Application of high-frequency ultrasound for the detection of surgical anatomy in the rodent abdomen

Rats are used extensively in abdominal disease research. To monitor disease progress in vivo, high-frequency ultrasound (HFU) can be a powerful tool for obtaining high-resolution images of biological tissues. However, there is a paucity of data regarding the correlation between rat anatomy and corresponding HFU images. Twenty-four adult male Sprague-Dawley (SD) rats underwent abdominal scans using HFU (40 MHz) surgical procedures to identify abdominal organs and major vessels as well as in situ scanning to confirm the imaging results. The results were compared with those of human abdominal organs in ultrasonographic scans. The rat liver, paired kidneys, stomach, intestines, and major blood vessels were identified by HFU and the ultrasonic morphologies of the liver and kidneys showed clear differences between rats and humans. Clinically relevant anatomical structures were identified using HFU imaging of the rat abdomen, and these structures were compared with the corresponding structures in humans. Increased knowledge with regard to identifying the anatomy of rat abdominal organs by ultrasound will allow scientists to conduct more detailed intra-abdominal research in rodents.

Haematopoietic stem cell transplantation in Taiwan: past, present, and future

In Taiwan, haematopoietic stem cell transplantation (HSCT) has been used to treat patients with haematological diseases since 1983. Thereafter till 2007, there were 2537 patients who had undergone HSCT in more than 15 hospitals. Their diseases included acute myeloid leukaemia in 27.8% of cases, non-Hodgkin's lymphoma 23.3%, acute lymphoblastic leukaemia 12.8%, chronic myeloid leukaemia 11.9%, severe aplastic anaemia 8.7%, and multiple myeloma 4.1%. Most of the cases received myeloablative conditioning regimens. More than 15% of cases received non-myeloablative regimens, and the mean age of these cases was at least 10 years older than those who received myeloablative regimens. The types of graft included peripheral blood (60.4%) and bone marrow (32.0%). A total of 35% of patients received autologous grafts. Of 1557 allogeneic HSCT patients, 338 (21.7%) received grafts from unrelated donors. Cord blood transplantation has been successfully performed in paediatric patients with thalassaemia major and with a large body size, and adult patients. The incidence of acute graft-versus-host disease was relatively low in Taiwan. On the contrary, a relatively higher proportion of hepatitis B carrier in the recipients had led to a higher incidence of reactivation hepatitis, which was markedly decreased following lamivudine prophylaxis. In conclusion, HSCT has become a routine therapy for major medical centres in Taiwan. Our unique experiences in the past decades also contributed to the progress of HSCT. With the establishment of professional association and patient supportive groups, we hope we can fully improve our daily practice and clinical as well as basic research in HSCT.

Effect of a periodized exercise training and active recovery program on antitumor activity and development of dendritic cells

AIM

Dendritic cells (DCs) are potent antigen-presenting cells that promote antitumor immunity in vivo when pulsed with tumor antigen. No studies have indicated that exercise training affects DC function. The purpose of this study was to investigate the effect of a 5-week periodized exercise training and active recovery program on the development of DCs, and to test their effect on the antitumor immunity of mononuclear cells (MNC) from blood and spleen against human leukemic U937 and murine lymphoma Yac-1 cells, respectively.

METHODS

Male Fisher 344 rats were divided into 2 groups: exercise and non-exercise group. The training protocol consisted of running on a motor-driven treadmill 6 days a week for consecutive 5 weeks, during which the running time, treadmill speed, and incline gradient were increased weekly. Active recovery parameters were set at 30% of the intensity of the previous day.

RESULTS

DC numbers increased significantly (P<0.05) in the exercise group compared to controls, but there were no significant changes in the expression of surface antigens CD80 and CD86. In exercise group MNC-conditioned medium (CM) prepared with 50 microg/mL phytohemagglutinin (PHA) significantly inhibited proliferation of U937 cells, and splenocyte-CM with PHA at 20 and 40 microg/mL significantly inhibited proliferation of YAC-1 cells greater than control group.

CONCLUSIONS

The 5-week periodized exercise training with active recovery promotes the number of DCs and enhances the activity of DCs against tumor cells.

Stem cells in the lung parenchyma and prospects for lung injury therapy

Until recently, it was thought that only embryonic stem cells were pluripotent and that adult stem cells were restricted in their differentiative and regenerative potential to become the tissues in which they reside. However, the discovery that adult stem cells in one tissue can contribute to the formation of other tissues, especially after injury or cell damage, implies that stem cells have developmental plasticity. For example, haematopoietic stem cells (HSCs) and mesenchymal stem cells (MSCs) from bone marrow can be used to regenerate diverse tissues at distant sites, including the lung. This article reviews the character of stem cells in the lung parenchyma and focuses on the potential uses of adult stem cells in research of lung injury and lung disease therapies.

Relatively favorable outcomes of post-transplant pulmonary function in patients with chronic myeloid leukemia receiving non-myeloablative allogeneic hematopoietic stem cell transplantation

Pulmonary function tests were performed in 20 patients with chronic myeloid leukemia before and after human leukocyte antigen-matched allogeneic sibling hematopoietic stem cell transplantation (HSCT) to identify any conditioning treatment effects on post-transplant function from January 1995 to December 2002. Of 20 patients, eight received non-myeloablative conditioning treatment and 12 received conventional myeloablative conditioning treatment. Pulmonary function tests including forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), and diffusion capacity for carbon monoxide (DLCO) were performed pretransplant, 6 and 12 months post-transplant. Possible pre-HSCT and post-HSCT risk factors were evaluated for association with pulmonary function. The results showed that myeloablative conditioning treatment had greater negative impact on FEV1, FVC, and DLCO than non-myeloablative conditioning therapy. We conclude that non-myeloablative allogeneic HSCT may apply a better transplant choice in patients who need special concern with post-transplant pulmonary function changes.

Hematopoietic stem cell transplantation for severe aplastic anemia--experience of an institute in Taiwan

Hematopoietic stem cell transplantation (HSCT) is an accepted treatment strategy for patients with severe aplastic anemia (SAA). We report our experience in a general hospital in Taiwan. From March 1985 to July 2001, 79 consecutive SAA patients, 46 male and 33 female, with a median age of 22 (4–43) years, received 80 courses of transplantation. Cyclophosphamide and total body radiation were used for the conditioning regimen, and cyclosporine-A and methotrexate for graft-versus-host disease (GVHD) prevention. Patients were followed for a median of 39 months (from 8 days to 194 months). Myeloid and platelet engraftment occurred in a median of 15 (8–27) days and 18 (8–77) days, respectively. Three patients had primary and three patients secondary graft failure. Five patients (6.8%) had grade II–IV acute GVHD in 73 evaluable patients. Chronic GVHD occurred in 23 (34.8%) patients, with extensive stage in six. Only two patients had CMV disease. The projected 3- and 5-year overall survival rates estimated by the Kaplan-Meier method were 76.08 and 74.13%, respectively. Age at transplant, non-sibling donor, mononuclear cell dose, grade II–IV acute GVHD, interval from diagnosis to transplant, and red blood cell and platelet transfusion before transplant were poor prognostic factors for overall survival by univariate analysis. Grade II–IV acute GVHD was the only prognostic factor affecting overall survival after multivariate Cox regression analysis (P=0.040). In conclusion, SAA patients receiving HSCT have good long-term survival. The low incidence of acute GVHD in our patients may be related to ethnicity.

Comparative genomic hybridization of esophageal squamous cell carcinoma: correlations between chromosomal aberrations and disease progression/prognosis

BACKGROUND

Esophageal carcinoma is a major cause of cancer-related deaths among males in Taiwan. However, to date, the genetic alterations that accompany this lethal disease are not understood.

METHODS

Chromosomal aberrations of 46 samples of esophageal squamous cell carcinoma (EC-SCC) were analyzed by comparative genomic hybridization (CGH), and their correlations with pathologic staging and prognosis were analyzed statistically.

RESULTS

In total, 321 gains and 252 losses were found in 46 tumor samples; thus, the average gains and losses per patient were 6.98 and 5.47, respectively. Frequent gain abnormalities were found on chromosome arms 1q, 2q, 3q, 5p, 7p, 7q, 8q, 11q, 12p, 12q, 14q, 17q, 20q, and Xq. Frequent deletions were found on chromosome arms 1p, 3p, 4p, 5q, 8p, 9p, 9q, 11q, 13q, 16p, 17p, 18q, 19p, and 19q. It was found that deletions of 4p and 13q12-q14 and gain of 5p were significantly correlated with pathologic staging. Losses of 8p22-pter and 9p also were found more frequently in patients with advanced disease. Gain of 8q24-qter was seen more frequently in patients with Grade 3 tumors. A univariate analysis found that pathologic staging; gains of 5p and 7q; and deletions of 4p, 9p, and 11q were significant prognostic factors. However, pathologic staging became the only significant factor in a multivariate analysis.

