Maximizing agricultural reuse of recycled nutrients: A spatially explicit assessment of environmental consequences and costs

Recovering nutrients from organic materials to reduce artificial fertilizer inputs requires the implementation of processing technologies and can involve considerable logistics and transportation costs. Reducing such costs by directly applying organic materials to agricultural land can contribute to pollution due to potential contaminants and unbalanced nutrient ratios. Assessing the cost of increased recycling requires a spatially explicit approach because availability of organic materials, nutrient demand and agro-ecosystem properties vary spatially. A multi-objective model was developed to estimate the trade-offs between costs of nutrient recovery and improvements in nutrient distribution for a case study area in The Netherlands. The evaluated recovery processes included solid-liquid separation followed by reverse osmosis to recover nutrients from pig manure which was compared to a conventional process via hygienisation and export. Results indicate that, even in a nutrient saturated area, replacement potential of artificial nitrogen (N) and phosphorus (P) fertilizers through locally reclaimed nutrients is limited to about 17% N and 55% P. A cost optimum was found when about 48% of the initial pig manure quantities were processed via nutrient recovery and directed to land. Increasing manure processing for nutrient recovery led to a redistribution of nutrients and trace metals (zinc (Zn) and copper (Cu)), resulting in more localized concentration. Zn and Cu were enriched by about 8% and 2%, respectively, when maximizing nutrient recovery. Our generic model offers a methodology to assess the trade-offs between increased recycling and associated spatial effects to facilitate sustainable recycling infrastructures for achieving more circular agriculture.

Systematic Lab Knowledge Integration for Management of Lipid Excess in High-Risk Patients: Rationale and Design of the SKIM LEAN Project

SKIM LEAN aims at exploiting Electronic Health Records (EHRs) to integrate knowledge derived from routine laboratory tests with background analysis of clinical databases, for the identification and early referral to specialist care, where appropriate, of patients with hypercholesterolemia, who may be inadequately controlled according to their cardiovascular (CV) risk level. SKIM LEAN addresses gaps in care that may occur through the lack of coordination between primary and specialist care, incomplete adherence to clinical guidelines, or poor patient's compliance to the physician's prescriptions because of comorbidities or drug side effects. Key project objectives include: (1) improved health professionals' competence and patient empowerment through a two-tiered educational website for general practitioners (GPs) and patients, and (2) implementation of a hospital-community shared care pathway to increase the proportion of patients at high/very-high CV risk (Familial Hypercholesterolemia, previous CV events) who achieve target LDL cholesterol (LDL-C) levels. Thanks to a close collaboration between clinical and information technology partners, SKIM LEAN will fully exploit the value of big data deriving from EHRs, and filter such knowledge using clinically-derived algorithms to risk-stratify patients. Alerts for GPs will be generated with interpreted test results. GPs will be able to refer patients with uncontrolled LDL-C within the shared pathway to the lipid or secondary prevention outpatient clinics of NIG hospital. Metrics to verify the project achievements include web-site visits, the number of alerts generated, numbers of patients referred by GPs, the proportion of secondary prevention patients who achieve LDL-C <100 mg/dl or a >50% decrease from baseline.

Ultrasound Guided versus Direct Vein Puncture in Central Venous Port Placement

Introduction

This study will report our experience on positioning of totally implanted venous catheter system (port-a-cath) as compared to ultrasound guidance versus blind technique.

Materials and Methods

From July 1996 to November 1999 in the vascular suite of the Europen Institute of Oncology, 427 port-a-cath were implanted in patients with neoplastic disease. All devices were implanted through the subclavian vein. 198 with ultrasound guided puncture and 229 following anatomical landmarks. All patients underwent a close and specific clinical and instrumental follow-up to evaluate possible complications.

Results

Use of Ultrasound (US) in subclavian vein catheterization has reduced the number of puncture attempts, with a better patient complicance, allowing a faster procedure and reducing peri-procedural complications. Ultrasound technique has shown reduction in early complications. In fact in our experience we had no pneumothorax events by using ultrasound guidance, versus 11 events with blind technique. US has shown no reduction in late complications: 3 thrombosis versus 6 thrombosis with US guidance, and 3 fractured and embolized catheter versus 2 cases. Fibrin-cuff percentage was the same in the two groups with only 1 case, as the dislocation of the catheter tip in the jugular vein with 2 cases in both groups. Moreover US let us to avoid the arterial puncture and to perform a more peripheral puncture of the subclavian vein, reducing the risk of “pinch-off” phenomenon and of haematoma, with no cases reported under US guidance versus 1 case respectively in direct vein puncture.

Conclusions

US guided puncture of subclavian vein for the implantation of venous catheter system is faster by reducing procedure time, it is easier for the operator and safer for the patient than blind technique by exposing anatomical structures. Morevover US guidance reduces early complications and limits costs.

Tips and tricks for a safe and effective image-guided percutaneous renal tumour ablation

Abstract

Image-guide thermal ablations are nowadays increasingly used to provide a minimally invasive treatment to patients with renal tumours, with reported good clinical results and low complications rate. Different ablative techniques can be applied, each with some advantages and disadvantages according to the clinical situation. Moreover, percutaneous ablation of renal tumours might be complex in cases where there is limited access for image guidance or a close proximity to critical structures, which can be unintentionally injured during treatment. In the present paper we offer an overview of the most commonly used ablative techniques and of the most important manoeuvres that can be applied to enhance the safety and effectiveness of percutaneous image-guided renal ablation. Emphasis is given to the different technical aspects of cryoablation, radiofrequency ablation, and microwave ablation, on the ideal operating room setting, optimal image guidance, application of fusion imaging and virtual navigation, and contrast enhanced ultrasound in the guidance and monitoring of the procedure. Moreover, a series of protective manoeuvre that can be used to avoid damage to surrounding sensitive structures is presented. A selection of cases of image-guided thermal ablation of renal tumours in which the discussed technique were used is presented and illustrated.

