Malignancies masquarading as psoas abscesses: An unusual presentation in a developing country

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Background: Psoas abscess is regarded as a rare disease in medical literature, more so as primary presentation of malignancy or its recurrence. We describe a series of 10 cancer patients who presented with psoas abscess seen in a 18 month period at a large tertiary care cancer hospital in northern India. They were subsequently diagnosed as having malignancy or recurrence of a past malignancy. Methods: A retrospective study of cancer patients who presented with psoas abscess was undertaken. We reviewed clinical data from patients who presented in the period from April 2005 to December 2006 at the Patel Cancer & Superspeciality hospital, Jalandhar, India. Results: In this period 10 cases of cancer met the diagnosis of psoas abscess at presentation. The average age was 51 years (range 20 to 85) with a male female ratio of 4:1. In 7 patients psoas abscess was the presentation at initial diagnosis while in 3 patients it was the presentation of recurrence/relapse. None of the patients had any predisposing conditions like IV drug use, diabetes mellitus, hematoma or HIV positivity.. Majority (7/10) of primary tumors were genito- urinary cancers (Renal - 2, Ureter - 1, Cervix - 1, Prostate - 1, Dysgerminoma - 1, Penis-1) while 3 were of unknown origin. Squamous cell carcinoma was the commonest histology (4/10), followed by metastatic adenocarcinoma (3/10). Majority of the abscess were left sided (7/10) corresponding to the side of primary lesion. Under lying destruction of iliac bone with metastasis was found in only 2 patients. Most of the patients (9/10) responded poorly to treatment ie chemotherapy and radiotherapy, all of them dying of disease progression within a year. Conclusions: Psoas abscess can be a rare presentation of intra abdominal malignancy. Pre disposing factors may not necessarily be present. Genito-urinary malignancies should be kept in the differential diagnosis of unexplained psoas abscesses. Development of psoas abscess does not always signify metastatic disease but portends a poor prognosis to treatment.

No significant financial relationships to disclose.

Randomized phase II study of trabectedin in patients with liposarcoma and leiomyosarcoma (L-sarcomas) after failure of prior anthracylines (A) and ifosfamide (I)

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Background: Trabectedin, a marine-derived antineoplastic agent, binds to the minor groove of DNA and has previously shown activity in L-sarcomas in single-arm trials. This multicenter, randomized study aimed to characterize the anticancer efficacy with two dosing regimens of trabectedin in pts with treatment-refractory L-sarcomas. Methods: Eligible pts had measurable advanced L-sarcoma, progression despite at least prior A and I, PS 0–1 and adequate organ function. Pts were randomized to IV trabectedin, 1.5 mg/m2, 24h every 3 weeks (q3wk-24h) or 0.58 mg/m2, 3h weekly × 3 on a 28-day cycle (qwk-3h). Primary endpoint is time-to-progression (TTP) and secondary endpoints PFS, overall survival, response, and safety. With 217 events, study provided 90% power to detect a 37% risk reduction in TTP (2-sided 5% significance). Results: 270 pts were randomized as of 5/31/06. Baseline characteristics were comparable: median (range) 2 (1–7) metastatic sites and 2 (1–6) prior regimens; 62% had additional prior agents; 67% had bulky (≥5cm) disease. In the q3wk-24h vs qwk-3h arms median n. cycles were 5 (1–37) vs 2 (1–21); 38% vs 19% received ≥7 cycles. In protocol-specified primary analysis, median (95% CI) TTP was 3.7 (2.1–5.4) vs 2.3 (2.0–3.5) mo [HR: 0.734; p=0.0302] favoring the q3wk-24h arm. Median PFS was 3.3 (2.1–4.6) vs 2.3 (2.0–3.4) mo [HR: 0.755; p=0.0418] and median survival (n=175 events) was 13.8 (12.5–17.9) vs. 11.8 (9.9–13.9) mo [HR: 0.823; p=0.1984]. Benefit from the q3wk-24h arm was more pronounced in pts with central pathology confirmed diagnosis of L-sarcomas. More neutropenia, ↑AST/ALT, emesis and fatigue occurred in the q3wk 24-h. Febrile neutropenia was rare (0.8–1.6%). No cumulative toxicities were noted. Conclusions: Trabectedin can provide clinical benefit to pts with L-sarcoma following failure of all conventional treatment options. Significantly better TTP was noted with the q3wk-24h regimen, although this resulted in somewhat more neutropenia and transaminitis without clinical consequences. No cumulative toxicities were apparent in either arm. Although both dosing regimens are efficacious, there appears to superior disease control with the q3wk-24h arm in this population.