CONCLUSIONS

CGH not only revealed novel chromosomal aberrations in EC-SCC, but also found possible genotypic changes associated with disease progression. Despite all of the possible associations of chromosomal aberrations with disease progression, the most important prognostic factor for patients with EC-SCC was pathologic staging.

Relapse of Graves' disease after successful allogeneic bone marrow transplantation

As shown in many reports, allogeneic BMT can help cure autoimmune diseases. Conversely, we present a 24-year-old woman with Graves' disease, which was diagnosed just before BMT for CML. The Graves' disease remitted immediately after BMT but relapsed 18 months later. Since the donor was free from thyroid diseases and the patient showed a rapid shift to complete donor chimerism after BMT, the autoimmune problem seemed neither to arise directly from the donor nor simply from the recipient's residual lymphocytes. On the contrary, it was most likely compounded by chronic GVHD as suggested by the accompanying GVHD symptoms and the absolute donor karyotype in bone marrow cells. A Graves' disease-susceptible HLA allele was also shared between recipient and donor, possibly enhancing the chances of this condition developing. Thus, allogeneic BMT may facilitate relapses in autoimmune diseases as well as alleviating them.

Comparative genomic hybridization of esophageal squamous cell carcinoma: correlations between chromosomal aberrations and disease progression/prognosis

BACKGROUND

Esophageal carcinoma is a major cause of cancer-related deaths among males in Taiwan. However, to date, the genetic alterations that accompany this lethal disease are not understood.

METHODS

Chromosomal aberrations of 46 samples of esophageal squamous cell carcinoma (EC-SCC) were analyzed by comparative genomic hybridization (CGH), and their correlations with pathologic staging and prognosis were analyzed statistically.

RESULTS

In total, 321 gains and 252 losses were found in 46 tumor samples; thus, the average gains and losses per patient were 6.98 and 5.47, respectively. Frequent gain abnormalities were found on chromosome arms 1q, 2q, 3q, 5p, 7p, 7q, 8q, 11q, 12p, 12q, 14q, 17q, 20q, and Xq. Frequent deletions were found on chromosome arms 1p, 3p, 4p, 5q, 8p, 9p, 9q, 11q, 13q, 16p, 17p, 18q, 19p, and 19q. It was found that deletions of 4p and 13q12-q14 and gain of 5p were significantly correlated with pathologic staging. Losses of 8p22-pter and 9p also were found more frequently in patients with advanced disease. Gain of 8q24-qter was seen more frequently in patients with Grade 3 tumors. A univariate analysis found that pathologic staging; gains of 5p and 7q; and deletions of 4p, 9p, and 11q were significant prognostic factors. However, pathologic staging became the only significant factor in a multivariate analysis.

CONCLUSIONS

CGH not only revealed novel chromosomal aberrations in EC-SCC, but also found possible genotypic changes associated with disease progression. Despite all of the possible associations of chromosomal aberrations with disease progression, the most important prognostic factor for patients with EC-SCC was pathologic staging.

Salvage therapy with single-agent paclitaxel by three-hour infusion in metastatic breast cancer: an experience in Taipei Veterans General Hospital

BACKGROUND

Paclitaxel is an active agent in the treatment of breast, ovarian, lung and head and neck cancers. In previous phase I and II trials, it exerted novel cytotoxic effect on several malignancies. Various doses and regimens of paclitaxel have been assessed in metastatic breast cancer, with responses between 20 and 62%. However, combination therapy with other anti-cancer drugs leads to a high incidence of side effects. Our aim was to evaluate the efficacy of paclitaxel given by 3 h infusion as salvage chemotherapy for patients with metastatic breast cancer.

METHODS

Between May 1999 and April 2000, 14 women with metastatic breast cancer were enrolled in this study and all the patients had to have measurable lesions. The median age of the patients was 48.7 years (range 39-56 years). All of them were definitely evidenced as having metastatic breast cancer and received complete courses of anthracycline-containing agents before applying paclitaxel. The protocol was single-agent paclitaxel (Anzatax, Faulding, Australia) at a moderate dosage of 175 mg/m(2) by 3 h intravenous infusion every 3 weeks.

RESULTS

A total of 75 cycles were administered to these 14 patients with a median of four delivered cycles (range 3-14) and the response rate was 28.6% (95% CI: 21-40%), including four partial remission, three stable disease and seven progressive disease. The median time to progression was 3 (range 3-7) months. Hematological toxicities were minimal with no evidence of severe (grade 3 or 4) leukopenia and thrombocytopenia. Hepatic toxicities were observed in 12 cycles with five in grade 3.

CONCLUSIONS

Our study indicates that utilizing single-agent paclitaxel exerts moderate activity on anthracycline-refractory metastatic breast cancer patients without excessive toxicities.

Comparison of ion release from new and recycled orthodontic brackets

Bracket corrosion can occur in the oral environment. The purpose of this study was to compare the release of metal ions from new and recycled brackets in artificial saliva and buffers with different pH values over a 12-week immersion period. The brackets were divided into 2 groups: new and recycled. The recycled bracket bases were coated with adhesive and the brackets were heat treated. Nickel, chromium, iron, and manganese ions were detected by atomic absorption. The surface characteristics of the brackets were examined by energy dispersive radiographic analysis. The results were as follows: (1) Recycled brackets released more ions than did the new brackets. (2) Greater amounts of nickel, iron, and manganese ions were released in artificial saliva than in the other buffers tested. (3) Ion release from brackets in a pH 4 buffer was greater than that observed in pH 7 or pH 10 buffers. (4) The total amount of ion release increased with time. (5) After a 12-week immersion, the total ion release averaged over the period did not exceed the recommended daily intake.

Molecular analysis of mucosa-associated lymphoid tissue (MALT) lymphoma of ocular adnexa

Lymphomas of mucosa-associated lymphoid tissue (MALT) are a distinct subgroup of extranodal B-cell non-Hodgkin's lymphomas. Most studies have failed to demonstrate the clonal rearrangement of BCL-1, BCL-2 or c-MYC genes for MALT lymphomas. Further, alteration of the p53 gene is rarely demonstrated in low-grade MALT lymphomas, but can be detected in high-grade disease. Lymphomas of the ocular adnexa represent approximately eight percent of all extranodal lymphomas, most of which are MALT lymphomas, but few studies had explored the alterations of BCL-1, BCL-2, c-MYC and p53 genes specifically for ocular MALT lymphomas. We investigated the changes to BCL-1, BCL-2, c-MYC and p53 genes in these lymphomas for Taiwanese patients. Clonal rearrangement for immunoglobulin heavy-chain (IgH), BCL-1, BCL-2, c-MYC and p53 genes was examined for 16 cases of ocular MALT lymphoma. Restriction-length polymorphism and polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP) of the DNA, corresponding to exons 5 through 9, followed by DNA sequencing, were utilized to analyze the possible mutations of the p53 gene for these tumors. Thirteen of the cases revealed rearranged IgH genes using Southern blotting or PCR. No rearrangement of BCL-1, BCL-2, c-MYC or p53 genes was discovered, with point mutation of the p53 gene in one case. As for other types of MALT lymphomas, BCL-1, BCL-2 and c-MYC genes are not implicated in the pathogenesis of the ocular sub-group. Although alteration of the p53 gene is rare for low-grade ocular MALT lymphoma, its role in disease progression merits further research.

Complete atrio-ventricular block as a major clinical presentation of the primary cardiac lymphoma: a case report

It is uncommon for malignant lymphomas to present primarily with cardiac invasion as the main clinical feature. What we are interested in is not only where the disease is, but also those symptoms that it may induce. Sudden onset of complete atrio-ventricular block is one of the most common clinical presentations. Cardiac tamponade is another common disease entity which, if it locates over outlets of great vessels, may also exert symptoms of obstructive vessels. Diagnosis can be made by needle aspiration under the guidance of transcutaneous or transesophageal echocardiography. Both CT scan and MRI play positive roles in the diagnosis of cardiac lymphomas, and the latter can even provide much more image information than the former. We report a 70-year-old male with primary cardiac lymphoma with initial clinical pictures of sudden onset of complete atrio-ventricular block. Chemotherapy was utilized with cyclophosphamide, vincristine and prednisolone (COP) initially for four courses and followed by adding doxorubicin (CHOP) for another three courses. The patient was still in remission status after treatment for 2 years.

Tamoxifen and colchicine-modulated vinblastine followed by 5-fluorouracil in advanced renal cell carcinoma: a phase II study

OBJECTIVES

Chemotherapy resistance of renal cell carcinoma (RCC) has been attributed in large part to multidrug resistance (MDR). Reported MDR-modulated chemotherapy for RCC, however, has resulted in only marginal response benefits. In this study, the MDR-modulated effect of paired tamoxifen and colchicine on vinblastine and the possible additive effect of 5-fluorouracil (5-FU) were investigated in the treatment of advanced RCC.

METHODS

Chemotherapy was administered every 4 weeks with biweekly vinblastine (4 mg/m(2)/day, intravenously on days 1 and 15) modulated by oral tamoxifen (100 mg/day) and colchicine (1 mg/day) from days -1 to 2 and from days 13 to 16. 5-FU (800 mg/m(2)/day from days 2 to 5) was administered after vinblastine administration as a continuous infusion.

