Safety and efficacy of regorafenib in patients with treatment-refractory metastatic colorectal cancer in Turkey: the single-arm, open-label REGARD study

OBJECTIVES

Regorafenib improved overall survival in patients with metastatic colorectal cancer (mCRC) refractory to standard therapies in two randomised, phase III trials, but has not been evaluated in Turkey. REGARD evaluated the safety and efficacy of regorafenib in Turkish patients with treatment-refractory mCRC.

DESIGN

Open-label, single-arm, phase IIIb study conducted between July 2013 and April 2015.

SETTING

11 tertiary centres in Turkey.

PARTICIPANTS

Eligible patients were adults with mCRC who had disease progression within 3 months after receiving their last dose of approved standard therapies and who had an Eastern Cooperative Oncology Group performance status ≤1. Patients were excluded if they had previously received regorafenib. Of 139 patients screened, 100 were treated and completed the study, and all 100 were analysed. Fifty-eight per cent were male.

INTERVENTIONS

Patients received oral regorafenib, 160 mg once daily, for the first 3 weeks of each 4-week cycle until disease progression, death or unacceptable toxicity.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary endpoint was safety, assessed by incidence of treatment-emergent adverse events (TEAEs). Progression-free survival (PFS) per investigator was the primary efficacy endpoint. There were no secondary endpoints.

RESULTS

The median treatment duration was 2.5 months (range 0.1 to 20.6). Ninety-six per cent of patients had at least one TEAE and 77% had a grade ≥3 TEAE. The most common grade ≥3 regorafenib-related TEAEs were hypophosphataemia (11%), fatigue (8%), hyperbilirubinaemia (6%), hand-foot skin reaction (5%), hypertension (5%), anorexia (5%) and increased alanine aminotransferase (5%). TEAEs led to dose reduction in 30% of patients. Regorafenib-related TEAEs led to treatment discontinuation in 17% of patients. Median PFS was 3.1 months (95% CI 2.9 to 3.8).

CONCLUSION

The regorafenib safety profile and PFS in REGARD were consistent with the results of previous trials of regorafenib in mCRC. Regorafenib is an option for patients in Turkey with treatment-refractory mCRC.

TRIAL REGISTRATION NUMBER

NCT01853319, ClinicalTrials.gov.

Aggressive course in a patient with mucin-producing urothelial-type adenocarcinoma of the prostate: A case report and review of the literature

Prostate cancer is one of the frequently seen types of cancers in men. The most frequent histological type of prostate cancer is the acinar adenocarcinoma. Mucin-producing urothelial-type adenocarcinoma of the prostate is a very rare subtype. The mucin-producing urothelial-type adenocarcinoma of the prostate has microscopic similarities with colon and bladder adenocarcinoma. It has a more aggressive clinical course and does not respond to androgen deprivation therapy. A 77-year-old male patient diagnosed with mucinous prostate cancer was presented in the current case report.

A national, multicenter, non-interventional, observational study on treatment patterns in patients with metastatic renal cell carcinoma in Turkey - NOTES study

Introduction

The introduction of targeted therapies in renal cell carcinoma has significantly improved its prognosis and treatment outcomes in recent years. Such treatment options are targeted therapies of the vascular endothelial growth factor (VEGF) pathway and the mammalian target of the rapamycin pathway. With the use of tyrosine kinase inhibitors (TKIs) and mammalian target of the rapamycin inhibitors, overall survival has increased up to 2 years. In Turkey, due to applicable reimbursement conditions for patients with metastatic renal cell carcinoma (mRCC), interferon use is mandated as a first-line treatment, thus providing information on the use of everolimus only after initial interferon and second-line VEGF-targeted treatments such as VEGF-TKI.

Patients and methods

To provide a first real-life data set in Turkey, we conducted a prospective, non-interventional, observational study and assessed the efficacy and safety of everolimus after two lines of treatment including interferon. A total of 100 patients with histologically confirmed mRCC were enrolled in the study from 11 centers between June 2012 and March 2014 (70 males and 30 females). Efficacy was assessed on the basis of progression-free survival and overall survival; safety of everolimus was assessed on the basis of adverse event occurrence.

