Oncological emergencies

Temporary abdominal closure in oncological patients: Surgical characteristics and implications

BACKGROUND AND OBJECTIVES

In critically ill patients, temporary abdominal closure (TAC) is utilized for conditions like abdominal compartment syndrome risk, gross abdominal contamination, and intestinal loop viability doubts. TAC techniques aim to safeguard abdominal contents, drain intraperitoneal fluids, and minimize fascia and skin damage. Our goal is to outline clinical characteristics and surgical outcomes in oncological patients undergoing peritoneostomy.

METHODS

Patients undergoing TAC with vacuum therapy at a tertiary oncological center were studied, with data sourced from an institutional database.

RESULTS

Forty-seven patients (54.3% female), with an average age of 63.1 ± 12.3 years, were included in the study. The primary tumor site was predominantly gastrointestinal (78.2%). Patients presented systemic signs of chronic disease, reflected by a mean body mass index of 18.2 ± 7.6 kg/m², hemoglobin level of 9.2 ± 1.8 g/dL, and albumin level of 2.3 ± 0.6 g/dL. Additionally, most patients had a low-performance status (53% Eastern Cooperative Oncology Group 1/2, 44.8% Karnofsky score ≤80, and 61.2% Charlson Comorbidity Index ≥6). Emergency surgical complications were the main reasons for initial surgery (68%), with the majority attributed to fecal peritonitis (65.9%). Only 14.8% of patients achieved complete abdominal closure with an average of 24.8 days until closure. The in-hospital mortality rate was 85.2%.

CONCLUSION

TAC is an alternative for oncological patients with surgical complications, but it carries a high mortality rate due to the compromised conditions of the patients.

Surgical oncological emergencies in octogenarian patients

BACKGROUND

Surgical oncological emergencies represent a frequent challenge in acute settings, with postoperative courses characterized by high morbidity and mortality. An accurate selection of patients who could benefit from surgery is essential to avoid unnecessary invasive treatment. In this study, we tried to determine if advanced age (>80 years) represents a risk factor for negative short-term outcome in patients undergoing emergency surgery for acute abdominal oncological illness.

METHODS

We retrospectively analyzed the records of patients who underwent emergency oncological surgery at the Department of Acute Care Surgery of Padua General Hospital from January 2018 to December 2022. One hundred two cancer patients were included in the study. Among them, 42 were aged ≥80 years (41%). Multiple preoperative and postoperative parameters were recorded, and the follow-up period was at least 90 days. Multivariate logistic regression analyses were used to identify factors associated with short-term postoperative outcomes.

RESULTS

In the octogenarian group, 30-day mortality was 11% vs. 9.5% in the younger group [p = not significant (ns)] and 90-day mortality was 17.6% in the octogenarian group vs. 20.5% in the younger group (p = ns). Postoperative morbidity and hospital length of stay were not significantly different in the two groups. Low albumin levels [odds ratio (OR) 30.6, 9.51-87.07] and elevated lactate dehydrogenase (LDH) levels (OR 26.4, 9.18-75.83) were predictive for short-term mortality in surgical oncological emergencies.

CONCLUSION

Advanced age is not a risk factor for negative outcomes in surgical oncological emergencies. Therefore, surgical options should be considered in octogenarians with oncological emergencies and acceptable clinical conditions. Serum albumin levels and LDH can help predict the postoperative outcome after surgery for oncological emergencies.

Early extracorporeal membrane oxygenation as bridge for central airway obstruction patients caused by neck and chest tumors to emergency surgery