RESULTS

Of 17 eligible patients with advanced RCC available for evaluation, 1 achieved a complete response (CR) and 3 a partial response (PR), with an overall response (CR plus PR) rate of 23.5%. The median overall survival time of all patients was 10 months (95% confidence interval [CI] 3.5 to 16.5); that of our patients with poor, intermediate, and favorable risks as stratified by Motzer's model was 6 (95% CI 1.7 to 10.3), 10 (95% CI 7.9 to 12.2), and 26 (95% CI 24.4 to 27.6) months, respectively. These results are encouraging in view of the poor efficacy of chemotherapy in RCC observed previously. Additionally, the treatment toxicity was limited: toxicity of grade 3 or greater occurred in only 1 patient with leukopenia, and no treatment-related mortality was found.

CONCLUSIONS

The encouraging response rates and overall survival with limited toxicity warrant further investigation of this combination therapy as an integrated part of immunochemotherapy for RCC.

Carcinoembryonic antigen in monitoring of response to systemic chemotherapy in patients with metastatic colorectal cancer

The response to chemotherapy of solid tumors is generally assessed by measuring tumors visualized by imaging. However, the response assessment based on imaging is not always feasible because patients often have disease not measurable by imaging, such as diffuse peritoneal dissemination. We evaluated the correlation between the change on imaging and change in CEA levels for assessing chemotherapeutic response of patients with metastatic colorectal cancer. Between July 1993 and August 1999 we retrospectively examined 136 patients with metastatic colorectal carcinoma, all of whom had measurable lesions. Forty patients received oral tegafur-uracil (300 mg/m2/day) plus folinic acid (60 mg/day) for 4 weeks, repeated every 5 weeks, as the firstline treatment. Another 96 patients received either a weekly intravenous bolus injection of 5-fluorouracil (400 mg/m2) plus folinic acid (20 mg/m2), or an intravenous bolus injection of 5-fluorouracil (425 mg/m2) plus folinic acid (20 mg/m2) for 5 consecutive days every month. Responders, based on CEA assessment, were defined as those with a greater than 50% drop in CEA level for more than 4 weeks. The pretreatment CEA levels were elevated beyond the normal cutoff value in 110 (81%) patients. A response rate of 18.4% (95% CI, 11.9-24.9%), including 8 complete remissions and 17 partial remissions, was achieved according to imaging studies. The response rate assessed by CEA was 25% (34/136). Sixteen responders (47%) based on CEA had no remission on imaging. The sensitivity of change in CEA levels in the prediction of true responders and progressive diseases on imaging were 72% and 81%, respectively. In terms of the positive predictive value, change in CEA levels in the prediction of true responders and progressive disease on imaging were 53% and 85%, respectively. Patients with remarkable falls on CEA levels survived significantly longer than nonresponders (P < 0.001, log-rank test). At follow-up of 48 months the median survival for responders and nonresponders assessed by CEA was 28 months and 13 months, respectively. These data suggest that measurement of CEA levels might be helpful in monitoring chemotherapeutic response when imaging study is unsuitable for assessing the response in clinical practice. Furthermore, measurement of CEA levels may be helpful in determining the prognosis of patients with metastatic colorectal cancer receiving chemotherapy.

Recognition of nucleoside triphosphates during RNA-catalyzed primer extension

In support of the idea that certain RNA molecules might be able to catalyze RNA replication, a ribozyme was previously generated that synthesizes short segments of RNA in a reaction modeled after that of proteinaceous RNA polymerases. Here, we describe substrate recognition by this polymerase ribozyme. Altering base or sugar moieties of the nucleoside triphosphate only moderately affects its utilization, provided that the alterations do not disrupt Watson-Crick pairing to the template. Correctly paired nucleotides have both a lower K(m) and a higher k(cat), suggesting that differential binding and orientation each play roles in discriminating matched from mismatched nucleotides. Binding of the pyrophosphate leaving group appears weak, as evidenced by a very inefficient pyrophosphate-exchange reaction, the reverse of the primer-extension reaction. Indeed, substitutions at the gamma-phosphate can be tolerated, although poorly. Thio substitutions of oxygen atoms at the reactive phosphate exert effects similar to those seen with cellular polymerases, leaving open the possibility of an active site analogous to those of protein enzymes. The polymerase ribozyme, derived from an efficient RNA ligase ribozyme, can achieve the very fast k(cat) of the parent ribozyme when the substrate of the polymerase (GTP) is replaced by an extended substrate (pppGGA), in which the GA dinucleotide extension corresponds to the second and third nucleotides of the ligase. This suggests that the GA dinucleotide, which had been deleted when converting the ligase into a polymerase, plays an important role in orienting the 5'-terminal nucleoside. Polymerase constructs that restore this missing orientation function should achieve much more efficient and perhaps more accurate RNA polymerization.

Single agent paclitaxel as a first-line therapy in advanced urothelial carcinoma: its efficacy and safety in patients even with pretreatment renal insufficiency

BACKGROUND

Cisplatin-based chemotherapy is the mainstay of the treatment for advanced urothelial cancer, but patients with renal insufficiency before therapy are usually contraindicated to receiving platinum-based chemotherapy. Paclitaxel is one of the most promising agents against advanced urothelial carcinoma in recent trials and it can be easily tolerated even in patients with compromised renal function. We conducted a study in order to evaluate the efficacy and safety of paclitaxel as a first-line therapy in advanced urothelial carcinoma patients.

METHODS

Thirteen advanced chemo-naive urothelial carcinoma patients with a median age of 71 years were studied, seven of them demonstrating renal insufficiency (pretreatment serum creatinine > or = 1.5 mg/dl). All 13 patients received a minimum of two cycles of paclitaxel 175 mg/m2, delivered by intravenous infusion for 3 h every 3 weeks.

RESULTS

Four of the 13 patients responded to treatment, a response rate of 30.8%, with two of these achieving complete remission and two showing partial responses. The median overall survival period of all 13 patients was nine months (95% Cl: 6.51-11.49) and our study revealed a statistical tendency in the difference of median overall survival time between responders and non-responders (13 months versus 7.5 months, log-rank p = 0.038), although the number of cases was limited. The differences in response rate and median overall survival time, comparing patients with renal insufficiency and those with normal renal function, were not significant. Treatment-related toxicity was mild, with only two (15.4%) patients suffering from grade 3-4 leukopenia. No treatment-related mortality was noted.

CONCLUSIONS

Single-agent paclitaxel can be used as a first-line therapy in advanced urothelial carcinoma patients, and is especially suitable for those with pretreatment renal insufficiency, since the antitumor activity is significant while toxicity is well tolerated.

Randomized trial comparing weekly bolus 5-fluorouracil plus leucovorin versus monthly 5-day 5-fluorouracil plus leucovorin in metastatic colorectal cancer

BACKGROUND/AIMS

The purpose of this study was to compare the efficacy and toxicity profiles of weekly intravenous (i.v.) bolus injection of 5-fluorouracil plus low-dose leucovorin with the Mayo Clinics' monthly 5-day schedule of 5-fluorouracil and leucovorin in the treatment of metastatic colorectal cancer.

METHODOLOGY

A total of 96 patients with previously untreated metastatic colorectal cancer were randomized to receive either a weekly i.v. bolus injection of 5-fluorouracil 400 mg/m2 plus leucovorin 20 mg/m2 (weekly arm), or i.v. bolus injection of 5-fluorouracil 425 mg/m2 plus leucovorin 20 mg/m2 for 5 consecutive days every 4 or 5 weeks (monthly arm). Therapy was continued until disease progression or unacceptable toxicity appeared. In the presence of disease progression, the study regimen was stopped and second-line treatment was instituted after the patient was discontinued from this study.

RESULTS

There was no significant difference of response rates between both regimens. The response rate were 14.3% in the weekly arm (2 CR and 5 PR, 95% CI: 2.6-25.2%) and 10.6% in the monthly arm (1 CR and 4 PR; 95% CI: 6.5-32.3%), respectively (P = 0.8957). The survival times were also similar between the two (P = 0.4207, log-rank test). The median survival were 15.8 months in the monthly arm and 18.4 months in the weekly arm. Hematologic toxicity was minimal in both arms. However, the monthly arm produced a higher toxicity in severe (grade 3-4) diarrhea (14.9% vs. 2%; P = 0.029) and stomatitis (8.5% vs. 0; P = 0.054).

CONCLUSIONS

Weekly bolus injection of 5-fluorouracil and low-dose leucovorin achieved a similar response rate and survival as compared with the Mayo Clinics' monthly 5-day schedule, but severe toxicity was less commonly seen using the weekly regimen. As current chemotherapeutic treatment for metastatic colorectal cancer is largely palliative rather than curative, the weekly bolus regimen may be a more favorable approach in managing metastatic colorectal cancer.

