Infectious complications of hepatic artery catheterization procedures in patients with cancer

A total of 353 hepatic artery catheterization procedures were carried out in 211 patients with cancer over a 1-year period (January-December 1988). The procedures included 49 embolizations in 32 patients, 123 chemoembolizations in 73 patients, and 181 chemoinfusions in 106 patients. The overall infection rate was 3.4%. Infectious complications occurred in 3.1% of patients undergoing hepatic artery embolization alone, 1.9% of patients undergoing hepatic artery chemoinfusion, and 4.1% of patients undergoing hepatic artery embolization followed by chemoinfusion. Four patients had infectious complications that included four episodes each of cholangitis, liver abscess, and septicemia. One patient developed a subphrenic abscess in addition to a liver abscess. Enteric gram-negative bacilli (aerobic and anaerobic) were isolated from all four patients. None of the patients had received prophylactic antibiotics. All patients responded to antimicrobial therapy and percutaneous drainage of abscesses.

Infections associated with biliary drainage procedures in patients with cancer

A total of 170 therapeutic biliary drainage procedures were carried out in 90 patients with cancer over a 1-year period (January-December 1988). There were 129 percutaneous transhepatic biliary drainage procedures done in 61 patients and 41 endoprostheses were placed in 29 patients. The overall infection rate related to these procedures was 60.6%, the rate being similar for the two procedures. Infectious complications were experienced by 50% of patients undergoing a biliary drainage procedure. The most common manifestation was cholangitis followed by bacteremia. Other infections included liver abscess, gallbladder abscess, and subphrenic abscess. The most common isolates were enteric gram-negative bacilli, followed by Enterococcus species, Candida species, and Staphylococcus epidermidis. The use of prophylactic antibiotics in 76% of infected patients failed to prevent biliary catheter-related infections. Two patients died of complications related to biliary sepsis. All other infected patients responded to antimicrobial therapy, which included various regimens of beta-lactam agents (third-generation cephalosporin, extended-spectrum penicillin, imipenem-cilastatin, and aztreonam) that were used in combination with an aminoglycoside in 15 patients.

Five-year survival in patients given intra-arterial chemotherapy prior to radiotherapy for advanced squamous carcinoma of the cervix and vagina

Five-year survival studies in patients with advanced gynecologic pelvic malignancy treated with intra-arterial chemotherapy followed by radiotherapy have not been reported in the literature. Forty-six evaluable patients entered into a study between 1981 and 1985 at the University of Texas-M.D. Anderson Cancer Center were reviewed for follow-up. Two patients were FIGO (International Federation of Gynecology and Obstetrics) Stage IIB cervical cancer, thirty-one patients were Stage III cervical cancer, seven patients were Stage IVA cervical cancer, and six patients were unstaged, cut-through cervical cancer, or primary vaginal carcinoma with bulky tumor volume. Seventeen patients had evidence of obstructive uropathy by intravenous pyelogram. Pretreatment lymphangiogram was carried out in 32 patients, 14 of whom were positive for pelvic lymph node involvement. Forty-four patients had received no prior therapy before initiating intra-arterial chemotherapy. Thirty-five (76%) of the patients responded to locally infused pelvic intra-arterial chemotherapeutic agents consisting of mitomycin-C, bleomycin, and cisplatin. Vincristine was given peripherally by intravenous access. There were 24 (52%) partial responders, 11 (24%) complete responders, and 11 (24%) nonresponders. Two (4%) patients progressed during treatment, while twenty-six (57%) patients relapsed after receiving chemotherapy followed by radiotherapy. Three additional patients died from treatment-related causes, one secondary to renal failure, one to massive pulmonary embolus, and one from a combination of pulmonary toxicity secondary to bleomycin and sepsis. Three of fifteen patients in complete remission died from unrelated causes with no evidence of disease. The 5-year survival rate for the study group was 30%, with a median survival duration of 18 months.