Results

The study results showed that the median progression-free survival with everolimus treatment was 8.1 months (95% CI: 5.1–11.1) and the median overall survival was 17.6 months (95% CI: 10.1–25.1), thus indicating a better overall response based on survival durations than those from the randomized Phase III REnal Cell cancer treatment with Oral RAD001 given Daily study results (4.9 and 14.8 months, respectively).

Conclusion

The study showed that everolimus treatment is a safe and effective treatment option in the treatment of mRCC after VEGF-TKI, with an acceptable safety and tolerability profile in real-life settings.

Biosimilar filgrastim vs filgrastim: a multicenter nationwide observational bioequivalence study in patients with chemotherapy-induced neutropenia

Background

We studied the comparative effectiveness of biosimilar filgrastim vs original filgrastim in patients with chemotherapy-induced neutropenia.

Patients and methods

This multicenter, observational study was conducted at 14 centers. The study included 337 patients experiencing neutropenia under chemotherapy. Patients were given either filgrastim 30 MIU or 48 MIU (Neupogen^®) or biosimilar filgrastim 30 MIU (Leucostim^®). Data regarding age, chemotherapeutic agents used, number of chemotherapy courses, previous diagnosis of neutropenia, neutrophil count of patients after treatment, medications used for the treatment of neutropenia, and duration of neutropenia were collected. Time to absolute neutrophil count (ANC) recovery was the primary efficacy measure.

Results

Ambulatory and hospitalized patients comprised 11.3% and 45.1% of the enrolled patients, respectively, and a previous diagnosis of neutropenia was reported in 49.3% of the patients, as well. Neutropenia occurred in 13.7% (n=41), 45.5% (n=136), 27.4% (n=82), 11.4% (n=34), and 2.0% (n=6) of the patients during the first, second, third, fourth, and fifth cycles of chemotherapy, respectively. While the mean neutrophil count was 0.53±0.48 before treatment, a significant increase to 2.44±0.66 was observed after treatment (p=0.0001). While 90.3% of patients had a neutrophil count <1.49 before treatment, all patients had a neutrophil count ≥1.50 after treatment. Neutropenia resolved within ≤4 days of filgrastim therapy in 60.1%, 56.7%, and 52.6% of the patients receiving biosimilar filgrastim 30 MIU, original filgrastim 30 MIU, and original filgrastim 48 MIU, respectively. However, there was no significant difference between the three arms (p=0.468). Similarly, time to ANC recovery was comparable between the treatment arms (p=0.332).

Conclusion

The results indicate that original filgrastim and biosimilar filgrastim have comparable efficacy in treating neutropenia. Biosimilar filgrastim provides a valuable alternative; however, there is need for further studies comparing the two products in different patient subpopulations.

The role of gamma probe activity counts in minimally invasive parathyroidectomy

Aim: The benefit of preoperative gamma probe in the diagnosis of adenoma in patients with histopathologically proven parathyroid (PT) adenomas was examined. Patients, material, methods: 20 patients with positive 99mTc MIBI uptake in PT scintigraphy with primary hyper-parathyroidism were enrolled in this study. 740 MBq 99mTc MIBI were injected 3 h before operation. Counts of four PT regions were obtained with gamma probe before surgery in the operation room. All suspected PT adenomas were resected and histopathologically diagnosed as adenomas. We also obtained counts of the resection region and the resected adenoma with gamma probe after the parathyroidectomy. Preoperative counts of adenoma bearing regions (ABR), non-adenoma bearing regions (NABR), postoperative resection region (PRR), resected adenoma counts (RA) were registered. Statistical analysis was performed by Wilcoxon rank test. Results: The mean counts of ABR, NABR, the PRR and RA were 462 ± 106, 230 ± 66, 164 ± 42, 374 ± 87, respectively. The mean counts from ABR were twofold higher than those of NABR. The PRR mean counts decreased by 64% when compared to the mean counts of ABR and by 55% when compared to the mean counts of RA. The differences in mean counts of ABR and NABR, PRR and ABR, PRR and RA (p <0.01) turned out as statistically significant. Discussion: According to our preliminary results, the region with the highest counts is at least 2 ± 0,4 times higher than the mean of the other three PT regions. Thus, it seems to be significant for PT adenoma. Resection of adenoma may be accepted as successful, if the count of ABR decreased more than 64% with decreased postoperative parathormone levels. Conclusion: This technique should not yet be applied instead of parathormone measurement or frozen technique. But it may replace the frozen technique used for confirmation of the diagnosis during the operation in the future.

