Continuous infusion 5-fluorouracil, etoposide and cis-diamminedichloroplatinum in patients with metastatic carcinoma of unknown primary origin

We conducted a phase II clinical trial of 5-fluorouracil (5 day continuous infusion), cis-diamminedichloroplatinum and etoposide in previously untreated patients with metastatic carcinoma of unknown primary origin. Of the thirty-six evaluable patients (21 adenocarcinoma, 14 undifferentiated carcinoma and 1 squamous cell carcinoma), eight patients responded to this treatment (4 CR, 4 PR). Responses were seen in both soft tissue and visceral disease. Toxicity was significant and included grade III/IV myelosuppression in over 90% of patients treated. Non-hematologic toxicity included nausea/vomiting and stomatitis. Although the remissions obtained in this study appear to be durable (median duration of complete remission greater than 24 months), the regimen does not appear to offer significant advantages over other less toxic and more easily administered cisplatin-based combinations.

Clinical regression of infected pancreatic necrosis. Case report

Infected pancreatic necrosis was diagnosed clinically and radiologically in a patient admitted for acute pancreatitis. As free gas in the pancreatic area was recognized, antibiotic therapy (ceftriaxone) was empirically introduced, while surgical drainage was being planned. After the second week, the patient rapidly started to improve, to the point that he could be discharged home without operation. Control CT-scans and general laboratory tests, at this phase and later on, confirmed a still enlarged gland but free of infection or ongoing inflammation. Cholelithiasis, which had been identified in an early ultrasound scan, was electively treated by cholecystectomy 2 mo after the onset of pancreatitis, in the absence of sepsis, and with uneventful recovery. This case illustrates the rare possibility of spontaneous regression of infected necrotic pancreatitis, without any type of operation or nonoperative drainage.

Phase II study of fluorouracil and recombinant interferon alfa-2a in previously untreated advanced colorectal carcinoma

We conducted a phase II clinical trial of fluorouracil (5FU) and recombinant interferon alfa-2a (rIFN alpha-2a) in 52 previously untreated patients with bidimensionally measurable metastatic colorectal cancer. During week 1, 5FU was administered as a continuous intravenous infusion, 750 mg/m2/d for 5 consecutive days. Intravenous bolus administration of 5FU 750 mg/m2 was given weekly for 7 weeks starting on day 12. rIFN alpha-2a (Roferon; Hoffman-LaRoche, Nutley, NJ), 9 x 10(6) U, was administered subcutaneously three times weekly during weeks 1 to 8. Patients were evaluated for response on week 9. Of 52 patients enrolled in the study, 51 were assessable for toxicity, and 45 were assessable for response. Fifteen patients experienced partial response, and one patient achieved a clinical complete response for an overall response rate of 35% (95% confidence interval [CI], 22%, 50%). Median duration of response is 7.5 months (range, 4 to 11 months). Seventy percent of patients entered on the study are alive with a median follow-up duration of 7 months. Twenty-five percent of patients developed grade 4 toxicity, and 82% developed grade 3 toxicity. One drug-related death in the presence of sepsis was reported, and two treatment-related seizures occurred. Our experience with this schedule produced a lower response rate with greater toxicity than previously reported. Current randomized trials comparing this schedule of 5FU with rIFN alpha-2a to 5FU plus folinic acid (leucovorin) or single-agent 5FU may determine its role in the treatment of advanced colorectal carcinomas.

[Contamination of enteral diet solutions in nosocomial environment]

The gastrointestinal tract is comparatively resistant to food-born germs, but recent studies suggest that nosocomial infections may be triggered by this route. In a study with industrialized diets, prepared with aseptic technique and stored up to 24 hours, aerobic and anaerobic contaminants were searched. Samples were taken after 0.8 and 24 hours, whereas half of these last two analyses were carried out in material left at room temperature, and the other half in refrigerated diets. Initial examination revealed 50% of positive cultures, but part of this was due to non-pathogenic Bacillus germs. After 8 and 24 hours 90% of the samples grew organisms, again with a large proportion of Bacillus, but also with several Gram-negative bacteria, as well as rare Gram-positives. Diarrhea and fever were not registered in patients submitted to enteral nutrition during the study period, nor could any episodes of bacteremia or septic shock be attributed to contaminated feeding material. This lack of clinical consequences of the reported bacterial isolations is not unexpected, and suggests that low concentrations of microorganisms were probably present in the preparations, below a critical level. Nevertheless, attention will be required in the future for better quality control of enteral nutrition mixtures, specially when resistant strains of Gram-negative species are identified, and also in the management of debilitated or immunologically compromised hosts.