Central airway obstruction caused by neck and chest tumors is a very dangerous oncological emergency with high mortality. Unfortunately, there is few literature to discuss an effective way for this life-threating condition. Providing effective airway managements, adequate ventilation and emergency surgical interventions are very important. However, traditional airway managements and respiratory support has only limited effect. In our center, using extracorporeal membrane oxygenation (ECMO) as a novel approach to manage patient with central airway obstruction caused by neck and chest tumors has been adopted. We aimed to show the feasibility: using early ECMO to manage difficult airway, provide oxygenation and support surgical procedure for patients with critical airway stenosis caused by neck and chest tumors. We designed a single-center, small sample size retrospective study based on real-world. We identified 3 patients with central airway obstruction caused by neck and chest tumors. ECMO was used to ensure adequate ventilation to emergency surgery. Control group cannot be established. Because traditional manner very likely led to death of such patients. Details of clinical characteristics, ECMO, surgery and survival outcomes were recorded. Acute dyspnea and cyanosis were the most frequent symptoms. All patients (3/3) showed descending arterial partial pressure of oxygen (PaO₂). Computed tomography (CT) revealed severe central airway obstruction caused by neck and chest tumors in all cases (3/3). All patients (3/3) had definite difficult airway. All cases (3/3) received ECMO support and emergency surgical procedure. Venovenous ECMO was the common mode for all cases. 3 patients weaned off ECMO successfully without any ECMO-related complications. Mean duration of ECMO was 3 h (range: 1.5-4.5 h). Under ECMO support, difficult airway management and emergency surgical procedure were finished successfully for all cases (3/3). The mean ICU stay was 3.3 days (range: 1-7 days), and the mean general ward stay was 3.3 days (range: 2-4 days). Pathology demonstrated the tumor dignity for 3 patients including 2 malignant cases and 1 benign case. All patients (3/3) were discharged from hospital successfully. We showed that early ECMO initiation was a safe and feasible approach to manage difficult airway for patients with severe central airway obstruction caused by neck and chest tumors. Meanwhile, early ECMO initiation could ensure security for airway surgical procedure.

International consensus on radiotherapy in metastatic non-small cell lung cancer

BACKGROUND

Lung cancer is the leading cause of cancer-related death worldwide, with non-small cell lung cancer (NSCLC) accounting for most cases. While radiotherapy has historically served as a palliative modality in metastatic NSCLC, considerable advances in its technology and the continuous development of cutting-edge therapeutic agents, such as targeted therapy and immune checkpoint inhibitors (ICIs), are increasing its role in the multi-disciplinary management of the disease.

METHODS

International radiotherapy experts were convened to consider and reach consensuses on the clinical utilities of radiotherapy in metastatic NSCLC, with the aim to provide patient-focused, up to date, evidence-based, recommendations to assist cancer specialists in the management of patients with metastatic NSCLC worldwide.

RESULTS

Timely radiotherapy can offer rapid symptom alleviation and allow subsequent aggressive treatment approaches in patients with heavy tumor burden and/or oncologic emergencies. In addition, appropriate incorporation of radiotherapy as concurrent, consolidation, or salvage therapy makes it possible to achieve long-term survival, or even cure, for patients with oligo-metastatic disease. Cranial radiotherapy plays an important role in the management of brain metastasis, potentially augmenting the response and prolonging survival associated with targeted agents and ICIs. However, key questions remain, such as the appropriate choice of radiation techniques, optimal sequence of systemic therapies and radiotherapy, and optimal patient selection for such combination strategies. Although a strong rationale for combining radiotherapy and ICIs exists, its optimal parameters in this setting remain to be established.

CONCLUSIONS

In the modern era, radiotherapy serves not only as a palliative tool in metastatic NSCLC, but also plays active roles in patients with oligo-focal disease, CNS metastasis and receiving ICIs.

Cardiac Tamponade as an Unusual Initial Clinical Manifestation of CIC-DUX4 Sarcoma

Patient: Male, 48-year-old

Final Diagnosis: Cardiac tamponade

Symptoms: Hypotension • tachycardia

Medication: —

Clinical Procedure: —

Specialty: Oncology

Imaging of acute abdomen in cancer patients

The pattern of disease causing acute abdominal pain has changed over last few decades, some of this has been attributed to intraabdominal cancers. The most common acute abdominal complaints in cancer patients are related to the gastrointestinal system. Abdominal emergencies in cancer patients can result from the underlying malignancy itself, cancer therapy and/or result from the standard pathologies causing acute abdomen in otherwise healthy population. Therapy-related or disease-related immunosuppression or high dose analgesics often blunt many of the findings which are usually expected in non-cancer general population. This complicates the clinical picture rendering the clinical exam less reliable in many cancer patients, and resulting in different pathologies which clinicians and the radiologists should remain aware of. This article focuses on imaging illustrations with differential diagnosis for various emergency scenarios related to acute abdomen specifically in oncologic settings.