[Table: see text]

Prevention of chemotherapy-induced delayed nausea and vomiting with aprepitant in patients recieving highly emetogenic-five day cisplatin regimens

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Background: It has been shown that addition of the NK1 receptor antagonist aprepitant to 5HT3 antagonist plus dexamethasone is more effective than just the 5HT3 antagonist plus dexamethasone for prevention of acute and delayed emesis due to high dose cisplatin and also that this effect lasts for multiple cycles. This study evaluated whether the antiemetic efficacy of aprepitant could be sustained for 5 day cisplatin regimens. Methods: Patients receiving cisplatin 20mg/m2/day for 5 days (PEB and TCF regimens ) were randomized to one of the following two regimens: (1) aprepitant 125 mg 1 hour before cisplatin on day 1 and aprepitant 80 mg on days 2 and 3 (n = 17); (2) placebo before cisplatin on days 2 to 7 (n = 19). All groups received ondansetron 32 mg and dexamethasone 20 mg before cisplatin, and dexamethasone 8 mg on days 2 to 7. The primary end point was complete response (no emesis and no rescue therapy) over 7 days following cisplatin in up to six cycles analyzed by a modified intent-to-treat approach. Secondary end point was evaluated using Functional Living Index-Emesis questionnaire. Treatment comparisons were made using logistic regression models and P value calculated using the chi square test due to small sample size. Results: In the acute period, 83% and 56% of patients were without emesis in groups I and II, respectively (P < .01 for group I v group II). In the delayed period upto day 5, the proportion of patients without emesis in groups I and II, was 59% and 32%, respectively (P < .01 for groups I v group II). In the extended period day 6 and 7 the proportion of patients without emesis in groups I and II was 50% and 38% respectively (P< .01 for groups I v II). The distribution of nausea scores in the delayed period beyond day 5 was lower when comparing group I with group II (P < .05 for days 6 and 7). Two serious adverse events of diarrhea were probably attributed to aprepitant. Conclusions: Once daily oral administration of aprepitant was effective and superior in reducing delayed emesis and nausea after 5 days cisplatinum regimen when added to 5HT3 antagonist plus dexamethasone. This benefit persists upto day 7. Confirming and extending previous results aprepitant should be used in triple combination in patients receiving 5 day cisplatin regimens.

No significant financial relationships to disclose.

Perifosine (P) as an active agent in the treatment of patients with advanced sarcoma

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Background: Clinical benefit rate (CBR), defined as complete or partial responses (RECIST) or stable disease > 4 months, has been taken as evidence for the activity of mTOR inhibitors in sarcomas, (Chawla ASCO 2006). P is a novel oral alkylphosphocholine that targets the PI3K pathway upstream from mTOR by inhibiting the phosphorylation of Akt. (Kondapaka, Mol Cancer Ther 2003). P's activity against sarcomas has now been evaluated in 121 patients enrolled in one of 3 phase (ph) I trials or 4 ph II studies. Five of these studies have been published. All of the data are in the Keryx database from which this analysis was performed. Methods: Dose-schedules in the ph I trials were weekly (wkly) 100–800 mg; loading dose (LD) 300 - 1,800 following by daily (d) 50 - 21 every 21 days; LD 400 - 900 & d 50 - 100 continuously. In the ph II trials doses were LD 900 & d 150 every 21 days, LD 900 and d 100 continuously, d 50 mg continuously; wkly 900, wkly1200 & wkly 1,500. Regimens that included a wkly or LD of 1,200 mg or more or a d dose of ≥ 150 mg were more toxic and are defined as “higher dose” for this analysis. Results: 121 pts with sarcoma were entered on studies prior to 9/1/2006 and could be assessed for CBR. CBR is shown in the table below. Toxicities were mainly gastrointestinal and/or fatigue. The percentage of pts with grade 0 nausea (N), vomiting (V), diarrhea (D) and fatigue (F) for lower dose P was 40, 60, 45 and 57% respectively compared to 29, 38, 24 and 66% for higher dose P. The proportion of patients with grade 2+ N, V, D and F was 19, 15, 17 and 21% for lower dose P and 46, 31, 40 and 21% for higher dose P. Conclusions: In the ph I/II studies of P the CBR was 50%. This compares favorably with the activity of the mTOR inhibitors. There was no suggestion of greater activity in those given higher doses of P, but there was substantially more toxicity and greater earlier withdrawal from therapy with the higher doses.

[Table: see text]

No significant financial relationships to disclose.

Amputation in Diabetic Patients

BACKGROUND

Foot ulcers and their complications are an important cause of morbidity and mortality in diabetes. The present study examines the amputation risk criterion and the long term outcome in terms of amputations and mortality in patients with diabetic foot.

METHODS

27 patients with diabetic foot lesions were studied. There were 15 patients with early lesions and 10 with advanced lesions. 15 patients were managed conservatively including local amputations and 12 with lower extremity amputations. 80% patients were males in 45-59 years of age group and all patients had more than 6 years of poorly controlled diabetes.

RESULTS

Precipitating factors included walking barefoot, history of minor trauma, infection, callosities or burns in 86% of patients. Major lower limb amputations were common in irregularly treated, poorly controlled diabetics due to infection in a limb devitalized by angiopathy and desensitised by neuropathy.

CONCLUSION

Diabetic foot ulcers are associated with high morbidity and mortality. Mortality was higher in ischaemic ulcers than neuropathic ulcers.