Phase II study of oral tegafur-uracil and folinic acid as first-line therapy for metastatic colorectal cancer: Taiwan experience

BACKGROUND

Tegafur-uracil has become an important regimen in the treatment of metastatic colorectal cancer. Tegafur is a prodrug that is converted to 5-fluorouracil (5-FU) and has been reported to be less toxic and to have a higher therapeutic index. The additional advantage of tegafur is oral administration, an important consideration to improve the quality of life in these patients. Tegafur in combination with uracil is thought to have greater anti-tumor activity due to the inhibitory effect of uracil on the degradation of 5-FU by hepatic dihydropyrimidine dehydrogenase. Tegafur with folinic acid has been reported with modest efficacy and acceptable toxicity. The purpose of this study was to evaluate the effectiveness and toxicity profile of oral tegafur-uracil plus folinic acid in Chinese patients with metastatic colorectal cancer.

METHODS

Between May 1998 and August 1999, 40 patients with metastatic colorectal carcinoma were enrolled in this study. All the patients had to have measurable lesions. The initial dose of tegafur-uracil was 300 mg/m2/day for 28 days, followed by a 7-day rest period. Folinic acid was administered orally at a dose of 60 mg/day concurrently with tegafur-uracil. For patients with neutrophil count <1500/microl or a platelet count <100,000/microl after treatment, the treatment was postponed for a maximum of 2 weeks. After that time, if the neutrophil count was 1000-1500/microl and the platelet count was 70,000-100,000 microl, the dose of tegafur-uracil was reduced by 50%, and if lower values resulted, the treatment was discontinued.

RESULTS

Forty patients received a total of 318 courses of treatment and a response rate of 32.5% (95% CI, 18-47%), including five complete remissions and eight partial remissions, was achieved. Toxicity was mild and generally tolerable. Gastrointestinal toxicities, including diarrhea, nausea and vomiting, were the major side effects. Seven incidences (17.5%) of grade 3-4 gastrointestinal toxicity were observed. Hematological toxicities were minimal with no evidence of severe (grade 3 or 4) leukopenia and thrombocytopenia. No episode of hepatic, renal, cardiac or neurological toxicity occurred. Two patients (5%) developed transient painful fissuring erythroderma over their palms and soles (the hand-foot syndrome).

CONCLUSIONS

The data from our study indicate that oral tegafur-uracil plus folinic acid is an active and tolerable first-line treatment for Chinese patients with metastatic colorectal cancer, with the additional advantage of being easily administered at home.

Vincristine-induced dysphagia suggesting esophageal motor dysfunction: a case report

Transient esophageal motor dysfunction with dysphagia was observed in a 62-year-old man receiving vincristine-containing chemotherapy for non-Hodgkin's lymphoma. Neurological examinations, including muscle strength of extremities, deep tendon reflexes and cranial nerves, were normal. However, the patient complained of severe numbness in the fingertips and toes. The results of esophagogram and esophagoscopy were unremarkable. However, a significantly prolonged esophageal transit time was observed. Vincristine was considered as the causative agent. Empirical vitamin and metoclopramide were prescribed for his neurological symptoms but there was no improvement. The symptoms of dysphagia subsided spontaneously 2 weeks later. However, prompt recurrence of severe dysphagia was observed again after administration of the second and third courses of treatment, which again disappeared upon discontinuation of the drug. Peripheral nerves and the gastrointestinal tract are often affected by vincristine. Common gastrointestinal tract symptoms of vincristine neuropathy may be colicky abdominal pain and constipation. However, vincristine-induced esophageal motor dysfunction with dysphagia is uncommon but generally reversible. The oncologist and chemotherapist should be aware of this complication.

Factors predictive of survival in patients with node-positive colorectal cancer in Taiwan

BACKGROUND/AIMS

Preoperative CEA levels, depth of tumor penetration, and the number of positive lymph nodes were reported as independent factors prognostic of survival in colorectal cancer patients. This study was carried out in an effort to evaluate the prognostic significance of these three factors in patients with Dukes' C colorectal cancer in Taiwan.

METHODOLOGY

Between 1992 and 1994, a total of 112 patients with node-positive colorectal cancer were evaluated retrospectively at the Veteran General Hospital-Taipei. All patients underwent potentially curative surgery and received 5-fluorouracil based adjuvant chemotherapy. Reference to the Dukes' classification was according to the classical criteria described in 1932 for carcinoma of the rectum and adapted for use in colonic tumors. Data on the location of the tumor, depth of penetration, number of positive lymph nodes, degree of tumor differentiation, and preoperative CEA levels were analyzed to understand their association with survival. Blood samples for CEA measurement were taken a few days before operation. A multivariate analysis using the Cox's proportional hazards regression model was then performed to determine the most important independent predictors of survival among all the possible variables.

RESULTS

Using univariate analysis the number of positive lymph nodes (P < 0.001), penetration of the bowel wall (P < 0.001), and preoperative CEA levels (P < 0.001) were found as significant prognostic factors, while the degree of tumor differentiation, location of the tumor, age and sex were not significant. Using multivariate Cox analysis the number of positive lymph nodes, penetration of the bowel wall, and preoperative CEA levels were still found as independent prognostic factors in node-positive colorectal cancer patients.

CONCLUSIONS

Data obtained from our study indicates that preoperative CEA levels, depth of tumor penetration, and the number of positive lymph nodes were independent prognostic factors in Dukes' C colorectal cancer patients. They could serve as appropriate modifications of the initial Dukes scheme in node-positive diseases.

Lack of mutations of BCL6 and BCL10 genes in mucosa-associated lymphoid tissue lymphomas of the orbital adnexa

Knowledge regarding the molecular pathogenesis and progression of mucosa-associated lymphoid tissue (MALT) lymphomas of ocular adnexa is limited. Eleven cases of ocular MALT lymphoma were analyzed by clonal rearrangement of antigen receptor genes using Southern blot hybridization. Polymerase chain reaction-single stranded conformational polymorphism analysis and DNA sequencing was utilized to analyze the mutations of BCL6 and BCL10 genes. Clonal rearrangement of immunoglobulin heavy genes was found in all 11 patients. No point mutation was found in BCL6 or BCL10 genes in any of the samples analyzed. We suggest that mutations of BCL6 and BCL10 genes are rare in low-grade MALT lymphoma of ocular adnexa and are unlikely to be involved in the pathogenesis of the disease. But the role of alterations of both BCL6 and BCL10 genes in the disease progression of low-grade MALT lymphoma require additional study.

Immunophenotypic and genotypic characteristics of chronic myelogenous leukemia in blast crisis

BACKGROUND

Chronic myelogenous leukemia (CML) may transform into blast crisis (BC) if not properly treated. Among patients with transformation, 20% to 30% will develop BC with lymphoid-associated antigens (Ly-BC), and the remaining cases with myeloid-associated antigens (My-BC) or with both (Mix-BC). In this study, we investigated the lineage of blast cells in CML-BC using immunophenotypic and genetic analyses and analyzed the prognostic significance of genotypic change in CML-BC.

METHODS

Twenty-one patients with CML-BC diagnosed at the Taipei Veterans General Hospital from 1982 to 1992 were included. Immunophenotyping was done by using the avidin-biotin immunoperoxidase technique. Genetic analyses were carried out by using Southern Blot hybridization. The prognostic influence of genotypic change was analyzed.

RESULTS

Thirteen patients (61.9%) expressed myeloid-associated antigens, one patient (4.8%) expressed megakaryoblast-associated antigens, four patients (19%) expressed B lymphoid-associated antigens and three patients (14.3%) expressed both myeloid and B lymphoid antigens. Clonal rearrangement of the immunoglobulin heavy chain (IgH) gene was found in six cases. Among them, four expressed B lymphoid markers only and two expressed both myeloid and B lymphoid markers. Patients with clonal IgH gene rearrangement tended to have a better response to chemotherapy (50% vs 8.3%, p = 0.08) and significantly longer survival (median survival, 5 months vs 3 months, p < 0.05) than did those with a germline configuration.

CONCLUSIONS

Clonal rearrangement of the IgH gene was found mostly in cases of Ly-BC and Mix-BC. We found that CML-BC with clonal rearrangement of the IgH gene had a more favorable prognosis than in cases with a germline configuration.

Comparison of the efficacy and safety of oral granisetron plus dexamethasone with intravenous ondansetron plus dexamethasone to control nausea and vomiting induced by moderate/severe emetogenic chemotherapy

BACKGROUND

Chemotherapy-induced nausea and vomiting can affect cancer patients' compliance with cytotoxic chemotherapy. Currently, there are some new antiemetic therapies for the treatment of chemotherapy-induced emesis. A single institution, randomized, open, parallel trial was done to compare oral granisetron plus intravenous (i.v.) dexamethasone with intravenous ondansetron for the prevention of moderate or severe emetogenic chemotherapy-induced acute and delayed emesis.

METHODS

Fifty-one cancer patients were treated with moderate/severe emetogenic chemotherapy and randomized to receive either oral granisetron 1 mg twice daily or i.v. ondansetron 8 mg every 8 hours combined with i.v. dexamethasone 10 mg on the day of chemotherapy. The efficacy and safety of the two antiemetic regimens were compared.

