Intergenerational accumulation of impairments in maternal behavior following postnatal social stress

Early adversity such as depressed maternal care can have long-term physiological and behavioral effects on offspring and future generations. Exposure to chronic social stress (CSS), an ethologically model of postpartum depression and anxiety, during lactation impairs maternal care and exerts similar effects on the F1 dam offspring of the stressed F0 dams. These changes associate with increased corticosterone and neuroendocrine alterations. CSS F2 offspring further display decreased social behavior as juveniles and adults and decreased basal levels of corticosterone. This current study investigates the intergenerational inheritance of alterations in maternal behavior in F2 CSS dams together with neuroendocrine and immune markers to explore whether aspects of maternal behavior are intergenerationally inherited through immune and neuroendocrine mechanisms. We find that defects in maternal care behavior persist into the F2 generation with F2 dams exhibiting a pervasively depressed maternal care and increased restlessness throughout lactation. This occurs together with reduced basal cortisol (in contrast to an increase in F1 dams), a lack of changes in neuroendocrine gene expression, and reduced serum ICAM-1 (intercellular adhesion molecule-1) levels - a marker for inflammation and blood-brain barrier integrity. The data support the hypothesis that the effects of chronic social stress can accumulate across multiple generations to depress maternal care, increase restlessness and alter basal functioning of the immune system and hypothalamic pituitary adrenal axis.

Hemophilia A and hemophilia B: focus on arthropathy and variables affecting bleeding severity and prophylaxis

Hemophilia A (HA) and hemophilia B (HB) are X-linked, recessive disorders. Although their clinical manifestations are essentially indistinguishable, it has been suggested that bleeding episodes in patients with HA are generally more severe and occur at higher frequency than in patients with HB. Nevertheless, considerable debate remains regarding the relative severity of HA and HB. Based on the relative risk of undergoing joint arthroplasty, it appears that patients with HA have more severe joint deterioration compared with patients with HB. Although it is difficult to speculate on the factors that might modify bleeding severity in patients with hemophilia, recent observations indicate that other coagulation proteins, such as tissue factor pathway inhibitor or polymorphisms in coagulation factor genes and genetic defects associated with hypercoagulability may account for the variability in clinical phenotype among patients with hemophilia. Numerous studies have provided evidence supporting the clinical and social benefits of administration of clotting factor in prophylaxis. However, it is still unclear why this approach is more commonly utilized in patients with HA than in those with HB.

The risk of venous thromboembolic disease in patients with monoclonal gammopathy of undetermined significance

BACKGROUND

Recent evidence indicates that patients with multiple myeloma receiving combination chemotherapy containing thalidomide are at a significantly high risk for venous thromboembolic disease (VTD). However, information on the occurrence of VTD in a related disorder, benign monoclonal gammopathy of undetermined significance (MGUS), is limited.

PATIENTS AND METHODS

We prospectively investigated patients with MGUS for the occurrence of VTD. The diagnosis of MGUS was based on well known criteria for the disorder. The variables examined were sex, age, race, presence of underlying conditions, level and type of immunoglobulin [serum monoclonal (M)-protein] platelet counts and level of fibrinogen.

RESULTS

Of a total of 310 patients with MGUS, 19 (6.1%) developed VTD after a median follow-up of 44 months (range 12-67 months). In a univariate analysis, age >/=65 years (P=0.01), M-protein >/=16 g/l (P=0.001) and progression to plasma cell or lymphoproliferative disorders (28 of 310 patients; P=0.001) were significant risk factors for VTD. In multivariate analysis, M-spike >/=16 g/l [risk ratio (RR)=6.3; 95% confidence interval (CI) 2.25-17.6; P=0.001] and future development of plasma cell or lymphoproliferative disorder (RR = 4.2; 95% CI 1.64-10.7; P=0.003) were variables strongly associated with the occurrence of VTD. A total of 46 patients (14.8%) died during the follow-up period of the study.

CONCLUSION

This study demonstrates that patients with MGUS are at increased risk for VTD. Although a clear reason for the pre-thrombotic state in these patients is not currently evident, few risk factors were identified in the group of patients examined.

Dysphagia following chemoradiation for locally advanced head and neck cancer

BACKGROUND

To assess the prevalence, severity and morbidity of dysphagia following concurrent chemoradiation for head and neck cancer.

PATIENTS AND METHODS

Patients who underwent chemotherapy and radiation for head and neck malignancies were evaluated for their ability to resume oral feeding following treatment. Modified barium swallow (MBS) studies were performed if the patients complained of dysphagia or if there was clinical suspicion of aspiration. The severity of dysphagia was graded on a scale of 1-7. If significant abnormalities were found, swallowing studies were repeated until resolution of dysphagia.

RESULTS

Between March 1999 and May 2002, 55 patients with locally advanced head and neck cancer underwent concurrent chemotherapy and radiation. Aspiration pneumonia was observed in eight patients, three during treatment and five following treatment. Five patients died from pneumonia. Two patients developed respiratory failure requiring intubation as a complication of pneumonia. At a median follow-up of 17 months (range 6-48 months), 25 patients (45%) developed severe dysphagia requiring prolonged tube feedings for more than 3 months (22 patients) or repeated dilatations (three patients). Among 33 patients who underwent MBS following treatment, 12 patients (36%) had silent aspiration (grade 6-7 dysphagia). Thirteen patients (39%) developed grade 4-5 dysphagia which required prolonged enteral nutritional support to supplement their oral intake. Most patients had severe weight loss (0-21 kg) during treatment, likely due in part to mucositis in the orodigestive tube.

CONCLUSIONS

Dysphagia is a common, debilitating and potentially life-threatening sequela of concurrent chemoradiation for head and neck malignancy. Physicians should be aware that the clinical manifestations of aspiration may be unreliable and insidious, because of the depressed cough reflex. Modified and traditional barium swallows should be performed following treatment to assess the safety of oral feeding and the structural integrity of the pharynx and esophagus. Patients with severe dysphagia may benefit from rehabilitation. Tube feeding should be continued for those with aspiration.