Phytochemicals and Gastrointestinal Cancer: Cellular Mechanisms and Effects to Change Cancer Progression

Gastrointestinal (GI) cancer is a prevailing global health disease with a high incidence rate which varies by region. It is a huge economic burden on health care providers. GI cancer affects different organs in the body such as the gastric organs, colon, esophagus, intestine, and pancreas. Internal and external factors like smoking, obesity, urbanization, genetic mutations, and prevalence of Helicobacter pylori and Hepatitis B and Hepatitis C viral infections could increase the risk of GI cancer. Phytochemicals are non-nutritive bioactive secondary compounds abundantly found in fruits, grains, and vegetables. Consumption of phytochemicals may protect against chronic diseases like cardiovascular disease, neurodegenerative disease, and cancer. Multiple studies have assessed the chemoprotective effect of selected phytochemicals in GI cancer, offering support to their potential towards reducing the pathogenesis of the disease. The aim of this review was to summarize the current knowledge addressing the anti-cancerous effects of selected dietary phytochemicals on GI cancer and their molecular activities on selected mechanisms, i.e., nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), detoxification enzymes, adenosine monophosphate activated protein kinase (AMPK), wingless-related integration site/β-catenin (wingless-related integration site (Wnt) β-catenin, cell apoptosis, phosphoinositide 3-kinases (PI3K)/ protein kinase B AKT/ mammalian target of rapamycin (mTOR), and mitogen-activated protein kinase (MAPK). In this review phytochemicals were classified into four main categories: (i) carotenoids, including lutein, lycopene, and β-carotene; (ii) proanthocyanidins, including quercetin and ellagic acid; (iii) organosulfur compounds, including allicin, allyl propyl disulphide, asparagusic acid, and sulforaphane; and (iv) other phytochemicals including pectin, curcumins, p-coumaric acid and ferulic acid. Overall, phytochemicals improve cancer prognosis through the downregulation of β-catenin phosphorylation, therefore enhancing apoptosis, and upregulation of the AMPK pathway, which supports cellular homeostasis. Nevertheless, more studies are needed to provide a better understanding of the mechanism of cancer treatment using phytochemicals and possible side effects associated with this approach.

Review of oncological emergencies in small animal patients

Oncological emergencies can occur at any time during the course of a malignancy and need to be recognized promptly to maximize successful outcomes. Emergencies are characterized as chemotherapy-induced, paraneoplastic syndromes, or directly related to the neoplasm. Prompt identification with treatment of these emergencies can prolong survival and improve quality of life, even in the setting of terminal illness. This review aims to educate the reader on the pathophysiology, clinical presentation and treatment of some of these emergencies, and to review the current veterinary literature to help educate veterinarians in primary and tertiary facilities to know how to diagnose and treat these serious conditions.

Real-Time Multimodal Bioimaging of Cancer Cells and Exosomes through Biosynthesized Iridium and Iron Nanoclusters

Multimodal bioimaging is a powerful tool for visualizing the abnormal state at the target site of the related disease. In this study, we used multimodal imaging techniques such as computed tomography, fluorescence, and magnetic resonance imaging to improve early and precise diagnosis of tumor. Herein, we reported the facile in situ biosynthesis of iridium and iron oxide nanoclusters (NCs) in cancer cells or tumor tissue. These NCs are used as a multimodal bioimaging probe to improve the image sensitivity and specificity toward the tumor. These NCs are applied for the in vivo multimodal imaging in the form of an imaging probe capable of enhancing the sensitivity of the image and specificity toward the tumor tissue. Our observation demonstrates that highly luminescent and magnetic NCs are not only biocompatible but also tumor-targeted because NC formation does not take place in normal cells and tissues. In addition, we isolated exosomes and the biosynthesized NCs internalized within exosomes, and these exosomes can be used as cancer biomarkers.

