Adjuvant chemoradiotherapy for "unfavorable" carcinoma of the ampulla of Vater: preliminary report

HYPOTHESES

Adjuvant chemoradiotherapy decreases the risk of local recurrence in patients with adenocarcinoma of the ampulla of Vater and high-risk features. Adjuvant chemoradiotherapy for this population can be administered safely and without much morbidity.

DESIGN

Controlled, prospective, single-arm study.

SETTING

Tertiary care referral hospital.

PATIENTS

From June 1995 to March 1999, 12 patients (7 men and 5 women; median age, 66 years; age range, 38-78 years) with "unfavorable" ampullary carcinoma were treated with adjuvant chemoradiotherapy. All patients underwent pancreaticoduodenectomy, and all pathologic findings were confirmed at Stanford University Medical Center, Stanford, Calif. Unfavorable features were defined as involved lymph nodes (n = 10), involved surgical margins (n = 1), poorly differentiated histological features (n = 3), tumor size greater than 2 cm (n = 6), or the presence of neurovascular invasion (n = 4).

INTERVENTIONS

Four to 6 weeks after undergoing pylorus-preserving pancreaticoduodenectomy with regional lymphadenectomy, patients began adjuvant chemoradiotherapy consisting of concurrent radiotherapy (45 Gy) and fluorouracil by protracted venous infusion (225-250 mg/m(2) per day, 7 days per week) for 5 weeks.

MAIN OUTCOME MEASURES

Local recurrence, distant recurrence, overall survival rate, and treatment-related toxic effects.

RESULTS

All patients completed the prescribed treatment course. Toxic effects were assessed twice a week during treatment and graded according to the National Cancer Institute Common Toxicity Criteria Scale. One patient required a treatment interruption of 1 week for grade III nausea/vomiting. No grade IV or V toxic effects were observed. At median follow-up of 24 months (range, 13-50 months), 8 of 12 patients were alive and disease free. One patient was alive but had disease recurrence. Three patients died of this disease (liver metastases). Actuarial overall survival at 2 years was 89%, and median survival was 34 months. One surviving patient developed a local recurrence and a lung lesion. Actuarial overall survival and median survival were better than in a parallel cohort with resected high-risk pancreatic cancer (n = 26) treated with the same adjuvant chemoradiotherapy regimen (median survival, 34 vs 14 months; P<.004).

CONCLUSIONS

Adjuvant chemoradiotherapy for carcinoma of the ampulla of Vater is well tolerated and might improve control of this disease in patients with unfavorable features.

Isolation of taxoids from cell suspension cultures of Taxus wallichiana

Cell suspension cultures of stem-derived callus of Taxus wallichiana in MS-F culture media were found to produce three C-14 oxygenated taxoids and one regular taxoid. The taxoids were identified as yunnanxane (1), 2 alpha, 5 alpha, 10 beta, 14 beta-tetraacetoxy-4(20),11-taxadiene (2), 2 alpha, 5 alpha, 10 beta-triacetoxy-14 beta-(2-methyl)-butyryloxy-4(20),11-taxadiene (3) and 1 beta-hydroxybaccatin I (4).

Adjuvant radiotherapy and concomitant 5-fluorouracil by protracted venous infusion for resected pancreatic cancer

PURPOSE

To assess the toxicity and clinical benefit from adjuvant chemoradiotherapy consisting of protracted venous infusion 5-fluorouracil (5-FU) and concomitant radiotherapy in patients with resected pancreatic cancer.

METHODS AND MATERIALS

Between 1994 and 1999, 52 patients who underwent pancreaticoduodenectomy received adjuvant chemoradiotherapy. The tumor bed and regional nodes received a dose of 45 Gy in fractions of 1.8 Gy followed by boost to the tumor bed if the surgical margins were involved (total dose, 54 Gy). The patients also received concomitant 5-FU by protracted venous infusion (200-250 mg/m(2)/day, 7 days/week) during the entire radiotherapy course.

RESULTS

Fifty-two patients (30 men, 22 women) were enrolled and treated on this protocol. The median age was 63 years (range, 38-78 years), and the median Karnofsky Performance Status was 80 (range, 70-100). Thirty-five percent had involved surgical margins and 59% had involved lymph nodes. All patients completed therapy, and there were no Grade IV/V toxicities observed. With median follow-up of 24 months (range, 3-52 months) for surviving patients, the median survival is 32 months, and 2-year and 3-year survivals are 62%, and 39%, respectively.

CONCLUSION

Radiotherapy with concomitant 5-FU by protracted venous infusion as adjuvant treatment for resected pancreatic cancer is well tolerated. This approach allows for greater dose intensity with reduced toxicity. The median survival of this cohort of patients compares favorably with our earlier experience and other published series.