Case report 682. Neuroepithelioma of soft tissues of the knee

Peripheral neuroepitheliomas should be included in the differential diagnosis of a soft-tissue tumor in the extremities or chest wall, especially in young adolescents. MRI provides useful information as to the extent of the tumor and relationship with adjacent structures, although it may not differentiate neuroepitheliomas from other, more common, soft-tissue sarcomas. Together with clinical and histological findings, MRI can assist in the diagnosis and treatment planning of this tumor.

MR appearance of the distended iliopsoas bursa

The purpose of this essay is to illustrate the MR appearance of the distended iliopsoas bursa. The bursa must be recognized on MR scans to avoid confusing it with malignant neoplasms and other lesions.

MDA-image: an environment of networked desktop computers for teleradiology/pathology

MDA-Image, a project of The University of Texas M. D. Anderson Cancer Center, is an environment of networked desktop computers for teleradiology/pathology. Radiographic film is digitized with a film scanner and histopathologic slides are digitized using a red, green, and blue (RGB) video camera connected to a microscope. Digitized images are stored on a data server connected to the institution's computer communication network (Ethernet) and can be displayed from authorized desktop computers connected to Ethernet. Images are digitized for cases presented at the Bone Tumor Management Conference, a multidisciplinary conference in which treatment options are discussed among clinicians, surgeons, radiologists, pathologists, radiotherapists, and medical oncologists. These radiographic and histologic images are shown on a large screen computer monitor during the conference. They are available for later review for follow-up or representation.

Prostatic urethra dilatation with the Gianturco self-expanding metallic stent: a feasibility study in cadaver specimens and dogs

In an effort to develop a transcatheter technique for dilatation of the prostatic urethra without the use of balloons, the feasibility of using Gianturco self-expanding stents was evaluated. Initially, eight human cadaveric prostatic urethras were stented to evaluate the ability of the stent to dilate the lumen. In all cases, the device attained its unconstrained diameter immediately on placement. Subsequently, stents were placed in the prostatic urethra of 12 dogs and followed up for 1 month (four dogs), 3 months (one dog), and 6 months (seven dogs). Five bare straight-end prostheses, one nylon-covered straight-end device, and six flared-end stents were used. Three of the bare straight-end stents migrated during the follow-up, whereas the nylon-covered and flared-end stents did not. Stent diameters greater than 1.3 times the urethral diameter caused moderate to marked edema and inflammation. After 6 months, white deposits were found on the solder points, presumably from electrolysis. Our experience suggests that placement of Gianturco self-expanding stents may be a useful method of dilating and maintaining the luminal diameter of the prostatic urethra, although care must be taken to select the proper stent size.

Intracranial chordoma in a preadolescent. Case report

Chordomas are rare tumors derived from notochord remnants occurring primarily in the sacrum, clivus, and cervical regions. Exceptionally, these tumors occur in children, though usually in the sacrum. Eight cases of clivus chordoma have been described in preteenagers. In this report, a clival chordoma with unusual radiologic features is described in an 11-year-old boy. The literature regarding this entity is reviewed.

Synthesis and in vitro receptor binding studies of fluorotamoxifen analogues

We describe the synthesis of new fluorotamoxifen analogues with the fluorine atom positioned on the end of the aliphatic chain of tamoxifen. The binding of fluorotamoxifens to cytosol estrogen receptors of rat uteri was determined with [3H]estradiol (5 nM). The fluorotamoxifens had similar or superior binding affinities compared with tamoxifen. The IC50 value was as follows: tamoxifen, 5 x 10(-7) M; fluorotamoxifen (VII), 5 x 10(-7) M; N,N-diethylfluorotamoxifen (IV)-cis, 1 x 10(-6) M, and trans, 2 x 10(-7) M; and (cis) fluoromethyl-N,N-diethyltamoxifen (VI) 1 x 10(-7) M. Therefore, the fluorinated tamoxifens have potential use in imaging estrogen receptors by PET.