Factors Associated with Short-Term Mortality After Surgical Oncologic Emergencies

BACKGROUND

The clinical outcome of patients with oncologic emergencies is often poor and mortality is high. It is important to determine which patients may benefit from invasive treatment, and for whom conservative treatment and/or palliative care would be appropriate. In this study, prognostic factors for clinical outcome are identified in order to facilitate the decision-making process for patients with surgical oncologic emergencies.

METHODS

This was a prospective registration study for patients over 18 years of age, who were consulted for surgical oncologic emergencies between November 2013 and April 2014. Multiple variables were registered upon emergency consultation, and the follow-up period was 90 days. Multivariate logistic regression analysis was performed to identify factors associated with 30- and 90-day mortality.

RESULTS

During the study period, 207 patients experienced surgical oncologic emergencies-101 (48.8 %) men and 106 (51.2 %) women, with a median age of 64 years (range 19-92). The 30-day mortality was 12.6 % and 90-day mortality was 21.7 %. Factors significantly associated with 30-day mortality were palliative intent of cancer treatment prior to emergency consultation (p = 0.006), Eastern Cooperative Oncology Group performance score (ECOG-PS) >0 (p for trend: p = 0.03), and raised lactate dehydrogenase (LDH) (p < 0.001). Additional factors associated with 90-day mortality were low handgrip strength (HGS) (p = 0.01) and low albumin (p = 0.002).

CONCLUSIONS

Defining the intent of prior cancer treatment and the ECOG-PS are of prognostic value when deciding on treatment for patients with surgical oncologic emergencies. Additional measurements of HGS, LDH, and albumin levels can serve as objective parameters to support the clinical assessment of individual prognosis.

Current management of surgical oncologic emergencies

Objectives

For some oncologic emergencies, surgical interventions are necessary for dissolution or temporary relieve. In the absence of guidelines, the most optimal method for decision making would be in a multidisciplinary cancer conference (MCC). In an acute setting, the opportunity for multidisciplinary discussion is often not available. In this study, the management and short term outcome of patients after surgical oncologic emergency consultation was analyzed.

Method

A prospective registration and follow up of adult patients with surgical oncologic emergencies between 01-11-2013 and 30-04-2014. The follow up period was 30 days.

Results

In total, 207 patients with surgical oncologic emergencies were included. Postoperative wound infections, malignant obstruction, and clinical deterioration due to progressive disease were the most frequent conditions for surgical oncologic emergency consultation. During the follow up period, 40% of patients underwent surgery. The median number of involved medical specialties was two. Only 30% of all patients were discussed in a MCC within 30 days after emergency consultation, and only 41% of the patients who underwent surgery were discussed in a MCC. For 79% of these patients, the surgical procedure was performed before the MCC. Mortality within 30 days was 13%.

Conclusion

In most cases, surgery occurred without discussing the patient in a MCC, regardless of the fact that multiple medical specialties were involved in the treatment process. There is a need for prognostic aids and acute oncology pathways with structural multidisciplinary management. These will provide in faster institution of the most appropriate personalized cancer care, and prevent unnecessary investigations or invasive therapy.

Mortality in emergency surgical oncology

PURPOSE

Cancer patients can experience problems related to their disease or treatment. This study evaluated reasons for presentation at the emergency room (ER) and outcome of surgical oncology patients.

METHODS

A retrospective chart review for all surgical oncology patients who presented at the ER of the UMCG for surgical consultation between October 1, 2012, and March 31, 2013.

RESULTS

A total of 200 cancer patients visited the ER for surgical consultation: 53.5 % with complications of (previous) cancer treatment, 25.5 % with symptoms caused by malignant disease, and 21.0 % with symptoms not related to cancer or cancer treatment. The 30-day mortality rate for patients with progressive disease was 25.5 %, and overall mortality rate was 62.8 %. The most frequent reason for ER presentation was intestinal obstruction (26.5 %), of which 41.5 % was malignant. Most cancer patients (59.5 %) did not undergo surgery during follow-up. The 30-day mortality for these patients was 14.3 % and overall mortality was 37.8 %. Most patients who died within the first 30 days after ER presentation had not undergone any surgery after presentation (89.5 %).