Pulsed radiofrequency treatment of piriformis syndrome in a pregnant patient with malignant mesenchymal tumor

Cancer is frequently seen in women of reproductive age. Diagnosis, management of treatment, and safety of the therapeutic approach are particularly important for these patients. Presently described is pain management in a case of pregnancy with malignant mesenchymal tumor. A 23-year-old woman in 30th gestational week presented with severe pain in right hip and back of the right thigh. Piriformis block successfully decreased pain and was followed by pulsed radiofrequency (PRF) to the piriformis muscle. PRF, as a non-neurodestructive method, is a safe and effective method to treat cancer pain in a pregnant patient.

Predictive and Prognostic Factors in Ovarian and Uterine Carcinosarcomas

BACKGROUND

Prognostic factors and the standard treatment approach for gynaecological carcinosarcomas have not yet been clearly defined. Although carcinosarcomas are more aggressive than pure epithelial tumours, they are treated similarly. Serous/clear cell and endometrioid components may be predictive factors for the efficacy of adjuvant chemotherapy (CT) or radiotherapy (RT) or RT in patients with uterine and ovarian carcinosarcomas. Heterologous carcinosarcomas may benefit more from adjuvant CT.

AIMS

We aimed to define the prognostic and predictive factors associated with treatment options in ovarian (OCS) and uterine carcinosarcoma (UCS).

STUDY DESIGN

Retrospective cross-sectional study.

METHODS

We retrospectively reviewed the medical records of patients with ovarian and uterine carcinosarcoma from 2000 to 2013, and 127 women were included in this study (24 ovarian and 103 uterine). Patients admitted to seventeen oncology centres in Turkey between 2000 and December 2013 with a histologically proven diagnosis of uterine carcinosarcoma with FIGO 2009 stage I-III and patients with sufficient data obtained from well-kept medical records were included in this study. Stage IV tumours were excluded. The patient records were retrospectively reviewed. Data from 104 patients were evaluated for this study.

RESULTS

Age (≥70 years) was a poor prognostic factor for UCS (p=0.036). Pelvic±para aortic lymph node dissection did not affect overall survival (OS) (p=0.35). Macroscopic residual disease was related with OS (p<0.01). The median OS was significantly longer in stage I-II patients than stage III patients (p=0.03). Adjuvant treatment improved OS (p=0.013). Adjuvant radiotherapy tended to increase the median OS (p=0.075). However, this tendency was observed in UCS (p=0.08) rather than OCS (p=0.6).Adjuvant chemotherapy had no effect on OS (p=0.15).Adjuvant radiotherapy significantly prolonged the median OS in patients with endometrioid component (p=0.034). A serous/clear cell component was a negative prognostic factor (p=0.035). Patients with serous/clear cell histology for whom adjuvant chemotherapy was applied had significantly longer OS (p=0.019), and there was no beneficial effect of adjuvant radiotherapy (p=0.4). Adjuvant chemotherapy was effective in heterologous tumours (p=0.026). In multivariate analysis, the stage and chemotherapy were prognostic factors for all patients. Age was an independent prognostic factor for UCS. However, serous/clear cell histology and radiotherapy tended to be significant prognostic factors.

CONCLUSION

The primary location, the histological type of sarcomatous and the epithelial component may be predictive factors for the efficacy of chemotherapy or radiotherapy in UCS and OCS.

Effectiveness and safety of cabazitaxel chemotherapy for metastatic castration-resistant prostatic carcinoma on Turkish patients (The Anatolian Society of Medical Oncology)

OBJECTIVE

Prostate cancer is among the most common cancers in males. Prostate cancer is androgen dependent in the beginning, but as time progresses, it becomes refractory to androgen deprivation treatment. At this stage, docetaxel has been used as standard treatment for years. Cabazitaxel has become the first chemotherapeutic agent which has been shown to increase survival for patients with metastatic Castrate Resistant Prostate Cancer (mCRPC) that progresses after docetaxel. Phase 3 TROPIC study demonstrated that cabazitaxel prolongs survival.