Endoscopic ultrasonography in staging rectal cancer

Endoscopic ultrasonography (EUS) was used to stage rectal cancer by assessing depth of invasion through bowel wall layers and/or involvement of lymph nodes. EUS findings were correlated with histopathologic findings to discern the usefulness of this modality in predicting which patients could be candidates for sphinctersaving procedures and the avoidance of abdominoperineal resection. The Olympus EU-M3 endoscopic ultrasound system was used to assess depth of penetration through rectal wall layers and to identify lymph nodes. Comparison of EUS findings to histopathologic findings was possible in 13 patients. EUS agreed with histopathology in 9 of 13 cases (69.3%) ( p = 0.07, kappa statistic). EUS agreed with histopathology as the presence or absence of lymph nodes in 9 of 13 cases (69.3%) (p = 0.07). However, the presence of lymph nodes could not necessarily predict metastatic involvement of these nodes. In one patient, invasion of vaginal cuff was correctly predicted. In nine cases, computed tomographic analysis (CT) was available for comparison to EUS in detection of penetration beyond the bowel wall. CT agreed with histopathology in 3 of 9 (33%), whereas EUS agreed with histopathology in 7 of 9 (78%).

The influence of nutritional status on skin anergy in experimental cancer

Malignant tumours as well as severe malnutrition can interfere with carcass weight, serum albumin and delayed hypersensitivity tests. In order to identify the separate effects of these two phenomena, Wistar rats were submitted to various nutritional manipulations prior to Walker-256 carcinosarcoma inoculation (TU). Six groups of well-nourished rats with positive response to the Keyhole Limpet Haemocyanin (KLH) test were studied. Three TU-bearing groups were established, [1] protein-deprived before and after TU (group DDT), [2] protein deprived before TU and later brought back to normal chow (group DNT), and [3] those receiving a complete diet throughout the experiment (group NNT). Identical control groups without TU, sham-injected, were called DDC, DNC and NNC. Tumour size and body weight were measured daily. KLH tests were done sequentially and serum albumin was determined at sacrifice. Results indicated that cancer produced marked changes in immune response. Malnutrition was responsible for anergy and weight loss, and further aberrations tended to occur when both conditions were present. Feeding was able to restore body weight and KLH response in tumour-bearing as well as in control rats, but subsequent deterioration occurred in cancer bearing rats after the first week of tumour development. It is concluded that cancer potentiates the effects of malnutrition, on body weight and immune response, but temporary recovery could be demonstrated after adequate refeeding.

[Repercussions of blood transfusions on postoperative complications in patients with multiple trauma]

Multiple factors connected with the trauma itself or with its therapy may cause post-operative complications in injured patients. In a previous study we have reported on a higher mortality rate in patients that received large quantities of blood. The present report concerns 223 cases of trauma by penetrating and non-penetrating injuries in which the possible influence of blood transfusions on subsequent morbidity was assessed. It was verified that transfused patients exhibited more infections and general complications, as well as a higher mortality rate than controls. A progressive effect related to the number of units of blood administered could be demonstrated. The most unfavorable outcomes correspond to the transfusions of more than 1500 ml of blood.

[The management of acute pancreatitis in pregnancy--the coadjuvant role of parenteral feeding]

Acute pancreatitis in pregnancy is not a frequent condition: only a few hundred cases have been published in the literature. Its diagnosis can be misguided by clinical manifestations of the pregnancy itself, and by the delay in ordering the required diagnostic tests. These facts may contribute to the serious prognosis of this disease, which in the past had a mortality of up to 20%. The treatment recommended is conservative. A surgical intervention in the event of biliary lithiasis is best to be postponed till after delivery. Parenteral alimentation can be helpful because of its effects in the promotion of pancreatic rest with simultaneous improvement of the nutritional conditions of the mother and the fetus.