Treatment of acquired haemophilia with factor eight inhibitor bypassing activity

Haemorrhagic manifestations in patients with acquired haemophilia can be fatal if not recognized and treated appropriately. A retrospective analysis of the efficacy of factor eight inhibitor bypassing activity (FEIBA) in patients with acquired haemophilia treated in three medical centres in the past 10 years was conducted. The median inhibitor titre at treatment was 128 Bethesda Units (BU) in patients with severe and 34 BU in patients with moderate bleeding; P = 0.001. The majority of patients received FEIBA at a dose of 75 u kg-1 every 8-12 h. The number of FEIBA doses administered was higher in patients with severe compared with moderate haemorrhage, 10 vs. 6 doses per bleeding episode; P = 0.001. Complete response (CR) was achieved in 76% of severe and 100% of moderate bleeding episodes with a total CR of 86%. When compared with patients with human inhibitor titre <50 BU, those with titre >51 BU at treatment had lower median porcine titre, 1 vs. 9.5 BU; P < 0.05, fewer doses of FEIBA, 6 vs. 8.5 doses; P < 0.05, and shorter time to CR, 29 vs. 42 h; P < 0.05. Patients exposed to factor VIII concentrates prior to FEIBA had significantly higher maximum recorded human inhibitor titre compared with patients without such exposure, 273 vs. 38 BU; P = 0.0001. Treatment with FEIBA was very well tolerated and with very few side effects. This study provides evidence that FEIBA is an effective agent in acquired haemophilia and suitable for all types of patients regardless of severity of haemorrhage, underlying disease or inhibitor titre.

Concurrent interferon-alpha and radiation for head and neck melanoma

Melanoma cells are resistant to radiation in part due to their capacity to repair sublethal damage. A large fraction dose is therefore often utilized. However, if the tumour is located close to critical structures with modest tolerance, high fraction doses increase the risk for late complications compared with standard fractionation, but using the latter alone risks the desired outcome. Concurrent systemic biotherapy with standard radiation fractions may therefore represent an acceptable compromise. The outcome of concurrent systemic interferon-alpha (IFNalpha) and radiation in three patients with head and neck melanoma was evaluated. Standard radiation fractions were used because of the radiosensitizing properties of IFNalpha. Acute toxicity was significant and required treatment interruptions. However, all side effects subsided following treatment. All three patients achieved local control at follow-up periods of 24, 18 and 19 months, respectively. One patient developed widespread distant metastases. The combination of IFNalpha with radiation is considered feasible in terms of outcome and should be investigated with a larger cohort of patients. Toxicity is significant, and the addition of radioprotectors could be desirable.

Analysis of factors related to the occurrence of chronic disseminated candidiasis in patients with acute leukemia in a non-bone marrow transplant setting: a follow-up study

BACKGROUND

Chronic disseminated candidiasis (CDC) is a serious complication of treatment in patients with acute leukemia. Although some general risk factors are known to predispose to systemic fungal infections, few studies have addressed the relevance of certain clinical and laboratory features in patients with CDC.

PATIENTS AND METHODS

To define a subset of patients at high risk for CDC, the authors evaluated the demographics and clinical and laboratory characteristics of 423 patients with acute leukemia. Patients who had bone marrow transplant before the diagnosis of CDC were excluded from the analysis. The diagnosis of CDC was based on blood cultures, liver biopsy, and imaging studies. The authors conducted 2 separate regression analyses on 3 subsets of patients: patients without documented candidiasis (n = 374), patients with CDC (n = 23), and patients with candidemia (n = 26).

RESULTS

According to multivariate analysis, younger age (P = 0.009; odds ratio [OR], 1.96; 95% confidence interval [CI], 1.72-2.99), duration of neutropenia of 15 days or longer (P = 0.0003; OR, 11.7; 95% CI, 3.04-45.1), and use of prophylactic quinolone antibiotics (P = 0.039; OR, 3.85; 95% CI, 1.11-13.4) emerged as independent factors related to the development of CDC in patients with acute leukemia. The presence of severe mucositis, colonization with Candida, and administration of high-dose ara-C were statistically significant parameters in univariate analysis only (P = 0.0001, P = 0.003, and P = 0.058, respectively).

CONCLUSIONS

On the basis of the results of this investigation, it is possible to define a subset of patients with acute leukemia at very high risk for CDC. Because of the morbidity and mortality of this infection, a targeted prophylactic approach may be more effective and less costly than the random administration of antifungal agents.

Disseminated intravascular coagulation in solid tumors: clinical and pathologic study

Disseminated intravascular coagulation (DIC) is a well known hemostatic complication of solid tumors. We evaluated the occurrence of DIC in 1117 patients with solid tumors. Of these patients, 76 (6.8%) were diagnosed with DIC. There were a total of 145 bleeding and clotting episodes reported in the 76 patients. Thrombocytopenia, hypofibrinogemia, elevated D-dimer and fibrinogen degradation products were the most common coagulation abnormalities encountered in patients with DIC. In multivariate analysis, older age (p = .0001), male gender (p = .009), advanced malignancies (p = .027), breast cancer (p = .038) and the presence of necrosis in the tumor specimen (p = .004), emerged as independent factors significantly related to the occurrence of DIC in patients with solid tumors. Of the 76 patients, 25 (33%) achieved response to treatment of DIC as defined in the study. Patients with early stage and advanced malignancies who developed DIC had inferior survival when compared with their counterparts without DIC (p = .039 and p = .005, respectively). Taken together, this study indicates that certain clinical and laboratory features are more common in patients with solid tumors who developed DIC. The occurrence of DIC appears to have an independent effect on survival of patients with cancer. Cooperative studies are encouraged to better address the usefulness and optimal prophylactic heparin regimen in patients at risk for DIC.

Prognosis for papillary serous carcinoma of the endometrium after surgical staging

BACKGROUND

To investigate the pattern of failure and the prognosis following pathological staging for uterine papillary serous carcinoma (UPSC).