PATIENTS AND METHODS

In this study, we evaluated a total of 103 patients who took cabazitaxel chemotherapy for mCRPC diagnosis in 21 centers of Turkey, retrospectively. This study included patients who progressed despite docetaxel treatments, had ECOG performance score between 0-2, and used cabazitaxel treatment. Patients received cabazitaxel 25 mg/m2 at every 3 weeks, and prednisolone 5 mg twice a day.

RESULTS

Median number of cabazitaxel cures was 5.03 (range: 1-17). Cabazitaxel response evaluation detected that 34% of the patients had a partial response, 22.3% had stable disease and 32% had a progressive disease. Grade 3-4 hematological toxicities were neutropenia (28.2%), neutropenic fever (14.5%), anemia (6.7%), and thrombocytopenia (3.8%). In our study, median progression-free survival (PFS) was 7.7 months and overall survival (OS) was 10.6 months.

CONCLUSIONS

This study reflects toxicity profile of Turkish patients as a Caucasian race. We suggest that cabazitaxel is a safe and effective treatment option for mCRPC patients who progress after docetaxel. Moreover, ethnicity may play important roles both in treatment response and in toxicity profile.

Quality of life of caregivers: a cross-sectional study

This descriptive study was conducted to evaluate the quality of life of cancer caregivers. One hundred and seventy-eight caregivers of patients who were diagnosed with cancer in Gaziantep oncology hospital participated in the study. Data were collected by using a questionnaire and quality of life scale. The scale was scored between 0 and 10, where '10' indicated the best and '0' indicated the worst level. It was determined that the majority of caregivers were young and female, the overall total score average of quality of life was 4.5 ± 1.1, and the subdomain with the lowest value was the psychological subdomain. All quality of life subdomain score averages and the overall total score averages were observed to be low in women, as well as in those who provided care for their own children, who lived in the same house with the patient and who gave care for 19-24 h daily.

Nine weeks versus 1 year adjuvant trastuzumab in patients with early breast cancer: an observational study by the Turkish Oncology Group (TOG)

BACKGROUND

Optimal duration of adjuvant trastuzumab in early breast cancer is an unresolved issue. In this observational study, we compared the outcome of 9 weeks and 1 year adjuvant trastuzumab in early breast cancer patients in Turkey.

METHODS

Records of 680 patients with HER2-positive early breast cancer who received adjuvant trastuzumab plus chemotherapy were obtained and patients were followed up to compare the disease-free survival (DFS) outcome of 9 weeks versus 1 year trastuzumab.

RESULTS

Nine weeks and 1 year trastuzumab was given to 202 (29.7 %) and 478 (70.3 %) patients, respectively. There was a significantly lower rate of patients with negative lymph nodes in the 9-week trastuzumab group. At median 3 years of follow-up from the date of starting trastuzumab, the DFS rates were 88.6 and 85.6 %, respectively (p = 0.670). When adjusted for all the prognostic factors that were significant on univariate analysis, again there was no significant difference in DFS between the groups (HR 0.675; 95 % CI 0.370-1.231; p = 0.200). Cardiac toxicity defined as a ≥15 % decrease in LVEF was significantly higher in the 1-year trastuzumab group (1.88 % versus none for 1-year and 9-week trastuzumab groups, respectively; p = 0.050).

CONCLUSION

The results of this observational study suggest that DFS outcome of 9 weeks of adjuvant trastuzumab may be comparable to 1 year adjuvant trastuzumab: this needs confirmation by randomized trials.

Intrapleural hyperthermic perfusion chemotherapy in subjects with metastatic pleural malignancies

OBJECTIVES

Malignant pleural effusion (MPE) means poor prognosis in the majority of cases. Intrapleural Hyperthermic perfusion chemotherapy (HIPEC) looks promising approach for these patients. We aimed to investigate whether cytoreductive surgery followed by HIPEC provides any survival benefit in cases with metastatic MPEs.