RESULTS

Oral granisetron plus i.v. dexamethasone had comparable antiemetic efficacy for the prevention of nausea in the first 24-hour period after initiation of chemotherapy compared with intravenous ondansetron plus i.v. dexamethasone. The complete response of antiemesis in the first 24-hour period after initiation of antiemetic therapy between granisetron and ondansetron were 84.0% (95% CI, 62.9%-95.6%) and 84.6 (95% CI, 64.0%-97.5%). The complete response for delayed emesis after initiation of antiemetic therapy between granisetron and ondansetron were 16.0% (95% CI, 4.5%-36.1%) and 19.2% (95% CI, 6.8%-40.7%0. There was diarrhea in 12% of patients receiving granisetron therapy and constipation in 23.1% of the ondansetron group.

CONCLUSIONS

Oral granisetron plus i.v. dexamethasone and i.v. ondansetron plus i.v. dexamethasone are potentially equally effective antiemetic agents in the prevention of moderate or severe emetogenic chemotherapy-induced acute or delayed emesis. Oral granisetron with dexamethasone appears to be a suitable alternative antiemetic agent in cancer patients who receive moderately or severely emetogenic chemotherapy.

Venous gangrene in a patient with adenocarcinoma of the lung

Cancer-related thromboembolism is a severe but not uncommon paraneoplastic syndrome in mucinous cancer patients. However, cancer-induced venous gangrene is extremely rare and has never been reported in the English literature. Here, we present a case of lung cancer complicated with venous gangrene of the left foot. An elevated serum anticardiolipin level was detected during hospitalization, but the patient's clinical condition stabilized after heparinization. We suggest that in cancer patients, an elevated serum anticardiolipin antibody level might be a warning sign of an impending thrombotic event and that low-molecular-weight heparin is a sensible choice in treating this kind of cancer-related thromboembolism.

Ruptured metastatic ovarian carcinoma presenting as acute abdomen

Acute abdomen is a challenge to first-line physicians because of frequently missed diagnoses and potential follow-on legal problems. Improving the management of these patients is of paramount importance, not only for saving lives, but also for reducing untoward problems associated with improper management. We present a case of a patient with acute abdomen due to intraperitoneal hemorrhage secondary to rupture of an ovarian tumor. Following emergency surgery, the patient was diagnosed with metastatic ovarian carcinoma. Because of improper preparation of the gastrointestinal tract, the patient underwent repeat exploratory laparotomy for colon carcinoma. Although this situation did not affect the outcome of the patient in this case, we are concerned that the patient did not benefit from a single operation, with primary complete excision of the tumor plus a colostomy. The outcome of patients with pelvic malignancy, especially those with ovarian carcinoma, might be better if initial surgery achieved optimal tumor debulking. This is possible with good preoperative planning and preparation. We emphasize the importance of preoperative preparation in spite of urgently needed care. Furthermore, every first-line physician should communicate the possibility of malignancy to patients and their families.

Preoperative carcinoembryonic antigen level as an independent prognostic factor in colorectal cancer: Taiwan experience

BACKGROUND

Preoperative carcinoembryonic antigen (CEA) level is considered as a factor predictive of survival in colorectal cancer patients. Patients with normal (<5 ng/ml) or lower preoperative CEA levels were reported to have significantly longer survival. This study was carried out in an effort to evaluate the prognostic significance of preoperative CEA levels of patients with colorectal cancer in Taiwan.

METHODS

Between 1990 and 1994, 218 patients with histologically confirmed colorectal cancers were evaluated retrospectively at the Veterans General Hospital-Taipei. All the patients had undergone potentially curative surgery. Patients with metastatic diseases were not included. 5-Fluorouracil-based adjuvant chemotherapy was administered if the patients had Dukes' C disease. Reference to the Dukes' classification was according to the classical criteria described in 1932 for carcinoma of the rectum and adapted for use in colonic tumors. Data on gender, age, degree of tumor differentiation, location of the tumor, tumor size, lymph node metastasis, penetration of the bowel wall and preoperative CEA levels were analyzed to determine their association with survival. Blood samples for CEA measurement were taken a few days before operation and were analyzed using the radioimmunoassay method. Multivariate analysis by Cox's proportional hazards regression model was performed to determine the most important predictors of survival among all of the possible variables.

RESULTS

By univariate analysis, the size of the tumor (p = 0.012), lymph node metastases (p = 0.007), penetration of the bowel wall (p < 0.001) and preoperative CEA levels (p < 0.001) were found to be significant prognostic factors, while gender, age, degree of tumor differentiation and location of the tumor were not significant. By multivariate Cox analysis, lymph node metastases (p = 0.003), penetration of the bowel wall (p = 0.0001) and preoperative CEA levels (p = 0.0001) were found to be independent prognostic factors in colorectal cancer patients.

CONCLUSIONS

The data from our study indicate that in addition to lymph node metastases and penetration of the bowel wall, the preoperative CEA levels are also an independent prognostic factor in non-metastatic colorectal cancer patients after curative surgery. This could serve as an appropriate modification to the initial Dukes' scheme in colorectal cancer.

Effect of oncostatin-M on proliferation and activity in osteoblastic MC3T3-E1 cells

BACKGROUND

Osteogenic cells (osteoprogenitor cells and osteoblasts) respond to specific cytokines, growth factors and hormones. Understanding which cytokines affect osteogenic cells and the consequences of those effects are central to understanding normal and pathologic bone remodeling. Oncostatin-M (OSM) is a glycoprotein interleukin-6 cytokine known to inhibit bone resorption in fetal long bone cultures. However, it is still unclear whether OSM affects bone formation. The aim of this study was to investigate the effects of OSM on bone formation (bone cell proliferation, differentiation and function).

METHODS

For the in vitro bone formation bioassay, MC3T3-E1 cells were plated into 35 mm Petri dishes and cultured in Dulbecco's modified eagle medium (DMEM). Various concentrations (1, 10, 100 or 1,000 units/ml) of OSM were added daily to the experimental dishes, while only DMEM was added in the control dishes during the proliferative and differentiated stages of MC3T3-E1 cell growth. The effect of OSM on bone formation was evaluated using 3H-thymidine incorporation, alkaline phosphatase expression, type I collagen synthesis assay and phase-contrast light microscopy.

RESULTS

OSM significantly decreased osteoprogenitor cell proliferation and alkaline phosphatase activity in a dose-related fashion. There was no effect on type I collagen synthesis noted at any OSM dose. Thus, OSM exerted significant inhibition on bone formation.

CONCLUSIONS

OSM is a potent inhibitor of bone formation by decreasing both osteoprogenitor cell proliferation and alkaline phosphatase activity.

Prognostic significance of immunoglobulin and T cell receptor gene rearrangements in patients with acute myeloid leukemia: Taiwan experience

We investigated the prognostic significance of lymphoid antigen receptor gene rearrangement in patients with newly diagnosed acute myeloid leukemia (AML). Thirty-nine patients were included in the study. Clonal gene rearrangement of immunoglobulin heavy chain (IgH) and T cell receptor beta chain (TCRbeta) was found in leukemic cells in 11 (28.2%) and 10 (25.6%) patients, respectively. Five (12.8%) had both IgH and TCRbeta gene rearrangements. Three of the seven (42.9%) B-lymphoid marker-positive and eight of the 32 (25%) B-lymphoid marker-negative patients had clonal IgH gene rearrangements. Five of the 11 (45.5%) T-lymphoid marker-positive and 5 of the 28 (17.9%) T-lymphoid marker-negative patients had clonal TCRbeta gene rearrangements. All patients were treated with similar regimens. The complete remission rate (62.5% vs 65.2%, p=1.000) and median survival (13 vs 14 months, p=0.366) were similar in patients with and without clonal IgH or TCRbeta gene rearrangements. In conclusion, while clonal rearrangements of IgH or TCRbeta genes were found in AML patients, they did not appear to effect the prognosis.

Fulminant hepatitis is significantly increased in hepatitis B carriers after allogeneic bone marrow transplantation

BACKGROUND

Bone marrow transplantation (BMT) is effective treatment for many hematologic disease, but performed in a population with a high endemic hepatitis B virus carrier rate, the incidence of liver function impairment and fulminant hepatitis (FH) is expected to be raised.

METHODS

Forty-three hepatitis B virus carriers received high-dose chemotherapy and BMT, 32 patients received an allogeneic graft, and 11 patients autologous marrow. Acute graft-versus-host disease prophylaxis consisted of methotrexate on day 1, 3, 6, and 11 and cyclosporine for 6 months.