PATIENTS AND METHODS

A retrospective review was conducted of 22 patients with UPSC, treated between 1989 and 1998 at a single institution. All patients were surgically staged. Two patients with advanced disease received chemotherapy only. Two patients with early-stage disease were followed without further treatment. Eighteen patients received postoperative irradiation; eight patients received whole abdominal irradiation (WART), and the remaining 10 patients, pelvic irradiation (PRT). In addition, seven of these patients received vaginal cuff irradiation with low-dose-rate or high-dose-rate brachytherapy. Toxicity, pattern of failure, and survival were evaluated and compared to the literature.

RESULTS

Seven patients (32%) developed distant metastases, three out of seven (42%) after WART. Four out of seven patients who had distant metastases died from disease progression during subsequent chemotherapy. All patients with distant metastases had locally advanced-stage disease at presentation (six stage III, one stage IV). Four patients with pelvic recurrences developed concurrent (2) and subsequent (2) distant metastases. Three patients had isolated distant metastases. No patient with early stage-disease (stage I and II) died from disease progression.

CONCLUSION

Pathological staging should be performed for all patients with UPSC to determine the prognosis as well as to tailor the treatment. The role of abdominal irradiation in the treatment of UPSC is yet to be determined; however, such an approach may not be necessary for the control of disease for patients with early-stage (I and II) disease. Patients with locally advanced-stage (stage III) disease are at risk of local regional failures and distant metastases despite WART. Therefore, the benefit of WART for advanced-stage disease is also questionable. Paclitaxel-based chemotherapy is currently being investigated in this setting.

Interferon-alpha combined with radiotherapy in the treatment of unresectable melanoma

A case of recurrent and twice resected sinonasal melanoma is presented. The large recurrent tumor was found to regress by a concurrent combination of 6660 cGy photon radiation and subcutaneous interferon-alpha injections given for a period of 8 weeks. Possible mechanisms of potentiation between interferon and radiation are discussed. The unexpected result in this case report raises interesting questions about this treatment combination.

Inhibitors against factor VIII in patients with cancer. Analysis of 41 patients

BACKGROUND

The spontaneous formation of neutralizing antibodies (inhibitors) to factor VIII (FVIII) in patients with cancer is a well known phenomenon. However, to the authors' knowledge there is lack of information in the literature with respect to the clinical course of these patients and the nature of the association between malignant tumors and acquired hemophilia.

METHODS

A retrospective study of 41 patients with cancer and acquired hemophilia was conducted. The patients were identified through a MEDLINE search between 1974-2000. All patients had detailed clinical and laboratory information available and descriptions of the course of the inhibitor in relation to cancer treatment. The patients were divided into two groups: responders and nonresponders. The stage of the tumor, inhibitor titer, FVIII level, and survival data were examined and compared between the two groups.

RESULTS

A total of 63 hemorrhagic episodes were reported in 25 patients with solid tumors and 16 patients with hematologic malignancies. The median inhibitor titer at the time of the diagnosis of acquired hemophilia was 14 Bethesda units (BU) (range, 1-435 BU). The complete response (CR) rate to treatment of the inhibitor was 70% and patients who achieved a CR were more likely to have early stage tumors (P = 0.0007) and a lower median inhibitor titer at the time of presentation compared with nonresponders (12 BU vs. 78 BU; P = 0.007). The overall survival was significantly higher in patients who achieved a CR compared with patients with a persistent inhibitor (75% vs. 17%; P = 0.0006).

CONCLUSIONS

Although it remains an uncommon occurrence, the development of inhibitors to FVIII should be considered as a cause of bleeding in some patients with malignant diseases. Because of the high response rate and the impact of this type of hemorrhage on cancer patients, efforts should be directed toward immunosuppression of the inhibitor in a fashion similar to that used in other patients with acquired hemophilia. To our knowledge the link between malignancy and the formation of antibodies to FVIII is unclear; however, it appears that treatment of cancer with chemotherapy or surgery may accelerate the eradication of the inhibitor in some patients. Long term prospective studies are needed to better assess the association between cancer and acquired hemophilia.

Future development of lymphoproliferative disorders in patients with autoimmune hemolytic anemia

The association between autoimmune hemolytic anemia (AIHA) and subsequent appearance of lymphoproliferative disorders (LPDs) has not been properly addressed in large-scale studies. We evaluated 107 patients with idiopathic (67 patients) or underlying (40 patients) immune disorders diagnosed with AIHA between 1992 and 1999. The following variables were examined in univariate and multivariate analysis: age; sex; type of AIHA (warm- or cold-active antibodies); presence of underlying immune disorders; and serum monoclonal protein. Of the 107 patients, 19 (18%) developed malignant LPDS: The median time to develop malignancy was 26.5 months (range, 9-76 months). At multivariate analysis, advanced age (P = 0.005), underlying autoimmune diseases (P = 0.002), and the presence of serum gammopathy (P = 0.045) were risk factors for future development of LPDs in these patients. Also, serum monoclonal IgM protein was a significant predictor (P = 0.0001) for the appearance of LPDs in patients with AIHA. The present study provides evidence that AIHA in some patients should be considered as a precursor of malignant LPDS: Knowledge of certain characteristics may help identify patients at risk for this transformation; periodic clinical and laboratory assessment of these patients is warranted.

Treatment of refractory T-cell malignancies using gemcitabine

We have treated 10 patients with relapsed or refractory T-cell malignancies using gemcitabine. The drug was administered intravenously over 30 min at a dose of 1200 mg/m2 on d 1, 8 and 15 of each 28-d cycle. The mean age of the patients was 62 years and the mean number of administered cycles was three. Of the 10 patients, two achieved a complete response and four a partial response, for an overall response rate of 60% (95% confidence interval 20--35%). The toxicity of chemotherapy was mild and manageable in all patients. These encouraging results warrant further investigation of gemcitabine either as a single agent or in combination regimens as early salvage treatment for patients with refractory T-cell haematological neoplasms.