METHODS

Between January 2009 and December 2011, 19 patients with metastatic MPEs were treated with HIPEC following surgical interventions such as pleurectomy/decortication and/or lung resection (group 1). Comparison was done with historical control groups consisted of patients who received either talc pleurodesis or pleurectomy/decortication followed by systemic treatment for the management of metastatic MPEs between June 2007 and June 2008 (group 2 and 3). Statistical analyses including overall survival, disease free interval were done for the group comparisons.

RESULTS

Median survival in group 1, 2 and 3 were 15.4, 6, 8 months, respectively. One year survival was 54.7% in group 1 where it was 0.6% and 0.8% in group 2 and 3, respectively. There was no operative mortality. Morbidity was occurred in 1 patient in group 1 (5.3%).

CONCLUSIONS

HIPEC combined with cytoreductive surgery seems to be a promising treatment option for subjects with metastatic MPEs. Further studies are needed for the optimization of HIPEC method, drug of choice, and the best combination therapy for the multimodal treatment.

Long-term survival in metastatic malignant melanoma: ipilimumab followed by vemurafenib in a patient with brain metastasis

A 46-year-old man was diagnosed with brain metastasis after a two-year history of melanoma. Paliative radiotherapy was administered followed by dacarbazine, temozolamide, ipilimumab, stereotactic radiosurgery, ipilimumab reinduction and finally vemurafenib, to which the patient showed objective responses. The patient received vemurafenib for four months and died after progresive disease. Long-term follow-ups after surgery have been reported in the literature. However, in patients with unresectable metastases, outcomes are mostly detrimental. The present patient survived for 40 months after brain metastasis. The unusually long survival observed in the present case indicates the sequential effectiveness of radiotherapy, chemotherapy, ipilimumab, stereotactic radiosurgery and vemurafenib.

A pilot study for human tumor/DNA banking: returned more questions than answers

A pilot study was performed for setting up the Dokuz Eylül University Breast Tumor DNA Bank (DEUBTB) to facilitate the sharing of tumor DNA/RNA samples and related data from cases collected by collaborators specializing in the breast cancer diseases between 2004 and 2006. The pilot study aimed to provide answers for certain questions on: (1) ethical concerns (informing the volunteer for donating specimen, anonymizing the sample information, procedure on sample request), (2) obtaining and processing samples (technical issues, flowchart), (3) storing samples and their products (storing forms and conditions), (4) clinical database (which clinical data to store), (5) management organization (quality and quantity of personnel, flowchart for management relations), (6) financial issues (establishment and maintenance costs). When the bank had 64 samples, even though it is quite ready to supply samples for a research project, it revealed many questions on details that may be answered in more than one way, pointing that all biobanks need to be controlled by a higher degree of management party which develops and offers quality standards for these establishments.

The role of gamma probe activity counts in minimally invasive parathyroidectomy. Preliminary results

AIM

The benefit of preoperative gamma probe in the diagnosis of adenoma in patients with histopathologically proven parathyroid (PT) adenomas was examined.

PATIENTS, MATERIAL, METHODS

20 patients with positive (99m)Tc MIBI uptake in PT scintigraphy with primary hyperparathyroidism were enrolled in this study. 740 MBq (99m)Tc MIBI were injected 3 h before operation. Counts of four PT regions were obtained with gamma probe before surgery in the operation room. All suspected PT adenomas were resected and histopathologically diagnosed as adenomas. We also obtained counts of the resection region and the resected adenoma with gamma probe after the parathyroidectomy. Preoperative counts of adenoma bearing regions (ABR), non-adenoma bearing regions (NABR), postoperative resection region (PRR), resected adenoma counts (RA) were registered. Statistical analysis was performed by Wilcoxon rank test.

RESULTS

The mean counts of ABR, NABR, the PRR and RA were 462 +/- 106, 230 +/- 66, 164 +/- 42, 374 +/- 87, respectively. The mean counts from ABR were twofold higher than those of NABR. The PRR mean counts decreased by 64% when compared to the mean counts of ABR and by 55% when compared to the mean counts of RA. The differences in mean counts of ABR and NABR, PRR and ABR, PRR and RA (p <0.01) turned out as statistically significant.