RESULTS

After a median follow-up period of 68 months (range: 1-11.5 years), 26 (81.3%) allogeneic BMT patients developed impaired liver function (LF), 5 progressed to FH on day 93, 169, 170, 180, and 468, respectively, and died after an average of 13.8 days (range: 1-45 days). Whereas only 4 (36.4%) autologous BMT patients developed impaired LF, and none FH. Impaired LF (P=0.026, chi-square), and FH (odds ratio=12.86, P=0.009 for coefficient) were significantly related to an allogeneic marrow graft, and the timing of liver function impairment coincided with cyclosporine withdrawal. Hepatitis B surface antigen (HbsAg) disappeared from the serum in 4/14 (28.6%) patients receiving a marrow graft from an HbsAg+ donor. HbsAg was not detected in the serum after BMT in 2/11 (18.2%) autologous BMT patients.

CONCLUSIONS

Hepatitis B virus carriers receiving a marrow graft from an HbsAg+ donor have a significantly increased risk of FH.

p53 gene mutations and rearrangements in non-Hodgkin's lymphoma

BACKGROUND

Alterations of the p53 gene have been associated with the progression of certain human malignancies. To establish further the correlation between p53 gene alterations and progression of non-Hodgkin's lymphomas (NHLs), the authors analyzed both mutations and rearrangements of the p53 gene in a cohort of 84 NHLs.

METHODS

Eighty-four NHLs were analyzed for p53 gene alterations. Point mutations of exons 5-9 were studied by polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP), and DNA rearrangements were studied by Southern blot analysis. RESULTS. Point mutations and DNA rearrangements of the p53 gene were detected in 6 (7.2%) and 3 (3.6%) patients, respectively. All p53 gene abnormalities were found exclusively in B-cell NHLs. Taken together, patients with p53 gene alterations had poorer survival than other patients (P = 0.024). However, of the three patients with p53 gene rearrangements, the two who appeared to have one normal allele showed a relatively better response to chemotherapy and had longer survival (27 and 47 months). In contrast, the remaining patient who had rearranged bands much stronger than the germline, and thus appeared to have both alleles rearranged, was refractory to chemotherapy and had poorer survival (6 months).

CONCLUSIONS

Patients with NHLs of intermediate and high grades who carried point mutations or rearrangements of p53 genes had worse outcomes than other patients. Patients with one abnormal p53 allele and one residual normal allele had a more favorable prognosis than those with two abnormal alleles.

ESHAP as salvage therapy for refractory non-Hodgkin's lymphoma: Taiwan experience

BACKGROUND

The ESHAP regimen, a combination of the chemotherapeutic drugs etoposide, methylprednisolone (solumedrol), high-dose cytarabine (ara-C) and cisplatin, has been shown to be active against refractory non-Hodgkin's lymphoma in therapeutic trials. We were interested in determining whether this regimen would be effective and tolerable for Chinese patients.

METHODS

Thirty-two patients with refractory/relapsed non-Hodgkins lymphoma (23 intermediate-grade and nine high-grade) were enrolled in this study. Etoposide was administered at a dose of 40 mg/m2/day as a 1 h intravenous infusion from day 1 to day 4, solumedrol 500 mg/day was given as a 15 min intravenous infusion from day 1 to day 5, ara-C 2 g/m2 was given as a 2 h intravenous infusion on day 5 and cisplatin was given at a dose of 25 mg/m2/day as a continuous infusion from day 1 to day 4. Clinical efficacy and toxicity were assessed on the basis of the WHO criteria.

RESULTS

Ten patients (31.3%, 95% Cl 15.2-47.4%) attained complete remission (CR) and seven had partial remission (PR). The overall response rate was 53.1% (95% Cl 35.8-70.4%). In eight of the 10 CR patients, the remission lasted for more than 8 months. The remaining two patients had CR of 5 and 6 months. The median duration of CR was 12.2 months (range 5-22 months). Myelosuppression with subsequent infections was the major toxicity. Severe leukopenia (WBC < 1000/microliter) lasted for an average of 12 days and thrombocytopenia (< 25,000/microliter) 18 days. One patient (3.1%) died of neutropenia-associated sepsis within 4 weeks after treatment. Non-myeloid toxicities included alopecia in 66% (28% grade 2, 22% grade 3), stomatitis in 72% (25% grade 2, 28% grade 3, 13% grade 4), hepatotoxicity in 9% (3% grade 2), renal toxicity in 13% (6% grade 2, 3% grade 3) and infection in 56% (18% grade 2, 25% grade 3, 13% grade 4). The majority of the responders relapsed within 2 years after ESHAP treatment. Median survival for all patients was 8.6 months.

CONCLUSIONS

ESHAP is an active and tolerable regimen in Chinese patients with relapsed/refractory lymphoma, but the duration of remission is brief and without significant impact on survival.

Toxic cardiogenic shock in a patient receiving weekly 24-h infusion of high-dose 5-fluorouracil and leucovorin

A 54-year-old man was treated with weekly 24-h infusion of high-dose 5-fluorouracil (2600 mg/m2) and leucovorin (100 mg/m2) for metastatic colon cancer. At first, he tolerated the treatment well and no significant toxicity was identified. After a total of eight courses of treatment, a stable disease was observed, but mild shortness of breath was found on occasion. The patient had no previous history of cardiac disease and the heart performance assessed by left ventricular ejection fraction before treatment was normal. Unfortunately, acute pulmonary edema with lethal cardiogenic shock occurred during the ninth course of treatment, in spite of intensive medical treatment. The chest X-ray showed extreme cardiomegaly. Repeated assessment of his heart function by echocardiogram and ventricular ejection fraction revealed a very poor cardiac performance. Toxic cardiogenic shock during weekly 24-h infusion of high-dose 5-fluorouracil and leucovorin is extremely rare. To the best of our knowledge, no case has been reported in the English literature. We report a case and the relevant literature about the incidence, clinical picture and possible pathophysiology on 5-fluorouracil-related cardioxicity is reviewed.

Phase II study of the modified regimen of etoposide, leucovorin and 5-fluorouracil for patients with advanced gastric cancer

BACKGROUND

The efficacy of the treatment of advanced gastric cancer is not very good. The response rate to the original etoposide--leucovorin--5-fluorouracil (ELF) treatment is 53% with tolerable side effects. Whether increasing the dose intensity by prolonging the duration of infusion with 5-fluorouracil (5-FU) and leucovorin (LV) from 3 to 5 days for advanced or metastatic gastric cancer patients would enhance the efficacy but not increase side effects is still unknown.

METHODS

Thirty-six advanced or metastatic gastric cancer and chemotherapy-naïve patients with measurable or evaluable diseases were scheduled to receive intravenous etoposide 100 mg/m2/day on days 2-4, LV 300 mg/m2/day intravenously and 5-FU 500 mg/m2/day intravenously on days 1-5, every 4 weeks. All patients who received at least two courses of chemotherapy were evaluated for tumor response, survival and response duration and toxicity according to the WHO criteria.

RESULTS

Thirteen patients showed a response, including five with complete response (CR). The overall response rate was 36% (95% confidence interval, CI, 20-52%) in the whole group and 46% (95% CI 28-66%) in the 28 patients with measurable disease. The median progression-free interval and overall median survival time were 5 and 7 months, respectively. The most frequent toxicity was alopecia (grade I/II 56.3%). The incidence of grade III or greater myelosuppression was 5.9%. No treatment-related death occurred.

CONCLUSIONS

The efficacy of the modified ELF by increasing the dosages of 5-FU and LV is not superior to the results of the original regimen, yet it is a relatively safe and tolerable combination regimen for advanced gastric cancer.

Navoban (tropisetron, ICS 205-930) and dexamethasone combination in the prevention of vomiting for patients receiving preconditioning high-dose chemotherapy before marrow transplantation

The anti-emetic efficacy of a combination of tropisetron and dexamethasone was studied in 33 patients who underwent bone marrow transplantation. Another 50 patients receiving conventional anti-emetic therapies in bone marrow transplantation served as control. On the first and second days of preconditioning chemotherapy, 51% and 36% respectively of patients in the tropisetron and dexamethasone group did not experience vomiting, compared with only 12% and 10% of control group patients (P < 0.001). The mean number of episodes of vomiting in the tropisetron and dexamethasone group was also significantly lower than in the control group (0.97+/-1.65 vs 3.50+/-2.45 and 1.30+/-1.40 vs 4.44+/-2.91 respectively, both P < 0.001). Control of vomiting in the two groups was not significantly different during days 3-6. Analysis of patients receiving busulfan and cyclophosphamide as the preconditioning regimen still showed better anti-emetic control in the tropisetron and dexamethasone group than in the control group on the first two days of treatment (total control rate 33.3% vs 6.5% and 44.4% vs 12.9% respectively, P < 0.001). Patients given tropisetron and dexamethasone combination more frequently suffered from dizziness and burning sensation of the chest. However, diarrhea and extrapyramidal symptoms were the most frequent adverse effects seen after using conventional anti-emetic combination. The combination of tropisetron and dexamethasone was thus superior to conventional anti-emetic combinations in preventing vomiting during preconditioning period of bone marrow transplantation. The adverse effects of this combination were minimal and well tolerated by patients.