Inhibitors against factor VIII in patients with cancer. Analysis of 41 patients

BACKGROUND

The spontaneous formation of neutralizing antibodies (inhibitors) to factor VIII (FVIII) in patients with cancer is a well known phenomenon. However, to the authors' knowledge there is lack of information in the literature with respect to the clinical course of these patients and the nature of the association between malignant tumors and acquired hemophilia.

METHODS

A retrospective study of 41 patients with cancer and acquired hemophilia was conducted. The patients were identified through a MEDLINE search between 1974-2000. All patients had detailed clinical and laboratory information available and descriptions of the course of the inhibitor in relation to cancer treatment. The patients were divided into two groups: responders and nonresponders. The stage of the tumor, inhibitor titer, FVIII level, and survival data were examined and compared between the two groups.

RESULTS

A total of 63 hemorrhagic episodes were reported in 25 patients with solid tumors and 16 patients with hematologic malignancies. The median inhibitor titer at the time of the diagnosis of acquired hemophilia was 14 Bethesda units (BU) (range, 1-435 BU). The complete response (CR) rate to treatment of the inhibitor was 70% and patients who achieved a CR were more likely to have early stage tumors (P = 0.0007) and a lower median inhibitor titer at the time of presentation compared with nonresponders (12 BU vs. 78 BU; P = 0.007). The overall survival was significantly higher in patients who achieved a CR compared with patients with a persistent inhibitor (75% vs. 17%; P = 0.0006).

CONCLUSIONS

Although it remains an uncommon occurrence, the development of inhibitors to FVIII should be considered as a cause of bleeding in some patients with malignant diseases. Because of the high response rate and the impact of this type of hemorrhage on cancer patients, efforts should be directed toward immunosuppression of the inhibitor in a fashion similar to that used in other patients with acquired hemophilia. To our knowledge the link between malignancy and the formation of antibodies to FVIII is unclear; however, it appears that treatment of cancer with chemotherapy or surgery may accelerate the eradication of the inhibitor in some patients. Long term prospective studies are needed to better assess the association between cancer and acquired hemophilia.

Reversion of primary hyperfibrinogenolysis in patients with hormone-refractory prostate cancer using docetaxel

Tumor-associated proteases play a major role in determining the biologic behavior and aggressiveness of prostate cancer. Several authors have described the association between the increased levels of urokinase plasminogen activator in the plasma and in the malignant prostatic tissue with the metastatic potential of prostate cancer. However, the direct effect of this activity in producing fibronogenolysis in patients with prostate cancer has not been addressed. To evaluate the role of chemotherapy in reversing fibrinogenolysis in patients with prostate cancer, eight patients with hormone-refractory prostate cancer, bleeding, and laboratory evidence of primary hyperfibrinogenolysis were treated with docetaxel. The drug was given 48 hr after initiation of all supportive measures. Laboratory data, including plasminogen, alpha 2-antiplasmin, and fibrinogen, were recorded before and after treatment. Prostate-specific antigen (PSA) was measured at the time of referral and before subsequent cycles (3 weeks). Five patients had resolution of the fibrinolytic process after one cycle of treatment with docetaxel. This was demonstrated by improvement in both the laboratory parameters and the bleeding episodes. Further follow-up showed stabilization of the hematologic parameters and reduction in PSA values in these patients. Two patients died from uncontrolled bleeding despite all supportive measures. One patient did not demonstrate response to this treatment in terms of normalization of the fibrinolytic indicators or reduction in PSA. Primary fibrinogenolysis associated with metastatic prostate cancer is a serious complication. Docetaxel appears to be effective in reversing this process in some hormone-refractory patients. Although this response appears to be due to antitumor activity, a direct effect on the fibrinolytic pathway induced by the tumor cannot be excluded. Further work in this area is warranted.

Prognosis for papillary serous carcinoma of the endometrium after surgical staging

Abstract.

Nguyen NP, Sallah S, Karlsson U, Vos P, Ludin A, Semer D, Tait D, Salehpour M, Jendrasiak G, Robiou C. for papillary serous carcinoma of the endometrium after surgical staging.

Background: To investigate the pattern of failure and the prognosis following pathological staging for uterine papillary serous carcinoma (UPSC).

Patients and methods: A retrospective review was conducted of 22 patients with UPSC, treated between 1989 and 1998 at a single institution. All patients were surgically staged. Two patients with advanced disease received chemotherapy only. Two patients with early-stage disease were followed without further treatment. Eighteen patients received postoperative irradiation; eight patients received whole abdominal irradiation (WART), and the remaining 10 patients, pelvic irradiation (PRT). In addition, seven of these patients received vaginal cuff irradiation with low-dose-rate or high-dose-rate brachytherapy. Toxicity, pattern of failure, and survival were evaluated and compared to the literature.

Results: Seven patients (32%) developed distant metastases, three out of seven (42%) after WART. Four out of seven patients who had distant metastases died from disease progression during subsequent chemotherapy. All patients with distant metastases had locally advanced-stage disease at presentation (six stage III, one stage IV). Four patients with pelvic recurrences developed concurrent (2) and subsequent (2) distant metastases. Three patients had isolated distant metastases. No patient with early stage-disease (stage I and II) died from disease progression.

Conclusion: Pathological staging should be performed for all patients with UPSC to determine the prognosis as well as to tailor the treatment. The role of abdominal irradiation in the treatment of UPSC is yet to be determined; however, such an approach may not be necessary for the control of disease for patients with early-stage (I and II) disease. Patients with locally advanced-stage (stage III) disease are at risk of local regional failures and distant metastases despite WART. Therefore, the benefit of WART for advanced-stage disease is also questionable. Paclitaxel-based chemotherapy is currently being investigated in this setting.

Autoimmune hemolytic anemia in patients with non-Hodgkin's lymphoma: characteristics and significance

BACKGROUND

The occurrence of autoimmune hemolytic anemia (AIHA) in patients with non-Hodgkin's lymphoma (NHL) is well known. However, there is lack of information in the literature in terms of the significance and impact of such phenomenon on the clinical course of these patients.