Percutaneous skeletal biopsy

Percutaneous bone biopsy has become an accepted means for tissue diagnosis in indeterminate metastatic disease, whereas needle biopsy for the evaluation of primary skeletal neoplasms is controversial. Needle biopsies are also of value in the diagnosis of inflammatory lesions and eosinophilic granuloma. The diagnostic accuracy of this procedure ranges from 50 to 94% in malignant disease, but is less favorable in benign disease. The low complication rate of about 0.2% makes the percutaneous approach an attractive alternative to surgical biopsy.

A pilot clinical and pharmacokinetic study of intracarotid cisplatin and bleomycin

Fifteen patients with progressive primary malignant or metastatic brain tumors were treated on a clinical and pharmacokinetic study with intracarotid cisplatin and bleomycin. Toxicity was tolerable and consisted mainly of nausea and vomiting. Neurologic toxicity included focal seizures (1), leukoencephalopathy (1), and motor weakness (1). Five patients had improvement in CT scans and four patients had stabilization of disease. Recommended dosage for future clinical trials are cisplatin 60 mg/m2 and bleomycin 100 units. Pharmacokinetics of intracarotid cisplatin revealed the jugular vein concentration was twice the peripheral vein level at the end of infusion. Cisplatin is a drug which has demonstrated in vitro activity against malignant gliomas (1). Clinical trials with intravenous administration of cisplatin has shown definite, although limited antitumor activity against primary brain tumors (2,3,4) and metastatic brain tumors (5,6). To enhance its antitumor effect, cisplatin has been administered by the intracarotid route (7,8,9). The results appear encouraging, but neurological and ophthalmological toxicity may occur (8). In our initial study with intracarotid cisplatin, 35 patients with malignant brain tumors (23 with primary brain tumors and 12 with brain metastases) progressing after cranial irradiation +/- chemotherapy were treated. Of 20 evaluable patients with primary tumors, 6 responded to therapy and 5 had stable disease. Five of 10 evaluable patients with brain metastases responded and 2 had stable disease. For responding primary brain tumor patients the median time to progression was 33 weeks. The recommended dose for intracarotid cisplatin was 60-75 mg/m2 administered every 3-4 weeks (7,8). Higher cisplatin doses produced more central neurological toxicity. There is limited data on the central nervous system pharmacology of cisplatin.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous lymph node biopsy

Advances in imaging modalities for detecting lymphadenopathy, the ease, safety, and accuracy of the tools and techniques, and the addition of refined ancillary studies for cytologic analysis will continue to increase the acceptance and use of percutaneous lymph node biopsy (PLNB) by fine-needle aspiration (FNA), especially in lymphomas.

AIDS knowledge and homophobia among French and American university students

22 male American and 24 male French college students' knowledge of AIDS scores were equivalent on a currently constructed 18-item questionnaire. Both groups answered more than 75% of the questions correctly. The American students' homophobic bias and reaction scores were higher than those of the French students on a 43-item homophobic questionnaire. The latter findings were interpreted as consistent with reduced effects of conservative, orthodox religion in France and the stability of traditional religious influence in America over the past three decades. No relation was found between knowledge of AIDS and homophobia in these small conveniently available samples.

Pediatric osteosarcoma: therapeutic strategies, results, and prognostic factors derived from a 10-year experience

Ninety-eight pediatric patients were treated with three separate protocols (Treatment and investigation of Osteosarcoma [TIOS] I, II, and III) and 47 developed recurrent disease (metastases and/or local recurrence). Actuarial overall disease-free survival (hereafter designated survival) was 43%. Over 90% of the patients were treated initially with preoperative intraarterial cisplatin (CDP). Postoperative chemotherapeutic regimens comprised high-dose methotrexate with leucovorin rescue (MTX-CF), Adriamycin [( ADR] doxorubicin; Adria Laboratories, Columbus, OH), and cyclophosphamide. Primary definitive treatment comprised amputation or limb salvage (TIOS I and TIOS III). Patients treated with preoperative CDP and surgery (TIOS I and III) had a 62% survival. Patients in TIOS II refused surgical extirpation; they were treated exclusively with chemotherapy and had a 23% survival. Survival in patients treated with amputation was 55% and limb salvage 58%. Prognostic factors considered significant in relation to development of pulmonary metastases comprised tumor burden (P = .04) and the percentage of tumor necrosis induced by preoperative chemotherapy (P = .01). Histopathologic subtype was marginally significant: chondroblastic was more favorable as opposed to osteoblastic (P = .05). These findings are compared with results and prognostic factors published in the literature.