DISCUSSION

According to our preliminary results, the region with the highest counts is at least 2 +/- 0,4 times higher than the mean of the other three PT regions. Thus, it seems to be significant for PT adenoma. Resection of adenoma may be accepted as successful, if the count of ABR decreased more than 64% with decreased postoperative parathormone levels.

CONCLUSION

This technique should not yet be applied instead of parathormone measurement or frozen technique. But it may replace the frozen technique used for confirmation of the diagnosis during the operation in the future.

Comparison of serum NO, TNF-alpha, IL-1beta, sIL-2R, IL-6 and IL-8 levels with grades of retinopathy in patients with diabetes mellitus

BACKGROUND

Vitreal interleukin (IL)-1beta (IL-1beta), IL-6, IL-8, tumor necrosis factor-alpha (TNF-alpha) and nitric oxide (NO) levels have previously been determined in patients with proliferative diabetic retinopathy (PDR). However, at present there is no cohort study linking serum levels of NO and many inflammatory cytokines such as TNF-alpha, IL-1beta, soluble IL-2 receptor (sIL-2R), IL-6 and IL-8 to the grade of the microvascular complications.

PURPOSE

To determine the relation between the stages of DR and the levels of serum NO, TNF-alpha, IL-1beta, sIL-2R, IL-6 and chemokine IL-8 in patients with diabetes compared with healthy controls.

METHODS

Fifty-three consecutive patients with diabetes (25 men, 28 women) with or without DR and 15 non-diabetic healthy subjects (seven men, eight women) as controls were included in this prospective study. As an indicator for NO, serum total nitrite (NO2- + NO3-) levels (end-product of NO) were measured by the Griess reaction. Serum TNF-alpha, IL-1beta, sIL-2R, IL-6 and IL-8 levels were determined by a spectrophotometric technique using an Immulite chemiluminescent immunometric assay. The patients with diabetes were classified into three groups according to the stage of DR: no DR (NDR; n = 16), non-proliferative DR (NPDR; n = 18) and PDR (n = 19). The data were analysed using a Mann-Whitney U-test and the results were expressed as mean +/- SE (range).

RESULTS

The levels of IL-1beta and IL-6 were below the detection limits of the assay (for each, <5.0 pg/ml) in all patients with diabetes and controls. Soluble IL-2R levels ranged from 260 to 958 U/ml, with the highest values observed in the patients with PDR. In 47 of the 53 samples (89%) tested for diabetic patients, IL-8 levels were above the detection limits of the assay (5.0 pg/ml). IL-8 levels ranged from <5.0 to 25.0 pg/ml, with the highest mean values observed in PDR patients. TNF-alpha was detectable in 46 of 53 patients with diabetes (87%), ranging from <4.0 to 26.4 pg/ml, with again the highest values obtained in the patients with PDR. Serum NO levels ranged from 80 to 188 micromol/l, with the highest values obtained in patients with PDR. Taken together, the mean serum NO, sIL-2R, IL-8 and TNF-alpha levels increased with the stage of DR and the highest levels were found in patients with PDR. The PDR patients had significantly (for each, P < 0.001) higher serum NO (166.8 +/- 3.2 micromol/l), sIL-2R (807.9 +/- 33.3 U/ml), IL-8 (17.9 +/- 0.4 pg/ml) and TNF-alpha (15.0 +/- 0.8 pg/ml) levels compared with NPDR patients (149.5 +/- 2.1, 659.4 +/- 23.4, 12.9 +/- 1.1, 11.5 +/- 0.6, respectively), NDR patients (115.9 +/- 5.8, 373.8 +/- 15.0, 8.3 +/- 1.0, 6.6 +/- 0.9, respectively) and controls (116.6 +/- 2.3, 392.4 +/- 16.6, 7.2 +/- 0.3, 7.3 +/- 0.5, respectively). Serum levels of these parameters for NPDR patients were also significantly (for each, P < 0.01) higher compared with those of NDR patients and controls. On the other hand, serum NO, sIL-2R, IL-8 and TNF-alpha levels of patients with NDR were comparable with those of controls (for each, P > 0.05).