PATIENTS AND METHODS

We analyzed the clinical and laboratory features, course and response of 16 patients with non-Hodgkin's lymphoma (NHL) and autoimmune hemolytic anemia (AIHA). Patients with small lymphocytic lymphoma and angioimmunoblastic lymphadenopathy with dysproteinemia were excluded from the analysis. The significance of certain parameters, such as cell type (B- vs. T-cell), stage of NHL and presence of serum monoclonal immunoglobulin were examined. The cohort consisted of 501 patients with NHL evaluated during the study period.

RESULTS

The response rate for the group of patients with NHL/AIHA and for the cohort was 44% and 62%, respectively; P = 0.0138. T-cell histology was overrepresented in the patients with AIHA/NHL (33% vs. 14%; P = 0.048). The occurrence of AIHA was not statistically significant among the four stages of NHL (P = 0.722), while a significantly higher proportion of patients with AIHA had serum monoclonol gammopathy when compared to the cohort (25% vs. 8%; P = 0.03). The patients with NHL who did not develop AIHA had better overall survival and median survival compared to the NHL/AIHA group (P = 0.006 and P = 0.0001, respectively).

CONCLUSIONS

The study provides for the first time a descriptive clinicopathologic analysis of patients with AIHA and NHL. Certain pathologic and laboratory features were more likely to be associated with the occurrence of AIHA in patients with NHL. Most importantly, was the adverse impact of AIHA on the survival of patients with NHL. Therefore, this finding should be taken in consideration when risk-stratifying patients with NHL.

Neuroblastoma producing spinal cord compression: rapid relief with low dose of radiation

Symptomatic spinal cord compression requires emergency treatment to alleviate symptoms and to avoid irreversible damage. We describe a successful decompression by low dose radiation to a progressing neuroblastoma in a child. Magnetic resonance imaging post radiation should be performed to assess the response of the tumor to radiation.

Angioimmunoblastic lymphadenopathy with dysproteinemia: emphasis on pathogenesis and treatment

Angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) is a rare lymphoproliferative disorder characterized by diffuse lymphadenopathy, fever, hepatosplenomegaly, hemolytic anemia, and polyclonal hypergammaglobulinemia. Morphologically, the involved lymph nodes demonstrate complete effacement of the normal architecture, prominent neovascularization and infiltration by immunoblasts and plasma cells. Other terms that have been used to describe this entity include diffuse plasmacytic sarcomatosis, immunoblastic lymphadenopathy, lymphogranulomatosis X, and immunologic aberrations in idiopathic reticulosis. Initially, AILD was thought to be a disease of B-cell origin that represented reactive immune response to unknown stimulus and high potential for malignant transformation. It is now evident that AILD in 80% of cases follows an aggressive course with short median survival, especially, if complete response with chemotherapy is not achieved. Immunologic and molecular studies have demonstrated that the majority of AILD cases are T-cell clonal disorders. Despite the numerous reports on the role of Epstein-Barr virus in this disorder, it is unknown whether the presence of this virus is associated with the immune defect that accompanies AILD, or whether it is a pathogenetic factor. In contrast to non-Hodgkin's lymphomas, a stage is not usually assigned to the patient since the disease is systemic in nature, subsequently, parameters such as extent of disease and tumor bulk used to identify high-risk patients with non-Hodgkin's lymphomas, do not appear to correlate with disease activity or prognosis in AILD. Treatment of AILD has been unsatisfactory, with approximately 25% of patients achieving complete and sustained remission when combined chemotherapy agents are used. This article is devoted to a discussion of the different manifestations, suggested pathogenesis, and treatment of AILD.

Combined preoperative chemotherapy and radiation for locally advanced rectal carcinoma

To determine the efficacy of combined preoperative chemotherapy and radiation therapy for locally advanced rectal carcinoma and the rate of sphincter conservation, a retrospective survey of 39 patients with locally advanced rectal carcinoma treated with various 5-fluorouracil- and leukovorin-based chemotherapy regimens and radiation prior to surgery in a single institution was reviewed. Toxicity, local control and survival were evaluated and compared to previous studies with similarly staged patients. Long-term follow-up was available on 35 patients. The actuarial local failure was 5.7% while the actuarial 5-year survival was 87%. The mortality rate was low (2.5%) and the rate of long-term serious complications acceptable (11.4%). Combined preoperative chemotherapy and radiation provided excellent local regional control despite the poor prognostic factors associated with size, fixation, and the initial advanced tumor stage with acceptable morbidity. In addition, patients with tumors located in the lower third of the rectum may be able to undergo sphincter-sparing surgery. Although the median follow-up is relatively short (32.4 months), the results are in accordance with previous studies of neoadjuvant combined chemotherapy and radiation for locally advanced rectal carcinoma in terms of local and distant control.

Diagnosis and monitoring response to treatment of hepatosplenic candidiasis in patients with acute leukemia using magnetic resonance imaging

Hepatosplenic candidiasis (HSC) is a morbid complication encountered in immunocompromised individuals, especially, those being treated with intensive chemotherapy protocols for acute leukemia. Immediate recognition of this complication and initiation of appropriate treatment is crucial in order to control the infection, decrease the morbidity and mortality, and avoid delays in treatment of the underlying condition. The definitive diagnosis requires either positive blood cultures for yeasts in the presence of abnormal findings on imaging studies consistent with HSC, or liver biopsy demonstrating yeast forms or pseudohyphae. We describe our experience in the evaluation of 15 patients with HSC using magnetic resonance imaging (MRI) as a diagnostic and follow-up tool. The diagnosis of HSC was established by liver biopsy in 11 patients (73%), and by positive blood cultures for Candida in 4 patients (27%). All patients had MRI findings consistent with HSC during the study period. Amphotericin B was administered intravenously to all 15 patients (median duration of treatment, 62 days). Repeat MR images were obtained at 2 weeks, 6 weeks and then at monthly intervals until the resolution of abnormalities. The median time for the disappearance of MRI lesions was 9 weeks. Alterations in the appearance of lesions on MRI were noted throughout chemotherapy in all the 13 (86.6%) responding patients. Our results suggest that MRI when used in patients with high clinical suspicion for HSC provide an alternative for liver biopsy or other invasive diagnostic procedures and that appropriate response to treatment can be safely monitored by obtaining sequential MRI studies.