Pancreatic tumors show high levels of hypoxia

PURPOSE

Because of the dismal outcomes of conventional therapies for pancreatic carcinomas, we postulated that hypoxia may exist within these tumors.

METHODS AND MATERIALS

Seven sequential patients with adenocarcinomas of the pancreas consented to intraoperative measurements of tumor oxygenation using the Eppendorf (Hamburg, Germany) polargraphic electrode.

RESULTS

All 7 tumors demonstrated significant tumor hypoxia. In contrast, adjacent normal pancreas showed normal oxygenation.

CONCLUSION

Tumor hypoxia exists within pancreatic cancers.

Successful management of an aneurysmal aortoesophageal fistula

We report a case of aortoesophgeal fistula secondary to the aneurysm of the descending thoracic aorta. The patient presented with massive hematemesis with bright red blood. Patient was operated upon emergently and survived without complication. Six other such cases with successful outcome have been reported before, which depends on the prompt diagnosis and early surgical intervention.

Pneumothorax necessitans presenting as a presternal pneumothoracocele

A 31-year-old woman who is an intravenous drug abuser developed sternoclavicular joint infection with mediastinal and subcutaneous tissue abscesses that communicated through an erosion in the manubrium caused by osteomyelitis. Air entrapment from a subsequent apical pneumothorax formed a localized anterior "pneumothoracocele." We referred to this condition as "pneumothorax necessitans," and we suggest including it in the differential diagnosis of anterior chest wall masses.

Immune-deficient bronchiectasis associated with X-linked lymphoproliferative disease

Bronchiectasis may occur with various congenital and acquired immunodeficiency diseases. The association of bronchiectasis and the X-linked lymphoproliferative disease (XLP), also known as Duncan's disease is unknown. We describe the case of a 39-year-old man with XLP, the oldest surviving, who developed chronic bronchiectasis with hemoptysis and required a pneumonectomy to control his symptoms.

Immunomonitoring followed by optimal dec therapy for successful management of clinical filariasis in an endemic area

Lymphatic filariasis continues to be the major cause of clinical morbidity in India and other developing tropical countries. One of the major lacunae in the effective management of clinical filarial cases is the non-availability of a suitable diagnostic test for confirming filaria aetiology in acute, chronic and occult clinical cases where microfilariae (mf) are not usually seen in peripheral circulation. Studies in our laboratory have shown the usefulness of filarial antibody and antigen assays using microfilarial excretory-secretory (mf ES) antigen in detecting microfilaraemic, acute and chronic filarial cases and in confirming filarial aetiology in occult infections. Diethylcarbamazine citrate (DEC) is the drug of choice for lymphatic filariasis. Different regimens of DEC have been explored in the treatment of microfilaraemic cases. Immunomonitoring has shown that the seroconversion of antigen and antibody positivity was found to be very helpful in determining appropriate period of DEC treatment for clinical relief and cure in clinical filarial patients and further they did not have recurrence in most of the cases. Optimal DEC (6mg/kg body wt/day for 21 days each month for 3-12 months) therapy was found to be very effective in acute and atypical clinical manifestations such as asthmatic bronchitis, pulmonary eosinophilia, monoarthritis, recurrent upper respiratory tract infections (URI), pneumonia (super imposed infections) in children and minimal hydrocele, epididymoorchitis, lymphangitis, lymphadenitis, acute abdomen, central serous retinopathy, tenosynovitis, pain and swelling in limbs and joints in adults living in filaria endemic areas.

Surgical filariasis: immunoscreening for filarial IgG antibodies using Wuchereria bancrofti microfilarial excretory-secretory antigen

A clinical study and immunoscreening was conducted on 363 suspected filarial patients attending the surgery out patient division of the MGIMS, Sevegram. The disease was significantly higher in males (86%) than in females (14%). Majority (52.9%) of the cases were in the age group of 11-30 years. The distribution of cases into three different grades of infection showed, 52.6%, 33.3% and 14.1% of the cases having acute (grade I), sub-acute (grade II) and chronic (grade III) stages of infection respectively. While 73% of the cases had genital manifestations, 23% were with lymphatic obstruction in limbs and the rest of the 4% suffered from manifestations like cellulitis, abscesses, haematuria and chyluria. Filarial IgG antibodies against microfilarial excretory-secretory (mf ES) antigen were detected in 89% of cases with genital manifestations, 87% of lymphoedema cases, 67% of lymphadenitis cases and 60% of cases with other clinical manifestations and 3% of endemic normals.