CONCLUSIONS

There is great variation in mortality rates for cancer patients presenting at the ER for surgical consultation. The mortality in this study was greatest for patients with progressive disease (30-day mortality 25.5 % and overall mortality 62.8 %), and the majority of patients who died within 30 days (89.5 %) had not undergone surgery after ER presentation. Surgery should only be performed in the acute setting when essential and when the expected outcome is favorable for the patient.

Surgical emergencies in oncology

An oncologic emergency is defined as an acute, potentially life threatening condition in a cancer patient that has developed as a result of the malignant disease or its treatment. Many oncologic emergencies are signs of advanced, end-stage malignant disease. Oncologic emergencies can be divided into medical or surgical. The literature was reviewed to construct a summary of potential surgical emergencies in oncology that any surgeon can be confronted with in daily practice, and to offer insight into the current approach for these wide ranged emergencies. Cancer patients can experience symptoms of obstruction of different structures and various causes. Obstruction of the gastrointestinal tract is the most frequent condition seen in surgical practice. Further surgical emergencies include infections due to immune deficiency, perforation of the gastrointestinal tract, bleeding events, and pathological fractures. For the institution of the appropriate treatment for any emergency, it is important to determine the underlying cause, since emergencies can be either benign or malignant of origin. Some emergencies are well managed with conservative or non-invasive treatment, whereas others require emergency surgery. The patient's performance status, cancer stage and prognosis, type and severity of the emergency, and the patient's wishes regarding invasiveness of treatment are essential during the decision making process for optimal management.

Imaging acute complications in cancer patients: what should be evaluated in the emergency setting?

Increased incidence world-wide of cancer and increased survival has also resulted in physicians seeing more complications in patients with cancer. In many cases, complications are the first manifestations of the disease. They may be insidious and develop over a period of months, or acute and manifest within minutes to days. Imaging examinations play an essential role in evaluating cancer and its complications. Plain radiography and ultrasonography (US) are generally performed initially in an urgent situation due to their wide availability, low cost, and minimal or no radiation exposure. However, depending on a patient's symptoms, evaluation with cross-sectional imaging methods such as computed tomography (CT) and magnetic resonance imaging (MRI) is often necessary. In this review article, we discuss some of the most important acute noninfectious oncological complications for which imaging methods play an essential role in diagnosis.

The lung cancer patient at the emergency department: a three-year retrospective study

INTRODUCTION

Currently, there are limited data on the lung cancer patient at the emergency department. Our objective is to review the medical charts of those patients to determine the frequency and main causes of emergency consultations and the predicting factors for hospital admissions and deaths.

METHODS

We conducted a retrospective study including all patients with lung cancer consulting at the emergency department of a cancer hospital.

RESULTS

From January 1, 2008 to December 31, 2010, 269 patients with lung cancer presented at the emergency, corresponding to 548 consultations (8.3% of all 6575 visits). During the same period, 626 patients for lung cancer were treated in our institution meaning that 43% of them are consulting at least once the emergency department during the course of their disease. The main reasons for consultation were respiratory symptoms (22.3%) and fever (19.9%). Emergency visit leads to hospital admission in 63% of the cases. In multivariate analysis, the main independent predictor factor of hospitalisation is arrival by ambulance (odd ratio 12), which is also the principal predictor of death during hospitalisation (odd ratio 9.5). The presence of signs at physical examination is also an important factor.

CONCLUSION

Our study shows that emergency visit is a frequent event for lung cancer patients and has identified simple factors predicting hospitalisation and deaths.

Neck neoplastic conditions in the emergency setting: role of multidetector computed tomography

Emergent conditions resulting from head and neck neoplasms and their treatment include acute airway obstruction, hemorrhage, spinal cord compression, bilateral vocal cord paralysis, and septic thrombophlebitis. These conditions require accurate diagnosis and rapid intervention to avoid severe permanent damage or death. Successful treatment requires a coordinated response by emergency medicine physicians, otolaryngologists, vascular surgeons, and radiologists. We review these head and neck oncological conditions, which present emergently, with a focus on radiological evaluation and interpretation.