Successful pregnancy following very high-dose total body irradiation (1575 cGy) and bone marrow transplantation in a woman with acute myeloid leukemia

A 22-year-old woman had a normal full-term delivery 6 years after a successful allogeneic bone marrow transplantation (BMT) for acute myeloid leukemia (AML). Conditioning therapy consisted of cyclophosphamide (120 mg/kg) and total body irradiation (TBI) to a total of 1575 cGy in seven fractions (225 cGy x 7, at a dose rate of 3.5 cGy/min). Graft-versus-host disease prophylaxis was with methotrexate and cyclosporin A. Grade I acute GVHD developed after BMT but there was no chronic GVHD. She became amenorrhoeic after BMT and serial gonadal testing indicated hypergonadotrophic hypogonadism. She became pregnant and delivered a full-term, healthy baby 6 years after BMT. Successful pregnancy after TBI of more than 1200 cGy is extremely rare. This case, to the best of our knowledge, is the second patient who received a higher dose of TBI (1575 cGy) to have a successful pregnancy. This and previous reports indicate that normal pregnancy is possible after BMT with TBI in excess of 1200 cGy.

Weekly 24-hour infusion of high-dose 5-fluorouracil and leucovorin in patients with advanced colorectal cancer: Taiwan experience

Between January 1994 and November 1995, 41 patients with metastatic colorectal carcinoma were enrolled in this study. All these patients had recurrent disease after a prior 5-fluorouracil based adjuvant chemotherapy or failed to achieve response by prior chemotherapy that included 5-fluorouracil. 5-Fluorouracil, 2600 mg/m2, was administered concurrently with 100 mg/m2 leucovorin over 24 hours of continuous intravenous infusion. The treatment was repeated every week until progressive disease was documented. Forty-one patients received a total of 810 courses of treatment. The overall response rate was 17.1% (95% confidence interval 5.6-28.6%). In two patients who achieved complete response, the liver was the metastatic site. The median survival was 18.4 months for responders and 12.6 months for non-responders. Gastrointestinal toxicities including diarrhea, stomatitis, nausea and vomiting were the major side-effects. Sixteen incidences (39.0%) of grade 2-3 gastrointestinal toxicities were observed. One patient (2.4%) developed a grade 3 cardiac toxicity, and another one (2.4%) had a grade 2 neurotoxicity. Hematological toxicities were minimal with no evidence of severe (grade 2 or more) leukopenia or thrombocytopenia. We conclude that in patients with pretreated metastatic colorectal cancer, weekly 24-hour infusion of high-dose 5-fluorouracil and leucovorin is associated with higher efficacy and tolerable toxicity. This regimen is a good option as a second-line treatment for those whose diseases are recurrent from or refractory to prior 5-fluorouracil, and deserves a longer period of follow-up.

Lethal acute pulmonary edema following intravenous naloxone in a patient received unrelated bone marrow transplantation

A 39-year-old man was diagnosed as having acute myeloid leukemia and received 6 courses of chemotherapy. The bone marrow revealed complete remission. He had no prior history of cardiac or pulmonary disease. HLA-matched unrelated bone marrow transplantation (BMT) was performed in September 1995. Pre-transplant studies including chest X-ray, electrocardiogram and pulmonary function test were normal. The procedure of BMT was smooth and serial bone marrow examination showed successful engraftment. Serial chest X-rays done every week after BMT were normal. There were no evidence of fluid overload but severe mucositis was noted. On the 38th day after BMT, intravenous injection of 10 mg morphine was prescribed to relief severe oral pain. Respiratory depression developed right after, and naloxone 0.4 mg was given by an intravenous route. One hour later, severe shortness of breath was noted and the emergent chest X-ray revealed acute pulmonary edema. He became unconscious 2 hours later and expired 24 hours after naloxone injection in spite of intensive medical treatment. Naloxone-induced acute pulmonary edema is an extremely rare but lethal complication. Only a few cases have been reported in English literature. We report a case of acute myeloid leukemia receiving unrelated BMT to develop acute pulmonary edema rapidly after intravenous injection of naloxone. The clinical features and pathogenesis are discussed.

Treatment of previously treated metastatic breast cancer by mitoxantrone and 48-hour continuous infusion of high-dose 5-FU and leucovorin (MFL): low palliative benefit and high treatment-related toxicity

For previously treated advanced breast cancer, there is no standard second-line therapy. Combination chemotherapy with mitoxantrone, high-dose 5-fluorouracil (5-FU) and leucovorin (MFL regimen) had been reported as an effective and well tolerated regimen. From October 1993 to November 1995, we treated 13 patients with previously chemotherapy-treated metastatic breast cancer by mitoxantrone, 12 mg/m2, on day 1 and continuous infusion of 5-FU, 3000 mg/m2, together with leucovorin, 300 mg/m2, for 48 h from day 1 to 2. Each course of chemotherapy was given every 4 weeks. Most of these patients had more than two metastatic sites, with lung metastasis predominant. Seven patients had been treated with anthracycline. Seven patients had previously received radiotherapy and seven had received hormone therapy. Median number of courses of MFL regimen given was six and the median cumulative dose of mitoxantrone was 68.35 mg/m2. One patient had complete response, seven had stable disease, none had partial response and five had progressive disease. The overall objective response rate was 7.6%. The median follow-up period was 14 months. Median survival was 16 months. Median progression-free survival was 5 months. A complete responder had relapse-free survival up to 17 months. Major toxicities were cardiotoxicity and leukopenia. Eight patients were dead in the last follow-up; two of them died of treatment-related toxicity. The MFL regimen achieves little palliative benefit and induces severe toxicity at a fairly high rate. Administration of this regimen to breast cancer patients who have been treated by chemotherapy and those with impaired heart function requires careful attention.

Augmentation of protein kinase C activity and liver cell proliferation in lead nitrate-treated rats

It is shown that lead alters calcium mediated cellular processes in several biological systems. Calcium enhances the activity of protein kinase C (PKC) which takes part in eliciting cell mitosis. In this study, the effects of lead nitrate on the activity of PKC enzyme were investigated in rat liver. The PKC activity was determined at 12, 24, 48, 72, 120, 168 hours after treatment with a single dose of lead nitrate in male Wistar rats. The results showed that the specific PKC activity of the purified particulate fraction was increased and reached a maximum at 24 hour, and lasted for 48 hours. This augmented activity of PKC was parallel with the increase of the lead level in the purified particulate fraction, although the protein levels of PKC alpha, PKC delta and PKC zeta were unchanged. Moreover, the frequency of mitotic cells also exhibited a significant increase, and like PKC activity, reached its maximum at 24 hour with accompany signs of liver enlargement. The results suggest that the PKC activation may be involved in promoting liver cell proliferation in lead nitrate-treated rats.

Acute myelomonocytic leukemia preceded by secondary amenorrhea and presenting with central diabetes insipidus: a case report

The patient, a 28 year-old female, received treatment for secondary amenorrhea two months before her first admission to our hospital. She was later found to have central type diabetes insipidus and acute myelomonocytic leukemia. A diagnosis of panhypopituitarism was established but there was no laboratory or radiological evidence of neuroleukemia. Complete remission was obtained after one course of induction chemotherapy. She received four more courses of chemotherapy including one course of high-dose cytosine arabinoside (Ara-C) and 14-day granulocytic colony-stimulating factor (G-CSF) for peripheral blood stem cell (PBSC) mobilization. Then she received autologous PBSC transplantation (Auto-PBSCT). Unfortunately leukemia relapsed 4 months after transplantation. The patient expired soon due to severe electrolyte imbalance and sepsis. Throughout the whole course, her pituitary function was only partially recovered after treatment and there was no laboratory or radiological evidence of CNS leukemia.

Factors predictive of response and survival in patients with metastatic colorectal cancer in Taiwan

5-Fluorouracil in combination with leucovorin has been shown to be active in therapeutic trials of metastatic colorectal carcinoma. In this study, we administered these drugs to 72 patients with metastatic colorectal carcinoma. Thirty-six of them without previous exposure to 5-fluorouracil were treated with weekly bolus injections of 5-fluorouracil (425 mg/m2) and leucovorin (25 mg/m2) supplemented with oral levamisole. Another 36 patients with or without prior 5-fluorouracil treatment received 5-fluorouracil 3,000 mg/m2 and leucovorin 300 mg/m2 in a 48-hour continuous infusion every two weeks. Clinical efficacy and toxicity were assessed by WHO criteria. Variables were tested for relations to response and survival by univariate and multivariate analysis. The response rate was 19.4% in weekly bolus arm and 13.9% in biweekly high-dose infusion arm (P = 0.527). Median survivals in the two arms were 18.4 months (weekly) and 21 months (biweekly) respectively (P = 0.708). Gastrointestinal side effects including nausea, vomiting, diarrhea and mucositia were the major toxicities of these regimens. By multivariate analysis, the only factor to influence response rate was the site of metastases (P = 0.009). The only factor to affect survival was performance status of the patient (P = 0.0001). We concluded that the two 5-fluorouracil based regimens are well-tolerated and shown to have a response rate comparable with previous reports of similar regimens in patients with metastatic colorectal cancer. Only liver metastases seemed to have a better response to therapy. Performance status is the most important prognostic factor in patients with metastatic colorectal cancer.