Low-dose interleukin 1 and tumor necrosis factor individually stimulate insulin release but in combination cause suppression

The macrophage-derived cytokines interleukin 1 (IL-1) and tumor necrosis factor (TNF) have direct effects on pancreatic beta cells and have been hypothesized to play important roles in the autoimmune beta cell lesion of type I diabetes because of two major effects on beta cells: altered insulin secretion and beta cell cytotoxicity. High doses of IL-1 are cytotoxic to beta cells and strongly inhibit insulin release; high-dose IL-1 plus TNF acts synergically to suppress further the insulin release. In contrast, we observed that the predominant effect of low-dose IL-1 and TNF when administered separately was the stimulation of insulin release. We therefore asked whether the combination of low-dose IL-1 plus TNF would act synergistically to stimulate or suppress insulin release. Studies were performed on cultured rat islets and both insulin release and cytotoxicity (51Cr release) were measured. After 2 days of culture, increasing doses of IL-1-25, 50, 75 and 100 ng/l--caused progressively increased cytotoxicity and impaired insulin release. In contrast, the lowest dose of IL-1 tested, 10 ng/l, increased insulin release but was still slightly cytotoxic. Tumor necrosis factor at doses of 10, 25, 62.5, 75 and 100 micrograms/l also was slightly cytotoxic but increased insulin release. The augmented insulin release declined progressively with increasing TNF dose. However the combination of insulin stimulatory doses of IL-1 (10 ng/l) and TNF (62.5 micrograms/l) suppressed insulin release. The effects of these two cytokines on insulin release demonstrated a similar pattern after 4 and 6 days of culture.(ABSTRACT TRUNCATED AT 250 WORDS)

Intracavernous papaverine for impotence in spinal cord injured patients

The majority of the spinal cord injury patients in our centre are young healthy males aged between 20 and 40 years. Loss of erection and inability to have coitus and father children have been responsible for inadequate sociosexual rehabilitation. In 1985, under urologist supervision, intracavernosal papaverine injection treatment was started in 101 volunteers, 65 paraplegics and 36 tetraplegics. Satisfactory erection sufficient for coital penetration was possible in 98 patients. Three had prolonged erection lasting beyond 4 hours. Only one required irrigation of the corpus with saline to achieve detumscence. One patient developed cavernosal fibrosis necessitating discontinuing the injection. Administration was under medical supervision so that possible complications of priapism/systemic effects could be promptly managed.

Vivax malaria causing priapism

We report a 14 year old boy who had priapism induced by vivax malaria. The onset was latent and course was protracted, refractory to anti-malarial and conservative treatment, but satisfactory detumescence was achieved after surgical intervention.

Indirect haemagglutination test for the assay of antibodies against Japanese encephalitis viral antigen in human & animal sera

The indirect haemagglutination (IHA) test was standardized for the assay of antibodies against Japanese encephalitis (JE) virus. Glutaraldehyde fixed sheep erythrocytes were sensitized with purified and concentrated JE vaccine (200-300% brain concentration). The JE vaccine made from Nakayama-NIH strain of JE virus was purified by protamine sulphate treatment and by ultracentrifugation in a sucrose gradient. The sensitized cells were quite stable in liquid as well as in lyophilized state both at -70 degrees C and 4-8 degrees C. These cells could be used for two years without much loss (4-8 times loss) in titre. The IHA test was as sensitive as the neutralization (N) test performed by plaque reduction method in chick embryo fibroblasts. The sensitivity of the test was influenced by the source of erythrocytes i.e., from the different sheep from which these were drawn. After standardization of the test, 16 human sera and 18 sera of immunized mice were assayed for antibodies against JE virus by N and IHA tests. There were no significant differences between titres of both human and mice sera determined by N and IHA tests (P greater than 0.05). The correlation coefficient between N and IHA titres for human sera was 0.60 (P less than 0.05) and for mice sera 0.82 (P less than 0.01). The IHA test has been found to be very simple, inexpensive, sensitive and reproducible.

The standardization of the reverse indirect haemagglutination test for the assay of the viral antigen of Japanese encephalitis vaccine

The reverse indirect haemagglutination (RIHA) test has been standardized for the assay of the viral antigen of purified Japanese encephalitis (JE) vaccine. Glutaraldehyde fixed sheep erythrocytes were sensitized with ammonium sulphate purified antibodies to JE vaccine raised in mice. The sensitivity of the erythrocytes fell to about one hundredth of the initial sensitivity in the first two days after preparation. After initial loss in sensitivity the stability of the cells became stabilized and the cells retained their titre for one year at 4-8 degrees C. The initial loss in sensitivity was not reduced by storing the cells at -70 degrees C, but after freeze drying the sensitized cells with a stabilizer one day after their preparation the cells retained their sensitivity. The RIHA test has been found to be a highly reproducible and sensitive method for detecting viral antigen in 5-10 ng of protein nitrogen. The sensitivity of the test was affected by the origins of the erythrocytes, i.e. from the different sheep from which they were drawn. To obtain results more rapidly, goose erythrocytes were used in place of sheep erythrocytes and the sensitized goose erythrocytes gave RIHA results in only 40 min.