Acquired hemophilia in patients with hematologic malignancies

OBJECTIVES

To evaluate the occurrence of acquired hemophilia in patients with hematologic malignancies and to assess their response to treatment.

DESIGN

Data on 8 patients with hematologic neoplastic disorders and inhibitor against factor VIII were analyzed retrospectively.

SETTING

Three large tertiary-care centers.

RESULTS

All 8 patients presented with spontaneous or posttraumatic hemorrhages. The mean inhibitor titer at the time of diagnosis was 79 Bethesda units (BU), and residual factor VIII activity was detectable in 3 patients. The inhibitor disappeared in 5 patients after a mean of 92 days, but persisted in the 3 other patients. The patients who achieved complete resolution of their circulating anticoagulant had lower mean inhibitor titers at the time of diagnosis than those who had persistent inhibitor (27 BU vs. 167 BU, respectively). Two patients died as a result of major hemorrhages that did not respond to treatment.

CONCLUSIONS

Antibodies against factor VIII may be responsible for some bleeding episodes in patients with lymphoid or myeloid malignancies. Acquired hemophilia in this setting should be differentiated from other causes of bleeding because the approach to treatment is different. No conclusion can be drawn regarding the association between the activity of the underlying illness and the inhibitor titer, although it appears that at least in some patients such a relationship may exist. The underlying pathogenetic mechanisms responsible for the production of autoantibodies against factor VIII remain unclear, but we provide a few explanations in this article.

Pathogenesis of thrombotic disorders in patients with cancer

Cancer patients experience several complications during the course of their illness which increase their morbidity and mortality. Thromboembolic phenomena are frequent and important events encountered in these patients. Although the exact mechanisms of thrombosis in this population of patients are largely unknown, speculations regarding the pathogenesis of clotting are presented in this short review. Interactions between elements related to the underlying neoplastic disorder, adherence to the vessel wall by cancer cells, indirect injury of the endothelial tissue, cytokine released by the malignant clone and disturbances in the clotting cascade to mention a few, are thought to be responsible for hypercoaguability in patients with cancer. More experimental and clinical studies are needed to clarify the etiology and management of these serious complications and concomitant diseases. Thrombotic complications are considered the second most common cause of death in patients with underlying malignant disorders. It has been estimated that 15% of patients with cancer will suffer from thromboembolic phenomena during their life (1,2). However, prospective data that examine the exact incidence of these complications are currently unavailable. Few investigators have estimated that the prevalence of serious thrombosis may be up to 50% in post mortem analysis (3).

Combined chemotherapy and radiation in the treatment of locally advanced head and neck cancers

Locally advanced head and neck cancers carry a poor prognosis because of a high rate of loco-regional recurrences as well as a high incidence of distant metastases. Standard therapy has been surgery followed by radiation therapy. Recent studies showed an improved survival rate when chemotherapy was added to radiation. The goal of this article is to provide a practical overview of the clinical trials using chemotherapy as a radiosensitizer for locally advanced head and neck malignancies. The rationale of using chemotherapy in combination with radiation is also discussed.

Amphotericin B lipid complex for the treatment of patients with acute leukemia and hepatosplenic candidiasis

Hepatosplenic candidiasis (HSC) is an emerging complication of the treatment of patients with acute leukemia. Treatment of this infection can be very difficult and data on the duration of antifungal therapy are not available. We evaluated the efficacy of amphotericin B lipid complex (ABLC) for the treatment of five patients with acute leukemia and HSC. The dose of the administered ABLC ranged between 5 and 11 mg/kg per day and the median duration of therapy was 4.3 months. Four patients had complete response to the above treatment with resolution of fever and improvement in the radiologic findings. One patient refused to continue treatment and subsequently died with relapsed leukemia and disseminated Candida infection. Preliminary data suggest that ABLC is a well-tolerated and effective treatment for HSC and should be considered for phase II trials as front line treatment for this type of deep seated fungal infections.

Bleeding problems in patients with liver disease. Ways to manage the many hepatic effects on coagulation

Liver disease is associated with a wide variety of abnormalities of the coagulation system and often with severe bleeding. Knowledge of the effects of liver disease and its complications on the various clotting factors may be useful in differential diagnosis. Therapy is difficult but should be approached in a stepwise fashion, with attention to the potential hazards of each intervention. The coagulation system and its interrelationship with liver function can be complex. To ensure the best care of patients with liver disease and bleeding, primary care physicians should not hesitate to enlist the assistance of specialists in clotting disorders and a reliable coagulation laboratory.

Intrathecal methotrexate-induced megaloblastic anemia in patients with acute leukemia

OBJECTIVE

To evaluate the occurrence of megaloblastic anemia induced by the infusion of therapeutic or prophylactic methotrexate in patients with acute leukemia.

DESIGN

Data on 3 patients with acute leukemia receiving intrathecal methotrexate were prospectively analyzed.

SETTING

Large tertiary-care center.

RESULTS

All 3 patients with acute leukemia developed megaloblastic anemia confirmed by examination of the bone marrow aspirate and biopsy. Two of the 3 patients had low folic acid levels, while all patients had normal serum B(12) levels. All patients responded favorably to a therapeutic trial of folic acid. The median time for recovery of the hematologic parameters in these patients was 7 days.

CONCLUSIONS

Intrathecally administered methotrexate may result in megaloblastic changes in the bone marrow of leukemic patients. The morphologic clues suggestive of folate deficiency in patients with acute leukemia may be masked by coexisting factors, such as the effects of cytotoxic treatment, prior transfusions, or persistent changes from the leukemic clone itself. Caution should be exercised to avoid attributing these changes to the neoplastic process, since the prognosis and treatment for the conditions involved are totally different. Repeat examination of the bone marrow, obtaining folic acid and vitamin B(12) levels, and a therapeutic trial of folic acid may help identify and reverse these changes.