Langerhans' cell histiocytosis with thyroid involvement masquerading as thyroid carcinoma

A 28-year-old woman was admitted to our Hospital with a chief complaint of progressive gingival swelling and loosening of teeth over about a year. According to past history, she had received total thyroidectomy 2 years previously due to thyromegaly. The thyroidectomy specimen was at first interpreted as 'poorly differentiated carcinoma of the thyroid'. One year ago, she began to be aware of gingival swelling and loosening of teeth. A gum biopsy was taken and the pathologic features were similar to her 'thyroid carcinoma'. Subsequent investigations, including immunohistochemical stain, showed the gum was heavily infiltrated with histiocyte-like Langerhans' cells which were positive for S-100 protein. Ultrastructural examination of the cells under electron microscope revealed many typical intra-cytoplasmic Birbeck granules. Langerhans' cell histiocytosis was diagnosed. Langerhans' cell histiocytosis with thyroid involvement is extremely rare and may run a relatively indolent course. Even on a retrospective examination, it may easily be confused with poorly differentiated carcinoma of the thyroid. We suspect that this error may have been made on other occasions and that the occurrence of this condition may be underreported.

Surgical treatment of congenital convex pes valgus

Congenital convex pes valgus is a rare, complex and heterogeneous anomaly of the foot, which is difficult to treat. From 1985 to 1994, we treated 14 patients (20 feet) with this deformity. There were six boys and eight girls. Six patients had bilateral involvement. Their ages at the time of surgery ranged from 4 to 32 months (mean, 13 mo). In eight patients (10 feet), the etiology was arthrogryposis multiplex congenita. The eitiology was unknown in six patients (10 feet). Associated problems included hip dislocation in seven patients, flexion or extension contractures of the knee in six patients, and clubfoot deformity in three patients. One patient had undergone previous surgery for release of a knee contracture. To achieve a plantigrade and balanced foot, all patients had one-stage surgical open reduction and circumferential release for the correction of deformities. At a minimum of 2 years following surgery, 11 patients (16 feet) had satisfactory results determined by a 10-point evaluation system based on both clinical and radiographic features. Satisfactory results and ambulatory prognosis were related to the etiology and severity of each patient's condition. Two patients (two feet) had scars with poor cosmetic appearance and two patients (three feet) had inadequate correction. We concluded that with adequate soft tissue release and complete talocalcaneonavicular joint reduction in one-stage surgery, proper postoperative maintenance, and physical therapy, satisfactory results in the treatment of congenital convex pes valgus can be achieved.

High-dose cytarabine and mitoxantrone as salvage therapy for refractory non-Hodgkin's lymphoma

High-dose cytarabine alone or in combination with mitoxantrone has been shown to be active against refractory non-Hodgkin's lymphoma in therapeutic trials. We administered these two drugs to 16 patients with advanced and refractory non-Hodgkin's lymphoma. Cytarabine was administered at 3 g/m2 as a 2-h intravenous infusion every 12 h on days 1-4 (8 doses) and mitoxantrone at 6 mg/m2/day as a 1-h intravenous infusion on days 1-5. The clinical efficacy and toxicity were assessed according to the WHO criteria. Five patients (31%, 95% CI: 8-54%) attained complete remission and two had partial remission. In three of the five complete remission patients, the remission lasted for > 4 months. The remaining two patients had complete remission for only 1.3 months. Myelosuppression with subsequent infection was the major toxicity of this regimen. Severe leukopenia (WBC < 1000/microliter) lasted for an average of 20 days and thrombocytopenia (< 25000/microliter) 18 days. Five patients (31%) died of treatment-related complications: neutropenia-associated sepsis in three, pneumonia in one and electrolyte imbalance in one. Nonmyeloid toxicities included alopecia in 100% (19% Gr.2, 75% Gr.3), stomatitis in 88% (13% Gr.2, 31% Gr.3), hepatotoxicity in 38% (6% Gr.2, 6% Gr.3), dermatitis in 31% (19% Gr.2), CNS toxicity in 25% (6% Gr.2, 6% Gr.3), infection in 38% (13% Gr.3, 19% Gr.4) and chemical conjunctivitis in 6% (Gr.2). We conclude that a proportion of refractory non-Hodgkin's lymphoma cases will respond to high-dose cytarabine+mitoxantrone, but that the treatment seems too toxic to be acceptable as salvage therapy for refractory non-Hodgkin's lymphoma.

Allogeneic bone marrow transplantation for Gaucher disease--a case report

A Chinese patient who presented painful disability of right hip was diagnosed as having type 1 Gaucher disease four years later when hepatosplenomegaly was found. Splenectomy was performed but her condition did not improve. So human leukocyte antigen (HLA)-matched sibling allogeneic bone marrow transplantation (BMT) was performed. The transplantation course was smooth. Although her bone marrow was in mixed chimeric state, symptoms disappeared and her growth caught up with normal level after BMT. Gaucher disease should be considered in cases with hepatosplenomegaly and bone disorder of unknown causes. Allogeneic BMT is an effective treatment, but the treatment-related risk should be seriously evaluated and the late complications should be closely monitored.

Orthoclone OKT3 for graft failure after allogeneic bone marrow transplantation: a case report

Orthoclone OKT3 has been used in the prophylaxis or treatment of acute graft-versus-host disease (GVHD). No previous report of Orthoclone OKT3 in the treatment of marrow allograft failure has been found. Here a case of chronic myelocytic leukemia is presented where the patient received unrelated bone marrow transplantation and developed late graft failure. After failing all other immunosuppressive agents, marrow allograft was successfully rescued by the use of Orthoclone OKT3.

Bone marrow transplantation with HLA partially matched related donors

BACKGROUND

Approximately one-fourth of patients who could benefit from bone marrow transplantation (BMT) are served by a genotypically identical sibling donor. When patients do not have an HLA-matched donor, alternative marrow sources should be explored. The way to allow survival in some patients is to perform two- or three loci HLA mismatched BMT. Preliminary results with BMT in partially-matched, related donors performed at Veterans General Hospital-Taipei are reported.

METHODS

Between 1985 and 1994, a total of 121 patients were enrolled in this study. Ten patients received BMT with HLA partially-matched, related donor, including 2 acute nonlymphocytic leukemia (ANLL), 5 chronic myelocytic leukemia (CML) and 3 severe aplastic anemia (SAA). Three and four hematologically malignant patients received cyclophosphamide (Cy) + radiotherapy (RT) and Cy + Busulfan(Bu) preconditioning regimens, respectively; three SAA patients received standard Cy + RT regimen. Additional prophylaxis against graft-versus-host disease (GVHD) consisted of methotrexate (MTX) and cyclosporin-A (CSA). The median follow up was 36 months. Seven were 2-loci disparate and 3 were 3-loci.

RESULTS

Engraftment developed with a mean of 20.9 days after transplant. Nonengraftment rate was 1/10 (10%), delayed graft failure 2/10(20%) and venoocculsive disease (VOD) 1/10(10%). The percentage of patients who developed grade II to IV acute GVHD was low (13.6% of those mismatched at 0 locus, 31.6% mismatched at 1 loci and 14.3% at > or = 2 loci. p = 0.181). Extensive chronic GVHD occurred in 16.7% (34.1% of those mismatched at 0 locus, 41.2% mismatched at 1 loci and 16.7% at 2 loci. p = 0.492). There were five deaths. The other 5 still survived at 36 months of follow-up. Log-rank analysis revealed no statistical significance between those mismatched at > or = 2 vs at 1 (p = 0.146) but the difference between those mismatched at > or = 2 and at 0 (p = 0.0359) was statistically significant.

CONCLUSIONS

When patients requiring BMT without an HLA identical sibling donor, an alternative transplant from haploidentical family members remains a viable option, especially when a patient has CML, SAA or other refractory hematologic malignancies.

Hypercapnic respiratory acidosis precipitated by hypercaloric carbohydrate infusion in resolving septic acute respiratory distress syndrome: a case report

Complications may occur when nutritional support is administered either parenterally or enterally. Inappropriate nutritional formulas with high carbohydrate loads can precipitate respiratory failure in patients with compromised lung function, induce respiratory distress which manifests as dyspnea and tachypnea in an originally normal lung condition, produce hypercapnic acidosis in mechanically ventilated patients with chronic obstructive pulmonary disease (COPD) as well as patients recovering from acute respiratory distress syndrome (ARDS) without chronic lung disease, or result in difficult weaning. Hypercaloric mixed substrates administered either parenterally or enterally can also have profound impacts on gas exchange and energy expenditure. This report describes a patient who experienced exacerbation of respiratory distress and hypercapnic acidosis during recovery from septic ARDS as the result of a nutritionally-related increase in CO2 production. As carbohydrate calories were decreased, CO2 production diminished and the hypercapnia was resolved. The importance of indirect calorimetry cannot be overemphasized during tailoring of nutritional support for the critically ill patients.