splicing. This study aimed to construct an m6A-related genes signature to accurately predict the prognosis of LUAD patients. From TCGA datasets, the LUAD patient data and m6A-related genes were retrieved. LUAD patients’ mutational features and differentially expressed genes (DEGs) were investigated. An univariate and LASSO model with m6A-related genes were constructed for the prediction of outcomes in LUAD. It was possible to develop a prognostic nomogram that could quantitatively predict LUAD patients’ overall survival chances at 1, 3, and 5 years. Research into biological processes and cell pathways was carried out using GSEA. This study found six m6A-related DEGs in LUAD patients, and three of these DEGs(HNRNPC, IGFBP3 and IGF2BP1) were linked to the clinical outcomes of LUAD patients. We found that the overall survival rate for all LUAD patients with high-risk subgroup was considerably lower. According to ROC curves, the prognostic signature demonstrated a high degree of accuracy in predicting future outcomes. In addition, we created a novel nomogram achieved great accuracy with this one as well. The researchers also found that the novel signature might favorably modulate the immune response, and high-risk scores samples were more susceptible to numerous chemotherapeutic medicines. Overall, we developed a m6A-related gene prognostic signature that effectively predicted outcomes of LUAD patients and gave an immunological perspective for creating customized therapeutics.

Early Warning Scores and Their Application in the Inpatient Oncology Settings

Early Warning Score (EWS) systems are tools that use alterations in vital signs to rapidly identify clinically deteriorating patients and escalate care accordingly. Since its conception in 1997, EWSs have been used in several settings, including the general inpatient ward, intensive care units, and the emergency department. Several iterations of EWSs have been developed with varying levels of sensitivity and specificity for use in different populations. There are multiple strengths of these tools, including their simplicity and their ability to standardize communication and to reduce inappropriate or delayed referrals to the intensive care unit. Although early identification of deteriorating patients in the oncology population is vital to reduce morbidity and mortality and to improve long-term prognosis, the application in the oncology setting has been limited. Patients with an oncological diagnosis are usually older, medically complex, and can have increased susceptibility to infections, end-organ damage, and death. A search using PubMed and Scopus was conducted for articles published between January 1997 and November 2020 pertaining to EWSs in the oncology setting. Seven relevant studies were identified and analyzed. The most commonly used EWS in this setting was the Modified Early Warning Score. Of the seven studies, only two included prospective validation of the EWS in the oncology population and the other five only included a retrospective assessment of the data. The majority of studies were limited by their small sample size, single-institution analysis, and retrospective nature. Future studies should assess dynamic changes in scores over time and evaluate balance measures to identify use of health care resources.

Oncologic Emergencies

A new cancer diagnosis is expected to affect approximately 1.9 million people in the United States in 2021. A small percentage of these patients will experience an emergent cancer-related complication. Oncologic emergencies may be encountered in emergency departments or require intensive care management. Patients newly diagnosed with cancer are more likely to present with emergencies related to the underlying malignancies. Oncologic emergencies can have various manifestations, ranging from mechanical obstruction due to tumor growth to metabolic derangements due to abnormal secretions from the tumor. Therefore, early identification and treatment of life-threatening oncologic events is critical. Although there are several different types of oncologic emergencies, this article focuses on metabolic emergencies (tumor lysis syndrome and cytoreductive hyperthermic intraperitoneal chemotherapy) and structural emergencies (increased intracranial pressure and vena cava thrombus). The purpose of this article is to provide acute care clinicians with an overview of selected oncologic emergencies and their evidence-based management.

Inorganic polyphosphate as an energy source in tumorigenesis

Cancer cells have high demands for energy to maintain their exceedingly proliferative growth. However, the mechanism of energy expenditure in cancer is not well understood. We hypothesize that cancer cells might utilize energy-rich inorganic polyphosphate (polyP), as energetic reserve. PolyP is comprised of orthophosphates linked by phosphoanhydride bonds, as in ATP. Here, we show that polyP is highly abundant in several types of cancer cells, including brain tumor-initiating cells (BTICs), i.e., stem-like cells derived from a mouse brain tumor model that we have previously described. The polymer is avidly consumed during starvation of the BTICs. Depletion of ATP by inhibiting glycolysis and mitochondrial ATP-synthase (OXPHOS) further decreases the levels of polyP and alters morphology of the cells. Moreover, enzymatic hydrolysis of the polymer impairs the viability of cancer cells and significantly deprives ATP stores. These results suggest that polyP might be utilized as a source of phosphate energy in cancer. While the role of polyP as an energy source is established for bacteria, this finding is the first demonstration that polyP may play a similar role in the metabolism of cancer cells.

Critically ill patients with cancer: A clinical perspective

Cancer patients account for 15% of all admissions to intensive care unit (ICU) and 5% will experience a critical illness resulting in ICU admission. Mortality rates have decreased during the last decades because of new anticancer therapies and advanced organ support methods. Since early critical care and organ support is associated with improved survival, timely identification of the onset of clinical signs indicating critical illness is crucial to avoid delaying. This article focused on relevant and current information on epidemiology, diagnosis, and treatment of the main clinical disorders experienced by critically ill cancer patients.

Twelve tips for teaching oncology to non-oncologists

Background: Teaching subspecialty care to trainees who are not pursuing that subspecialty poses many challenges. These challenges are amplified in the teaching of oncology to non-oncologists because there are more new therapies emerging in oncology than in any other discipline, and there are few oncologic issues managed by generalists without consultation. Concurrently, there is an increasing need for generalists to manage many aspects of care for patients with cancer.Aim: To provide 12 tips for oncologists to use to educate trainees on their oncology rotations.Method: The tips provided are based upon the available literature and the authors' own experience.Results: The 12 tips presented offer specific strategies for oncologists to enhance their teaching by selection of appropriate content and enhancing delivery. Focus is placed on aspects of oncology that trainees are likely to encounter as a generalist or non-cancer subspecialist. While oncology is used as the case study, these strategies are adaptable to any subspecialty area.Conclusion: Oncologists and other subspecialists can be core medical educators.

