Chemotherapy for pancreatic cancer: a neuroimaging clinicopathologic correlation

Multifocal Necrotizing Leukoencephalopathy: Expanding the Clinicopathologic Spectrum

Multifocal necrotizing leukoencephalopathy (MNL) is a rare condition typically described in patients undergoing chemotherapy or with HIV/AIDS. As a pathologic entity, it is characterized by multiple small foci of necrosis typically within white matter of the pons and occasionally in other areas. Herein we describe findings in 6 patients with MNL, 5 diagnosed at postmortem examination and 1 by surgical biopsy. Histopathologic features were characteristic, with generally small foci of necrosis, most frequently within the pontine base, although larger lesions were seen in the frontal white matter and basal ganglia. Axonal swellings, occasional dystrophic calcification and minimal microglial activity or reactive responses were common. Glial fibrillary acidic protein immunoreactivity was absent or markedly reduced within the lesions although it remained well defined in the surrounding areas. The underlying clinical circumstances ranged from HIV/AIDS, hematologic malignancy, chemotherapy for malignancies to postcardiac transplant, the latter reported for the first time. A significant common thread identified in our cases was altered immune status. A second common factor, which has also been previously implicated, was the presence of significant ongoing infection or sepsis. The role of concurrent inflammatory processes, specifically proinflammatory cytokine release in the context of these complex clinical scenarios is discussed with possible pathogenetic considerations.

Skull metastasis from ampulla of Vater adenocarcinoma: case report

We report a rare case of skull metastasis from ampulla of Vater adenocarcinoma in a patient with controlled primary neoplasm. This 65-year-old Korean man presented with headache and painful parietal scalp swelling, but he did not show any neurological deficits. Computed tomography revealed an osteolytic mass that invaded and expanded through the skull tables in full-thickness. On magnetic resonance images following Gadolinium injection, the mass appeared slightly hypointense signal on all sequences and intense heterogeneous enhancement. He underwent surgical excision with artificial grafting of calvaria and dura. Postoperative radiation therapy was ensued for metastatic adenocarcinoma, and he was well for the follow-up period of 3 months. To the best of our knowledge, this is the first such case that involved the skull.

Phase 1 study of N1-N11-diethylnorspermine (DENSPM) administered TID for 6 days in patients with advanced malignancies

This was a dose escalation Phase 1 trial designed to determine the maximum tolerated dose (MTD) and dose-limiting toxicities (DLT) of DENSPM.

METHODS

Adult patients with refractory solid tumors were treated with DENSPM administered by intravenous infusion in 100 ml of normal saline over 30 minutes. The daily dose of DENSPM was divided into three equal doses administered approximately every eight hours for six days. Courses were repeated every 28 days.

RESULTS

Twenty-eight patients were enrolled in the study. Dose levels of DENSPM explored were 25 mg/m2/day (3 patients), 50 mg/m2/day (9 patients), 60 mg/m2/day (5 patients), 75 mg/m2/day (6 patients), 94 mg/m2/day (3 patients) and 118 mg/m2/day (2 patients). The DLT for DENSPM was central nervous system toxicity characterized by aphasia, ataxia, dizziness, vertigo and slurred speech occurring at dose levels > or = 94 mg/m2/day, which was also the MTD.

SAFETY

The most frequent drug-related adverse events were asthenia (9 patients), injection site reaction (6 patients) and anemia (6 patients). One patient was removed from the study due to CNS toxicity. There were no treatment-related deaths. No trends were observed regarding hematologic toxicities, biochemical changes or changes in vital signs.

EFFICACY

Nineteen of the 28 patients enrolled in the study were assessed for response. No objective responses were observed. Five patients had stable disease as the best response to therapy.

CONCLUSIONS

Because the DLT was CNS and because of the relatively low doses that could be safely administered on this schedule as compared with a once-a-day schedule, this regimen was not recommended for Phase 2.