[Traumatic injuries of the colon: primary suture or colostomy?]

The indications for colostomies in traumatic lesions of the colon were prospectively analysed in the light of the anatomical and functional impairment, the time that elapsed after the injury and additional risk factors. In the period between January 1981 and June 1986 75 patients were operated for colonic trauma: 39 had gunshot wounds, 29 suffered stab wounds and seven had blunt injuries. Colostomies were indicated in 47 patients that presented the most severe lesions, whereas the other 28 patients underwent primary repair. Infectious complications occurred in 21 cases; they were related to a pre-operative interval of more than 10 hours, severity of colonic lesion (CIS) grade III to V, blood transfusion of more than 2500 ml, the presence of colostomy, and an abdominal trauma index (PATI) of more than 25. Five patients died in consequence of infectious complications (p less than 0.05), all of them suffering from severe injuries. These findings suggest that in acute trauma of the colon after less than 6 hours colostomy is justified when the CIS is III to V, the PATI more than 25, or in hemodinamically unstable patients.

Gastroduodenal mucosal injury during hepatic arterial infusion of chemotherapeutic agents. Lack of cytoprotection by prostaglandin E1 analogue

Eighteen colorectal cancer patients with liver metastases receiving hepatic arterial infusion of chemotherapeutic agents (mitomycin-C + 5-FUDR) were randomized to receive misoprostol (a prostaglandin E1 analogue) or placebo as a mode of cytoprotection against inadvertent gastroduodenal mucosal injury. Four of 10 patients on misoprostol and 3 of 8 patients on placebo developed gastroduodenal mucosal injury (p greater than 0.1), which was confirmed by endoscopy. Significant tumor responses to chemotherapy were equally distributed between the two groups. Although our sample size was small and type II error (false-negative trial) cannot be excluded, these data strongly suggest that prophylaxis with misoprostol does not prevent the acute gastroduodenal mucosal injury associated with hepatic arterial infusion of chemotherapeutic agents.

Hepatitis in patients receiving intraarterial chemotherapy for metastatic colorectal carcinoma

Fifty-one patients with metastatic colorectal carcinoma confined to the liver received intraarterial chemotherapy through the hepatic artery via a subcutaneous pump. The chemotherapy consisted of sequential 14-day infusions of floxuridine (FUDR) and dichloromethotrexate (DCMTX) or a 14-day infusion of FUDR and bolus mitomycin (MMC). Twenty-four patients (47%) developed hepatitis with an elevation of hepatic serum transaminase (serum glutamic oxaloacetic transaminase, SGOT, or serum glutamic-pyruvic transaminase, SGPT). The median time to develop hepatitis was 11 weeks after initiation of chemotherapy. The morphologic effects of chemotherapy were evaluated in eight patients with hepatitis. All the patients with hepatitis had normalization of the serum transaminases after temporary cessation of chemotherapy. There was a trend toward a greater chance of remission in patients who developed hepatitis. Sixty-seven percent of the patients with a therapeutic response had hepatitis, whereas only 33% of the patients without a response had hepatitis. However, this difference was not statistically significant. The occurrence of hepatitis was not related to FUDR dose, drug program (FUDR-DCMTX vs. FUDR-MMC), pump flow rate, hepatic arterial anatomy, sex, or age of the patients.

Nutritional management of thoracic duct fistulas. A comparative study of parenteral versus enteral nutrition

Thoracic duct fistulas represent one of the serious technical complications of head and neck surgery, and reoperation for control of the leakage involves considerable morbidity and mortality. In an attempt to define the possibilities of both enteral and parenteral nutrition in the treatment of this problem, two comparable groups of patients were given, respectively, one or the other of these modalities. Significant advantages for parenteral nutrition could be demonstrated regarding duration of therapy (p less than 0.05), closure rate (p less than 0.05), and nutritional response (p less than 0.05). These results strongly recommended the utilization of parenteral nutrition in the primary therapy of thoracic duct fistulas.