CONCLUSION

The results of the present study suggest that NO, sIL-2R, IL-8 and TNF-alpha may play important roles in the pathophysiology and progression of DR. We think that these potentially inflammatory cytokines and NO with their endothelial implications may act together during the course and progression of DR. These molecules may serve as therapeutic targets for the treatment and/or prevention of diabetes with its systemic and ocular microvascular complications.

Dacarbazine-induced carotid artery and deep venous thrombosis in a patient with leiomyosarcoma: case report

Thromboembolic events are a common and important cause of morbidity and mortality in cancer patients that require early diagnosis and treatment. Reports have suggested that chemotherapeutic agents may contribute to this risk. In this case report, a 60-year-old male patient on chemotherapy (dacarbazine and doxorubicin) for leiomyosarcoma with no previous history of thromboembolism developed left carotid artery thrombosis 3 days after the first cycle of chemotherapy. A low molecular weight heparin was started for a possible cerebrovascular accident-related thrombosis. In the second cycle, he developed right femoral vein thrombosis only 2 days after initiating the chemotherapy. The chemotherapy protocol was changed and the patient did not develop any thrombosis during the 1-year follow-up. In the literature, no thrombotic complications have previously been reported due to either dacarbazine or doxorubicin. In conclusion, elderly patients on chemotherapy should be carefully monitored for thromboembolic complications and, in case of thrombosis, the chemotherapy protocol should be changed.

Paroxysmal Nocturnal Haemoglobinuria in the Differential Diagnosis of Unresponsive Iron Deficiency Anemia: A Case Report

A 16-year-old male patient who was on oral iron treatment for iron deficiency anemia for the last one year was seen at the Haematology clinic with complaints of weakness, pallor, and jaundice. A complete blood count revealed Hb of 4.2 mmol/L, Hct of 0.14, and MCV of 76 fl. A blood smear showed 50% neutrophils, 40% lymphocytes, and 10% monocytes with anisocytosis, poikilocytosis, polichromasia in erythrocytes and normoblasts. Reticulocyte count was under 1%. There was a slight erythroid hyperplasia in the bone marrow aspiration. Biochemical examinations showed total bilirubin of 3.9 mg/dL, indirect bilirubin of 3.4 mg/dL, and lactate dehydrogenase (LDH) of 6085 U/L (220-450). In re-evaluating the history of the patient, he was seen to be complaining of dark discoloration of morning urine. Perl's reaction was found to be positive for hemosiderin in the urine sediment. Because Ham's test was positive, the levels of CD55, 58, and 59 proteins on erythrocyte membranes were found to be lower. The patient was started 32 mg of methylprednisolone and his anaemia was improved by the 14th day of treatment. When evaluating iron deficiency anemia resistant to iron supplementation, PNH should be kept in mind.

Delayed gastric emptying in conscious male rats following chronic estrogen and progesterone treatment

Several clinical observations and animal experiments have led to speculation concerning the possible effects of pregnancy and pregnancy-associated sex steroids on gastrointestinal function. It was reported that estrogen increases intestinal contractile activity, while progesterone or the combination of estrogen and progesterone decreases it. In order to measure gastric emptying, a methylcellulose test meal was given orally into the stomach of conscious rats. In progesterone-treated rats, at the dose of 0.2 mg/kg, gastric emptying was not significantly different from that of the control, but it was found to be significantly delayed at the dose of 10 mg/kg (P < 0.05). Estrogen treatment at doses of 20 micrograms/kg and 600 micrograms/kg significantly delayed gastric emptying, when compared with controls (P < 0.001). Combined therapy of estrogen and progesterone induced a significant delay in gastric emptying rate compared with the control group (P < 0.001). In the animals with pseudopregnancy treatment (100 micrograms/kg estrogen+ 15 mg/kg progesterone; 7-12 days) the gastric emptying rate was significantly different from that of the control (P < 0.05). We conclude that both estrogen and progesterone exert inhibitory effects on gastric emptying, and this may account for the disturbances in gastrointestinal function that pregnant women frequently experience.