Expandable metallic biliary endoprostheses: preliminary clinical evaluation

A biliary endoprosthesis constructed of self-expanding metallic "Z" stents was placed in 23 patients with obstructive jaundice. The biliary obstruction was due to a malignant neoplasm in 21 patients and a postoperative biliary stricture in two patients. The lesions affected the intrahepatic biliary ducts in 13 patients. Twelve patients had undergone radiation therapy before stent placement. The endoprostheses consisted of 196 expandable metallic biliary stents placed singly (n = 10) or in tandem (n = 186). As many as 18 stents were used to relieve an obstruction in one patient. A transhepatic approach was employed in all patients except one in whom stents were placed through a T-tube tract. Within 1 week after placement, all stents expanded to at least 90% of their original diameter. Three misplaced, two deformed, and two dislodged stents caused no obvious clinical problems. At follow-up, which ranged from 2 to 59 weeks, five patients experienced recurrent jaundice. Two patients with recurrent jaundice due to obstruction of the bile duct containing the stent were treated with external catheter drainage. The expandable biliary endoprosthesis is suggested as an effective treatment for benign and malignant biliary obstruction.

Intracarotid cisplatin-based chemotherapy in patients with malignant melanoma and central nervous system (CNS) metastases

Twenty-three patients with malignant melanoma metastatic to the central nervous system (CNS) were treated with intracarotid cisplatin-based chemotherapy. Twenty-two had failed prior cranial radiation therapy (one patient refused radiation therapy) and had progressive brain metastases documented by computerized tomography (CT). Intracarotid cisplatin 40-75 mg/m2 was administered alone (seven patients) with 1,3-bis(2-Chloroethyl)-1-nitrosourea (BCNU) (13 patients) or bleomycin (three patients). Courses were repeated monthly with CT scan. Seven patients (30%) had objective improvement in CT scans and three patients (13%) had stabilization of disease. The median time to tumor progression for responding patients was 20 weeks (range 8-34 weeks) while stable disease ranged from 9-12 weeks. In three patients the extracranial disease progressed while the brain metastases responded. Neurological and retinal toxicity were potential complications of therapy. Intracarotid cisplatin-based chemotherapy may be useful for palliation in selected patients with malignant melanoma and CNS metastases.

Experimental evaluation of ethanol-ethiodol for transcatheter renal embolization

Adult mongrel dogs were used to evaluate and compare the use of ethanol and ethanol-Ethiodol for transcatheter renal arterial embolization. Each agent was administered into a main renal artery in five dogs and evaluated with regard to ease of use, radiopacity, arterial occlusion, parenchymal damage, and toxicity. Both agents were easy to inject, and no complications were encountered in any of the animals. Ethiodol added the ability to fluoroscopically monitor the infusate for reflux and distribution, yielded a more homogeneous distribution of the ethanol within the renal vasculature, and increased the embolic effects of the ethanol. Adding Ethiodol to ethanol should decrease the latter's complications since administration can be monitored fluoroscopically and a smaller volume of ethanol could perhaps be used to achieve the desired result. Additional research is needed to determine the safety of administering larger volumes of Ethiodol into the renal artery.

Covert self poisoning with brodifacoum, a 'superwarfarin'

The clinical course of a patient poisoned with the 'superwarfarin' brodifacoum and a method for estimation of plasma levels is described. It was characterised by prolonged depression of Vitamin K-dependent clotting factors poorly responsive to Vitamin K administration.