Primary lymphoma of the liver--a case report

A case of primary lymphoma of the liver who presented with a rapidly increasing mass in the right upper abdomen is reported. Histological examination confirmed the diagnosis of diffuse, intermediate cell type of Non Hodgkins Lymphoma and was identified as "B" cell type by the use of specific monoclonal antibodies. The case is being reported for its rarity and the clinical importance of recognizing such cases because of excellent prognosis.

Aggressiveness - the key to a successful outcome in Fournier's Gangrene

Nine patients with Fournier's gangrene were managed during last five years in various service hospitals. Mean age was 51 years (range 21-81 years). Most of these patients were from middle and upper class. Common predisposing factors included diabetes mellitus, alcohol abuse and poor personal hygiene. Streptococcus haemolyticus, Staphylococcus aureus and E coli were the commonest organisms cultured in most of these patients. Our experience indicates that the lower gastrointestinal tract should be considered as a possible cause of infection in all patients with Fournier's gangrene as 5 patients developed this condition following anorectal abscesses. All these patients were treated with a common approach of resuscitation, broad spectrum antibiotics, immediate surgical excision of all necrotic tissue, nutritional therapy and early skin coverage without any mortality. The surgeon should be more aggressive in the initial therapy and make the first surgery more definitive. There is no place for conservative management. The patients with perianal sepsis in elderly should be referred early for surgery.

Higher succinate than acetate levels differentiate cerebral degenerating cysticerci from anaerobic abscesses on in-vivo proton MR spectroscopy

We present three patients with large intraparenchymal isolated degenerating cysticerci in whom the diagnosis was primarily based on in-vivo proton MR spectroscopy, and subsequently confirmed histologically. We suggest that the presence of succinate alone or more succinate acetate indicates the presence of degenerating cysticerci and differentiates them from anaerobic brain abscesses, which show acetate alone or in higher concentration than succinate, even when the clinical and imaging features are similar.

Broad identification of bacterial type from pus by 1H MR spectroscopy

BACKGROUND

Abscess formation is a common bacterial infection and requires an immediate antimicrobial approach for apposite treatment. Delay in patient treatment is usually a common feature, as the bacterial identification of clinical samples is based on the culture, which is a time-consuming exercise. The current study was aimed at developing an alternative technique with the potential for rapid bacterial group identification.

MATERIALS AND METHODS

In the present study we performed ex vivo proton magnetic resonance spectroscopy of 40 pus samples collected from abscesses in different locations and the results have been retrospectively compared with the microorganism identified in the pus culture. In addition, the microbes obtained from the culture have been further subcultured and studied with magnetic resonance spectroscopy to identify the bacterial fingerprint in the pus sample seen on spectroscopy.

RESULTS

On reviewing the spectra obtained from the various abscesses, they were found to be qualitatively similar for a particular bacterium. The similar spectral pattern of the pus with obligate aerobes/anaerobes and pure cultures of the same bacteria suggests its strict metabolism under in vivo and in vitro conditions, respectively.

CONCLUSIONS

The characteristic metabolite pattern of obligate anaerobes may be used as a prototype for its rapid identification. This information may be of value for more appropriate clinical management of such cases.

Aggressiveness - The key to a Successful Outcome in Necrotizing Soft Tissue Infection

16 patients with necrotizing soft tissue infections were managed during last three years in various service hospitals. The experience indicates that there is considerable overlap in clinical findings and bacteriology. The infections seem to be variations of the same disease process, a spreading necrotizing infection. The number of these patients suggests that there is an increasing incidence of this entity. Staphylococcus and coliforms were the commonest organisms cultured in most of these patients. Because of the high mortality rate upto 50% as reported, we advocate aggressive and early treatment of this condition. Urgent radical exploration, excision of all necrotic tissue and adequate drainage of the deep fascial planes was done in all patients until healthy tissue planes were reached. A strong index of suspicion aids early diagnosis which ensures a favourable outcome. Our study indicates that the lower gastrointestinal tract should be considered as a possible cause of infection in all patients with synergistic gangrene. The involvement of the perineum and scrotum was most common. All these patients were treated with a common approach of resuscitation, broad spectrum antibiotics, immediate surgical excision of all necrotic tissue, aggressive nutritional therapy and early skin coverage with 20% mortality. The infection was primary in 8, postsurgical in 4 and following trauma in 4 cases. In majority of patients, Staphylococcus with beta haemolytic streptococci and E coli were the organisms isolated initially. Mortality was highest in intensive infections extending the abdomen and chest. Aggressive, effective and early treatment of necrotizing soft tissue infections is imperative to prevent a fatal outcome. Urgent radical exploration by the most experienced surgeon available is essential and includes wide excision of all necrotic tissue and adequate drainage of the deep fascial planes until indubitably healthy tissue is experienced. The surgeon must be prepared to proceed to a laparotomy, diverting colostomy or a suprapubic cystotomy where there exists any element of doubt. Aggression is also of significance in resuscitation, early institution of empirical broad spectrum antibiotic therapy, elaborate repeated daily dressings with hydrogen peroxide and to allow further debridement till the process is controlled.