Review of Current Principles of the Diagnosis and Management of Brain Metastases.

Brain metastases are the most common intracranial tumors and are increasing in incidence as overall cancer survival improves. Diagnosis of brain metastases involves both clinical examination and magnetic resonance imaging. Treatment may involve a combination of surgery, radiotherapy, and systemic medical therapy depending on the patient's neurologic status, performance status, and overall oncologic burden. Advances in these domains have substantially impacted the management of brain metastases and improved performance status and survival for some patients. Indications for surgery have expanded with improved patient selection, imaging, and intraoperative monitoring. Robust evidence supports the use of whole brain radiotherapy and stereotactic radiosurgery, for both standalone and adjuvant indications, in almost all patients. Lastly, while systemic medical therapy has historically provided little benefit, modern immunotherapeutic agents have demonstrated promise. Current investigation seeks to determine the utility of neoadjuvant radiotherapy and laser interstitial thermal therapy, which have shown benefit in limited studies to date. This article provides a review of the epidemiology, pathology, diagnosis, and treatment of brain metastases and the corresponding supporting evidence.

Opioid Management in the Dying Child With Addiction.

The dramatic increases of opioid use and misuse in the past 15 years have resulted in a focus on the responsible and judicious use of opioids. In this Ethics Rounds, the commentators analyze the case of a 16-year-old girl with lymphoma and opioid misuse whose caregiver may have diverted her opioids. She is now at the end of life and prefers to die at home. The commentators, oncologists, palliative care providers, ethicists, and a medical student agree that supporting the patient's goals and practicing good opioid stewardship are not incompatible. They identify additional information that would be required to analyze the case more fully such as the nature of the evidence for misuse and diversion and whether bias inadvertently contributed to these concerns. They agree that multimodal analgesia, including but not limited to opioids, is important. Safeguards could include a contract, directly observed therapy, and/or urine drug screens. Supervision or removal of a caregiver diverting medication or admission of the patient misusing medications would be alternatives if the initial plan was unsuccessful. Such patient-centered care requires well-developed substance misuse treatment, pain management, and home hospice that are adequately reimbursed.

Outcomes and Disposition of Oncology Patients With Non-neutropenic Fever and Positive Blood Cultures.

Children with cancer and non-neutropenic fever (NNF) episodes are often treated as outpatients if they appear well. However, a small subset have bloodstream infections (BSIs) and must return for further evaluation. These patients may be directly admitted to inpatient units, whereas others are first evaluated in outpatient settings before admission. The best practice for securing care for patients discovered to have outpatient bacteremia are unclear. To determine outcomes and compare time to antibiotics between the 2 disposition, we retrospectively reviewed all NNF initially treated as outpatients and later had positive blood cultures from 2012 to 2016. Of 845 NNF cases initially treated in outpatient settings, 48 episodes (n=43 patients) had BSIs. Of those, 77.1% (n=37) were re-evaluated as outpatients and admitted; 14.6% (n=7) were direct admissions. The median time to antibiotic did not significantly differ between outpatient re-evaluations (119 min) and direct admissions (191 min), P=0.11. One patient met sepsis criteria upon return and required intensive care unit admission for vasopressor support. No patient died within 1 week of the febrile episode. Most patients with NNF and BSIs initially discharged are stable upon return. Institutions should evaluate their patient flows to ensure that patients receive timely care.

Isolation of Extracellular Vesicles for Cancer Diagnosis and Functional Studies.

Extracellular vesicles (EVs) are a diverse category of cellular export products that are present in a variety of biofluids and cell culture media. EVs contain a wide variety of macromolecules that represent a sampling of the cytoplasmic or endosomal compartments and function in cell-to-cell paracrine and endocrine signaling; it has been demonstrated that pathological states such as oxidative stress, transformation, apoptosis, and various cell injuries induce cells to increase their EV release rate, simultaneously altering their composition to reflect the altered state of the cellular origin. Specifically, in patients with solid tumors, EVs are released from cancerous cells at a higher rate than from healthy cells and are enriched in tumor signature molecules. Because of their stability, increased concentration, and unique signatures in cancer patients, EVs have become the subject of investigation for diagnostic and prognostic purposes. Moreover, understanding EVs' biogenesis and biological role could lead to novel insights toward cellular cross talk and complex biological pathways in cancer research. To make use of EVs for diagnostic and mechanistic cancer research, standardized well-characterized methods are required. This chapter provides an overview of two EV isolation techniques and provides detailed instructions on the isolation of EVs by ultracentrifugation, the labor-intensive gold standard, and concentrated polymer precipitation, a faster, higher-yield technique that can be utilized in cancer research.

The role of 8q24 copy number gains and c-MYC expression in amelanotic cutaneous melanoma.

Cutaneous melanomas may be quite heterogeneous in their clinical, histological and molecular findings. Correlating these features may help identify distinctive subgroups of melanomas and improve our overall understanding and prognostication of melanoma. We recently identified a subgroup of melanomas with increased chromosomal copy number gains in 8q24 at MYC having several distinctive clinical and histopathological characteristics, including an aggressive clinical course and an amelanotic clinical and histological appearance. It has been postulated that oncogenes such as MYC may have regulatory effects on genes critical to melanin pigment synthesis, specifically microphthalmia-associated transcription factor (MITF), which is known to have a key role in regulating the expression of tyrosinase (TYR), an important enzyme in the production of melanin pigment. We investigated the possible mechanism underlying the amelanotic appearance of melanomas with gains in 8q24 by evaluating the relationship between melanomas with and without 8q24 copy number gains and c-MYC, MITF and TYR protein expression. Immunohistochemical analysis of c-MYC, MITF and TYR was performed on 36 melanomas with gains in 8q24 and 40 melanomas without gains in 8q24. The melanomas with gains of 8q24 correlated with elevated c-MYC protein expression and melanomas without gains in 8q24 showed significantly decreased c-MYC protein expression. A direct relationship between the presence of gains in 8q24 and decreased MITF expression, as well as between c-MYC and TYR protein expression was also observed. Our results suggest that MYC can have a role in the pigmentary pathway of melanoma. In amelanotic melanomas with gains in 8q24, downregulation of TYR and other melanocyte-specific genes may be mediated by MYC leading to transcriptional suppression of MITF. As MITF is a frequently used marker to establish melanocytic lineage in melanoma, our study also raises the important clinical consideration that amelanotic melanomas, especially those with gains in 8q24 may lack expression of MITF.

The effect and safety of short-term creatine supplementation on performance of push-ups.

The effects of short-term oral creatine (Cr) supplementation on exercise performance and on blood pressure and renal function were assessed. Thirty-five healthy, active duty, U.S. Army volunteers (20 men and 15 women; age, 22-36 years) at Fort Sam Houston, Texas, supplemented their diet for 7 days with 20 g/day of either Cr or taurine (as placebo). There was no significant difference in 2-minute push-up counts between the Cr and taurine groups from before to after supplementation (p = 0.437; power = 0.98). The Cr group demonstrated a significant increase in serum creatinine levels (p < 0.001), compared with the taurine group, and this increase could be misinterpreted as impairment of renal function. No adverse changes in blood pressure, body composition, weight, or serum Cr phosphokinase levels were observed. We conclude that short-term Cr supplementation appears to be safe but does not enhance push-up performance.