Hyperviscosity Syndrome in Paraprotein Secreting Conditions Including Waldenstrom Macroglobulinemia

Hyperviscosity syndrome is a serious complication associated with high levels of paraproteins in patients with hematological malignancies. Therapeutic advances in disease control may reduce the incidence of hyperviscosity syndrome; however, management of acute cases requires an understanding of key symptoms and prompt treatment to mitigate serious consequences.

The role of specialized hospital units in infection and mortality risk reduction among patients with hematological cancers

MOTIVATION

Patients with hematological malignancies are susceptible to life-threatening infections after chemotherapy. The current study aimed to evaluate whether management of such patients in dedicated inpatient and emergency wards could provide superior infection prevention and outcome.

METHODS

We have developed an approach allowing to retrieve infection-related information from unstructured electronic medical records of a tertiary center. Data on 2,330 adults receiving 13,529 chemotherapy treatments for hematological malignancies were identified and assessed. Infection and mortality hazard rates were calculated with multivariate models. Patients were randomly divided into 80:20 training and validation cohorts. To develop patient-tailored risk-prediction models, several machine-learning methods were compared using area under the curve (AUC).

RESULTS

Of the tested algorithms, the probit model was found to most accurately predict the evaluated hazards and was implemented in an online calculator. The infection-prediction model identified risk factors for infection based on patient characteristics, treatment and history. Observation of patients with a high predicted infection risk in general wards appeared to increase their infection hazard (p = 0.009) compared to similar patients observed in hematology units. The mortality-risk model demonstrated that for infection events starting at home, admission through hematology services was associated with a lower mortality hazard compared to admission through the general emergency department (p = 0.007). Both models show that dedicated hematological facilities and emergency services improve patient outcome post-chemotherapy. The calculated numbers needed to treat were 30.27 and 31.08 for the dedicated emergency and observation facilities, respectively. Infection hazard risks were found to be non-monotonic in time.

CONCLUSIONS

The accuracy of the proposed mortality and infection risk-prediction models was high, with the AUC of 0.74 and 0.83, respectively. Our results demonstrate that temporal assessment of patient risks is feasible. This may enable physicians to move from one-point decision-making to a continuous dynamic observation, allowing a more flexible and patient-tailored admission policy.

Concurrent Cardiac Tamponade and Superior Vena Cava Syndrome: A Concerning Situation

Diffuse large B-cell lymphoma (DLBCL) is the most commonly diagnosed lymphoma; as per the Surveillance, Epidemiology, and End Results (SEER) database 2006-2015, incidence of DLBCL is 7.0/100,000 per year. Superior vena cava (SVC) syndrome and cardiac tamponade are life-threatening oncological emergencies with an overlap in clinical manifestations. While SVC syndrome may commonly be seen with mediastinal masses, literature search shows only one prior case of cardiac tamponade resulting from DLBCL. Here, we present a case of a patient with a concurrent diagnosis of DLBCL and non-small cell carcinoma of the lung (NSCLC), presenting with respiratory symptoms initially but subsequently worsening with hemodynamic compromise. He was found to have cardiac tamponade secondary to DLBCL and was treated appropriately for it but failed to improve clinically due to co-existing SVC syndrome that was not treated. The patient expired in the intensive care unit (ICU) within 24 hours of acute clinical deterioration. This case highlights that in absence of a clinical suspicion for both conditions, identification of one can lead to an overlooked diagnosis of the other. When associated with hemodynamic instability, urgent intervention is mandatory and failure to recognize and treat either of the two may result in grave outcome. This case attempts to alert medical personnel regarding two major oncological emergencies where an accurate diagnosis and urgent intervention can prevent mortality and morbidity.

Characterization of people with hemato-oncological diseases admitted to an emergency unit

Abstract Objectives: To identify the demographic and clinical profile and the reasons for seeking care of people with hemato-oncological diseases attended at an emergency unit. Methods: This descriptive, correlational, quantitative study was carried in the emergency unit of a general teaching hospital in the state of Rio Grande do Sul, with a sample of 65 patients with hemato-oncological diseases. Simple descriptive statistics were used for the evaluation of the data. Results: There was a predominance of males (61.5%), with a mean age of 63.4 ± 1.7 years, of white skin color (95.4%), with incomplete elementary education (55.4%) and married (53.8%). There was a high rate of patients with cancer receiving end-of-life care (52.3%), a prevalence of palliative care (55.4%), with the outcome most observed being discharge from the unit (52.3%). According to the primary site of the cancer, a predominance of lymphomas and leukemias was observed (30.8%). Regarding the reason for attending the unit, pain (41.5%) was the most prevalent symptom. Conclusion and implications for practice: Identifying these characteristics can contribute to nursing care for patients with hemato-oncological diseases, considering the specificity of this care and the care practice in emergency units.

Oncologic Emergencies-The Old, the New, and the Deadly

Cancer continues to be a leading cause of death despite a broader understanding of its biology and the development of novel therapies. Nonetheless, with an increasing survival of this population, intensivists must be aware of the associated emergencies, both old and new. Oncologic emergencies can be seen as an initial presentation of the disease or precipitated by its treatment. In this review, we present key oncologic emergencies that may be encountered in daily practice, complications associated with innovative therapies, and treatment-related adverse events.