Oncological emergencies: clinical importance and principles of management

Oncological emergencies are common conditions associated with significant morbidity and mortality. Delay in diagnosis and treatment can result in unfavourable outcomes. Cancer itself, cancer-related hormones or cytokines, or treatment effects can cause emergency problems. Febrile neutropaenia, frequently associated with chemotherapy, can lead to life-threatening conditions. Treatment requires systematic evaluation and early empirical antibiotics. Hypercalcaemia of malignancy is the most common metabolic emergency in cancer patients. Non-specific clinical features may cause delay in diagnosis and increase morbidity and mortality. Treatment includes active fluid resuscitation, diuretics and intravenous bisphosphonates. Superior vena cava syndrome is usually caused by external compression. Computerised tomography is useful to confirm diagnosis, evaluate the extent of disease and guide invasive tissue diagnosis. Treatment and prognosis depend on the underlying malignancies. Spinal cord compression is a true emergency due to risk of permanent neurological impairment. Localised back pain is the most common presenting symptom while late presentation of neurological deficit is associated with irreversible outcomes. Magnetic resonance imaging is the investigation of choice. Treatment includes corticosteroids, radiotherapy and/or decompressive surgery.

Superior vena cava obstruction: dangers of a missed diagnosis

We report the case of a 7 year old girl who presented to the Children's Emergency Department with a 6 week history of bilateral facial and neck swelling. She had felt generally unwell, tired, with a recent onset of dry cough, and had presented multiple times to her general practitioner (GP) who after initially unsuccessfully trying an antihistamine, had given her five courses of soluble Betamethasone (corticosteroid) over six weeks, for presumed allergy; this temporarily relieved her symptoms for a couple of days each time. On subsequent referral to Accident and Emergency she was found to have a superior mediastinal mass, with a left pleural effusion and mediastinal deviation to the right. Further investigation confirmed the diagnosis of a T-cell lymphoma causing superior vena cava obstruction of blood flow through the SVC to the right atrium and is a classical oncological emergency. This case report highlights the importance of recognizing superior vena cava obstruction and the need for awareness of malignancy as a differential diagnosis when initially presented with a child with non-specific respiratory findings. We highlight that acute tumour lysis syndrome, a life threatening metabolic emergency that results from massive cytolysis of malignant cells, may occur after a single dose of corticosteroids and one should be aware of this potentially life-threatening complication.

The role of the primary care physician during the active treatment phase

Although more research needs to be done to determine the optimal role for PCPs during the active phase of cancer treatment, patients, PCPs, and oncologists all see a significant role for primary care in the care of patients with cancer. In the United States, family physicians are actively involved in the care of cancer patients, especially in provision of support, education, and care of intercurrent illness and chronic disease. Fatigue, depression, pain, and psychosocial distress are important symptoms that should be screened for and addressed. The PCP should be aware of adverse effects of chemotherapy and radiation and cancer-related emergencies. Sexual and intimacy concerns, including contraception and fertility, are important to patients entering active cancer treatment but may not be addressed adequately in usual cancer care. Advising the patient in active cancer treatment on issues of general health including common nutritional issues can provide value through the treatment period. Use of CAM is common and several modalities have been shown to benefit patients in the course of cancer treatment.

Managing cancer and its intercurrences: the family deciding to seek emergency care for the child

This study aimed to understand how the family of a child with cancer manages the illness and its intercurrences at home, and how it makes the decision of taking the child to an emergency care service. Oral History was used as the methodological strategy and data analysis was based on the "Family Management Style Framework". Participants were six mothers between 28 and 47 years old, who were experiencing their child's cancer treatment. The possible need for emergency care is incorporated into the family routine as a resource to manage the illness whenever it goes beyond the mother's capacity to keep control over the symptoms, which is permeated by suffering, derived from the uncertainties this creates. Helping the mother to develop skills to get stronger and reduce the suffering resulting from the situations that generate uncertainties and insecurities in her daily life with the child with cancer is a challenge.