Magnetic resonance imaging in aggressive fibromatosis

The magnetic resonance imaging (MRI) features of aggressive fibromatosis in 11 patients (five with recurrent tumour) and its contribution to patient management are described. Tumour signal intensity ranged from being low to isointense with respect to muscle on T1-weighted images while being predominantly of heterogenous increased signal intensity on T2-weighted images. A post-contrast (Gd-DTPA) study demonstrating diffuse tumour enhancement was of value in assessing tumour extent in two patients. CT in six patients and angiography in two patients provided no additional information while tumour relationship to neurovascular structures and extent was better appreciated on MRI. MRI was accurate in predicting resectability in all six patients who had surgery.

Myristylated polyomavirus VP2: role in the life cycle of the virus

The double-stranded genome of the small DNA tumor virus, polyomavirus, is enclosed in a capsid composed of a major protein, VP1, which associates as pentameric capsomeres into an icosahedral structure, and two minor proteins, VP2 and VP3, whose functions and positions within the structure are unknown. The N-terminal glycine of the VP2 coat protein has been shown to be cotranslationally acylated with myristic acid. To study the function of this modification and the role of VP2 in the life cycle of polyomavirus, the N-terminal glycine, critical to the myristylation consensus sequence, has been altered to a glutamic acid or a valine residue by site-directed oligonucleotide mutagenesis. The glycine----glutamic acid mutant DNA has been further studied. When transfected into cells permissive for the polyomavirus full lytic life cycle, this mutant DNA replicated at levels comparable to those of wild-type viral DNA, and small amounts of nonrevertant (mutant) virus could be harvested from the cultures. The virus particles viewed by electron microscopy appeared slightly distorted, but the ratio of full to empty particles was similar to that produced in a wild-type viral infection. Mutant virus was capable of reinfecting permissive cells but with a considerably reduced efficiency.

Liposome distribution after intravenous and selective intraarterial infusion in dogs

In an effort to improve hepatic uptake of liposomes for drug delivery, empty vesicles were administered by means of selective arterial infusion. Negatively charged, multilamellar liposomes were labeled with technetium-99m and infused into healthy adult dogs. Each dog received 100 mg/m2 of lipid over 10 minutes at 2 mL/min. Liposomes were administered via the common hepatic artery after proximal occlusion of the gastroduodenal artery, via the cranial mesenteric artery, and via the cephalic vein. Distribution (liver, spleen, and lungs) was determined by computer-assisted external imaging techniques. On the average, after arterial infusion, 69.2% of the total activity was located in the liver, 3.6% in the spleen, 3.2% in the lungs, and 3.5% in the general circulation. Following venous injection, 50.7% of the radioactivity was found in the liver, 9.1% in the spleen, 8.6% in the lungs, and 6.7% in the peripheral blood. Once the liposomes entered the systemic circulation, they were cleared at the same rate (half-life beta = 21.5 hours) independent of their route of administration. Increased hepatic liposome uptake should translate into higher local and lower systemic liposomal drug levels.

Fine needle aspiration biopsy in lymphoma

Patients with lymphoma undergo excisional biopsy of an affected lymph node for initial classification of their disease because accurate classification depends on the histologic characteristics of the neoplasm. However, fine needle aspiration cytology has a role in the management of lymphoma patients, particularly in those with recurrent or residual masses following treatment. Moreover, immunologic markers, nucleic acid flow cytometry, cytogenetics, and molecular genetics, which do not depend on histologic characteristics and can be performed on fine needle aspirates, are acquiring more importance in the management of patients with these diseases, particularly in those with non-Hodgkin's lymphoma. These latter tests add objectivity to the cytologic diagnosis of the B-cell lymphomas and increase its accuracy. In most series, the accuracy of fine needle aspiration in patients with lymphoma approaches 90%, with minimal complication rates.