Hepatosplenic candidiasis in patients with acute leukaemia

A retrospective study of 23 patients with acute leukaemia and hepatosplenic candidiasis (HSC) was conducted to evaluate clinical treatment characteristics in terms of amount and duration of antifungal agents and to assess treatment outcome. Patients were admitted to two major tertiary care centres between 1990 and 1998. The diagnosis of HSC was based on clinical, blood cultures, histologic and imaging studies. Patients were treated with amphotericin B without interruption of the planned chemotherapy regimens. Serial magnetic resonance imaging (MRI) studies were the main tool for following patients' response and activity of the fungal lesions in conjunction with clinical and laboratory parameters. Treatment with amphotericin B was continued until resolution of all clinical symptoms and signs attributable to HSC, obtaining negative blood cultures and the appearance of at least healed lesions on MRI. Amphotericin B was discontinued in four patients because of severe nephrotoxicity (two patients), or continuous fever and persistent fungal lesions on MRI (two patients). Amphotericin B lipid complex (ABELCET) was successfully used as salvage therapy for these refractory patients. Four patients died with evidence of HSC despite treatment and supportive measures. The response rate for treatment of HSC was 82%. The mean total dose of amphotericin B including empirical treatment was 4 g and the median duration of treatment for responding patients was 112 d. The median number of days of anti- fungal treatment before the disappearance of fever was 19 d. Our results confirmed the need for protracted courses of antifungal agents for the successful eradication of HSC. Chemotherapy for the underlying disorder should not be interrupted or delayed in order to treat HSC.

Hepatosplenic candidiasis in patients with acute leukemia: increasingly encountered complication

Hepatosplenic candidiasis (HSC) is an increasingly recognized complication of treatment with chemotherapeutic agents. The true incidence of HSC is not known, but most experts agree that there has been an increase in its occurrence during the past 15 years, and most of them attribute this rise to the use of more intensive chemotherapeutic regimens in the treatment of hematologic malignancies, especially, acute leukemia. The most recognizable risk factor predisposing for this complication is prolonged neutropenia. The diagnosis of HS requires high clinical suspicion and expertise in the interpretation of the histopathologic and radiologic data. Most importantly, treatment of the condition requires prolonged administration of antifungal drugs and continuous monitoring using combination of clinical, laboratory and radiologic tests in order to ascertain eradication of the infection. In this minireview I will present a summary of the data available in the literature in combination with our prospective experience in the investigation of HSC.

The role of 2-chlorodeoxyadenosine in the treatment of patients with refractory angioimmunoblastic lymphadenopathy with dysproteinemia

Treatment of patients with angioimmunoblastic lymphadenopathy with dysproteinaemia (AILD) often constitutes a challenge for the clinical haematologist. Single-agent and combination chemotherapy have failed to increase the response rate or survival of patients with AILD. A total of seven patients with refractory or relapsed AILD were treated with 2-chlorodeoxyadenosine (2-CdA) for variable number of cycles. The overall response rate was 57% with two patients (28.5%) achieving complete and sustained response. 2-Chlorodeoxyadenosine appears to be an active agent for patients with previously treated AILD. Phase II studies evaluating the efficacy of this agent as front-line treatment for AILD are justified, especially in the absence of any effective therapy for this disorder.

Selected coagulation disorders associated with cancer

The association between cancer and the increased tendency for bleeding and clotting is well established. Many investigators have reported on the interaction between tumor-related and plasma-related factors that may be responsible for this predisposition in cancer patients. The precise role of any of these factors in thrombosis or bleeding remains speculative. A good understanding of the course of the underlying malignancy, mechanisms of actions of the agents used for treatment, and a high degree of clinical suspicion are required to direct practicing physicians towards an objective and timely diagnosis of these complications. The goal of this article is to provide a broad overview of a few important hemostatic problems encountered in cancer patients.

Antibodies against factor VIII in patients with solid tumors: successful treatment of cancer may suppress inhibitor formation

Between 1995 and 1998, we treated 5 patients with anti-factor VIII antibodies and spontaneous bleeding. All patients had underlying malignant conditions. Initial control of the bleeding episodes and reduction in inhibitor titer was achieved in all patients. Disappearance of factor VIII inhibitor occurred in 3 patients after either resection of the tumor or chemotherapy. Immunosuppression therapy failed to eradicate the antibody in 2 patients with metastatic disease. Antibodies against factor VIII appearing in certain patients may be directly associated with the underlying malignancy, rather than a coincidental finding. Attempts to reduce the titer or eradicate the inhibitor may fail if recognition of the underlying condition is not sought, or an appropriate treatment of cancer is not offered.

Evaluation of bleeding disorders. A detailed history and laboratory tests provide clues

A single, optimal screening laboratory test for hemostasis would evaluate vascular, platelet, coagulation, and fibrinolytic functions. Unfortunately, such a test does not exist. The key factor in determining the presence of a bleeding diathesis is obtaining a detailed patient history. Results of coagulation tests should always be interpreted in the context of such a history. Screening tests include platelet count, PTT, and PT. Subsequent investigations depend on the results of these tests.

Recurrent warfarin-induced skin necrosis in kindreds with protein S deficiency

Warfarin-induced skin necrosis is a rare complication of anticoagulant treatment. The incidence of this complication is undetermined, but it has been estimated to occur between 1:100 and 1:10,000 of patients treated with anticoagulants. Coumarin skin necrosis occurs almost exclusively in patients with venous thrombosis between the 3rd and 10th day after beginning anticoagulation. Although protein C deficiency is the most common underlying hypercoagulable state reportedly associated with warfarin skin necrosis, very few cases have been linked to congenital protein S deficiency. This article addresses the association of hereditary protein S deficiency and warfarin skin necrosis, and provides suggestions for management.

Hepatosplenic fungal disease: diagnostic accuracy and spectrum of appearances on MR imaging

OBJECTIVE

We describe our 6-year experience in the prospective examination of patients with suspected hepatosplenic fungal disease to show the diagnostic accuracy of MR imaging and the spectrum of appearances on MR images.

SUBJECTS AND METHODS

All patients who underwent MR examination for suspected hepatosplenic fungal disease from January 1990 to January 1997 in three university institutions were included in the study. Patients presented with persistent fever or no response to antibacterial antibiotics. Patients were grouped as acute, subacute treated, and chronic treated, according to the duration of their symptoms. Patients with 2 weeks or fewer of possible infection were acute presentation, patients on antifungal therapy longer than 2 weeks but shorter than 3 months were subacute treated presentation, and patients on antifungal therapy for 3 months or longer or who had completed antifungal therapy and had a history of hepatosplenic fungal disease were chronic treated presentation. MR studies were prospectively interpreted for the presence of hepatosplenic fungal lesions. The appearances of fungal lesions in patients in each category were determined. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for detecting lesions in patients with acute presentation were also determined.

RESULTS

Sixty-nine patients were included in the study. MR imaging revealed signs consistent with hepatosplenic fungal lesions in 22 (32%) of 69 patients and no demonstration of hepatosplenic lesions in 47 (68%) of 69 patients. In the 60 patients with acute presentation, MR imaging in 13 patients revealed hepatosplenic lesions that were interpreted as fungal disease. True-positive lesions were present in 11 of these 13 patients. These lesions measured less than 1 cm in diameter and were best shown as well-defined high-signal-intensity foci on T2-weighted images. The remaining two of the 13 patients had false-positive lesions; one was shown to have tuberculosis, and the other had graft-versus-host disease. For acute presentation, MR sensitivity was 100%, specificity was 96%, positive predictive value was 85%, negative predictive value was 100%, and accuracy was 97%. In the five patients with subacute presentation, lesions were present that measured less than 1 cm in diameter and were best shown as mildly hyperintense on T1-weighted images. A perilesional ring nearly void of signal intensity was seen on unenhanced and gadolinium-enhanced T1-weighted images in all five patients. The four patients with chronic healed lesions all had lesions that were 1-3 cm in diameter with irregular, angular polygonal margins. These lesions, which were best shown on images obtained immediately after gadolinium administration, appeared as regions of diminished enhancement with no perilesional changes.

CONCLUSION

MR imaging has high diagnostic accuracy for the diagnosis of acute hepatosplenic fungal disease. Patients with acute, subacute treated, and chronic healed presentations may have lesions that can be distinguished by their MR appearances.

Inhibitors to clotting factors

Clot formation is the final result of interaction among multiple plasma proteins; after activation, it results in the conversion of fibrinogen to fibrin and cross-linking of fibrin by activated factor XIII, which stabilizes the formed clot. Deficiency or functional abnormality of the factors involved in these reactions causes bleeding disorders. Natural inhibitors of clotting factors include antithrombin III, protein S, and protein C. When activated, these proteins inactivate specific clotting factors, providing a regulatory mechanism that serves to control the coagulation response and limit the extension of the clot. Physiologic or natural inhibitors should not be confused with acquired inhibitors of coagulation factors, which are discussed in this review. Inhibitors to coagulation factors, also known as circulating anticoagulants, are antibodies that neutralize specific clotting proteins, thereby interfering with their normal function. Antibodies may be directed against isolated clotting factors, as is the case with factor VIII or IX inhibitors. On the other hand, the antiphospholipid antibodies are known to develop against multiple coagulation proteins. In contrast to patients with antibodies against isolated clotting factors, who commonly present with spontaneous bleeding, individuals with antiphospholipid antibodies may be asymptomatic or present with venous or arterial thrombosis. In this article I refer to inhibitors developing in patients with hemophilia A or other congenital factor deficiency as alloantibodies, and to spontaneous formation of antibodies in patients without prior history of hemorrhagic diathesis as autoantibodies. The antiphospholipid antibodies are discussed separately.

Nodular liver involvement in light chain multiple myeloma: appearance on US and MRI

Nodular liver infiltration with multiple myeloma is very rare and its findings on MR images have not been, to our knowledge, previously described. The authors report a case of light chain multiple myeloma nodular liver involvement and describe its appearance on US and MRI. Despite their rarity these lesions have distinct MRI features and should be considered in the differential diagnosis of multiple lesions with high SI on T1-weighted images.

Gamma/delta T-cell hepatosplenic lymphoma: review of the literature, diagnosis by flow cytometry and concomitant autoimmune hemolytic anemia

Hepatosplenic gamma/delta T-cell lymphoma is recognized as a subset of peripheral T-cell lymphoma in the REAL classification. Histologically these tumors are characterized by a mixture of small to medium-sized atypical lymphocytes. To date, approximately 15 cases of hepatosplenic gamma delta T-cell lymphoma have been reported. Affected individuals are usually young adults with a median age of 34 years. Patients commonly present with B symptoms and hepatosplenomegaly, but an absence of lymphadenopathy. The disease follows an aggressive course with median survival of 12-14 months and poor response to combination chemotherapy agents. Occasionally, the occurrence of frank blast transformation constitutes a terminal event for the patient. Although cytopenias are relatively common, nonimmune hemolytic anemia has been reported in one patient only. This is the first report of autoimmune hemolytic anemia associated with hepatosplenic gamma delta T-cell lymphoma.

Littoral cell angioma in a patient with Epstein syndrome

A 61-year-old male with Epstein syndrome and chronic renal failure was admitted to our institution for kidney transplantation. He was asymptomatic at the time of evaluation. Physical examination revealed pallor and marked splenomegaly measuring approximately 12 x 10 cm below the left costal margin. Because of this finding, and a history of resected non-small lung cancer, a CT scan of the abdomen was obtained. This demonstrated massive, diffusely nodular splenomegaly. This article describes the histopathologic and immunohistochemical findings of littoral cell angioma, a novel splenic tumor. Also, we discuss the differential diagnosis and include a description of the imaging study performed. To our knowledge, this is the first case report of littoral cell angioma occurring in a patient with Epstein syndrome, and the first radiographic appearance of this rare tumor.