Teaching points

• Cryoablation, radiofrequency and microwave ablation have different advantages and disadvantages.

• US, CT, fusion imaging, and CEUS increase an effective image-guidance.

• Different patient positioning and external compression may increase procedure feasibility.

• Hydrodissection and gas insufflation are useful to displace surrounding critical structures.

• Cold pyeloperfusion can reduce the thermal damage to the collecting system.

Chemosaturation with percutaneous hepatic perfusions of melphalan for hepatic metastases: experience from two European centers

PURPOSE

Chemosaturation with percutaneous hepatic perfusion (PHP; Hepatic CHEMOSAT(®) Delivery System; Delcath Systems Inc, USA) is a minimally invasive, repeatable regional therapy for unresectable hepatic metastases. It uses a system of catheters and filters to isolate hepatic venous blood from the systemic circulation, allowing delivery of high-dose chemotherapy to the hepatic artery. Effluent hepatic venous blood is filtered before being returned to the systemic circulation, thereby reducing exposure to chemotherapy. We describe our experiences with chemosaturation-PHP at 2 European centers.

MATERIALS AND METHODS

14 patients presented unresectable hepatic metastases from solid tumors; 13 received 1 - 3 sessions of chemosaturation-PHP. Melphalan 2.0 (n = 1) or 3.0 (n = 12) mg/kg was given as a 30-minute infusion into the hepatic artery. 12 patients were evaluable for tumor response.

RESULTS

One complete (cholangiocarcinoma, n = 1) and 6 partial responses (ocular, n = 3 or cutaneous melanoma, n = 3) were observed, 5 patients had stable disease (ocular melanoma, n = 3; breast cancer, n = 1; gastric cancer, n = 1). Mild to moderate filter-related toxicity (i. e. thrombocytopenia, anemia) was observed immediately post-procedure. Grade 3/4 melphalan-related pancytopenia developed after 1 - 2 weeks. All hematological events were managed effectively with transfusions and/or other supportive measures. The new high-efficiency filter showed milder toxicity and faster recovery. In one case, chemosaturation-PHP was abandoned prematurely due to heparin-induced vaginal bleeding, and one patient died due to retroperitoneal hemorrhage from heparin anti-coagulation.

CONCLUSION

Chemosaturation-PHP for non-resectable liver metastases is a feasible treatment option when performed by an experienced multi-disciplinary team. It may be a promising regional therapy for patients with no effective treatment options.

Catheter rupture and distal embolisation: a rare complication of central venous ports

Central venous access devices placed through a percutaneous subclavian approach may be compressed by neighbouring bony structures, leading to biomaterial fatigue, catheter fracture at the compression site, and possible embolisation of distal fragment into the central veins. The aim of this paper is to review the experience of the authors, including more than 1300 subclavian port placements, carried out during a five-year period, discussing possible causes and therapeutic options of this rare complication. Nine patients out of 1320 (0.68%) experienced this complication during the five-year period of this study. Two patients only showed a retrospective radiologic evidence of the 'pinch-off sign' (e.g. initial compression of the catheter at the costo-clavicular junction). No patients had symptoms from the embolised catheter fragment; the most frequent symptom (8 out of 9 cases) was a painful swelling around the port area during infusion, related to the extravasation of medications or fluids into the subcutaneous tissue. The site of embolised segment varied from azygos vein to right pulmonary artery; however, these findings did not affect the outcome, and all the embolised fragments were successfully retrieved through a transfemoral approach using a radiologic interventional technique. No fatality occurred. The catheter fracture and embolisation of the distal fragment are a well-known complication of subclavian central venous long-term cannulation, whose estimated overall incidence is 0.5-1%. Diagnosis is usually based on the radiologic appearance of the catheter compression (so called 'pinch-off sign'), which is far from being constant; a clinical suspicion can derive from intermittent malfunction, which claims differential diagnosis with the pres-ence of a fibrin sleeve around the tip of the catheter. Once diagnosed, the treatment is always an interventional radiologic approach, which has a very high success rate. When it fails, the possibility to leave the fragment embolised in the central veins, heart or pulmonary arteries, should be considered, being the thoracotomy and open catheter retraction questionable, at present time, in patients who have no symptoms and limited life-expectancy.

High-intensity focused ultrasound (HIFU) in patients with solid malignancies: evaluation of feasibility, local tumour response and clinical results

PURPOSE

The purpose of this study was to evaluate the safety and efficacy of ultrasound-guided high-intensity focused ultrasound (USgHIFU) for ablation of solid tumours without damaging the surrounding structures.

MATERIALS AND METHODS

A specific written informed consent was obtained from every patient before treatment. From September 2008 to April 2009, 22 patients with 29 lesions were treated: nine patients with liver and/or soft-tissue metastases from colorectal carcinoma (CRC), six with pancreatic solid lesions, three with liver and/or bone metastases from breast cancer, one with osteosarcoma, one with muscle metastasis from lung cancer, one with iliac metastasis from multiple myeloma and one with abdominal liposarcoma. The mean diameter of tumours was 4.2 cm. All patients were evaluated 1 day, 1 month and 3 months after HIFU treatment by multidetector computed tomography (MDCT), positron-emission tomography (PET)-CT and clinical evaluation. The treatment time and adverse events were recorded.

RESULTS

All patients had one treatment. Average treatment and sonication times were, respectively, 162.7 and 37.4 min. PET-CT or/and MDCT showed complete response in 11/13 liver metastases; all bone, soft-tissue and pancreatic lesions were palliated in symptoms, with complete response to PET-CT, MDCT or magnetic resonance imaging (MRI); the liposarcoma was almost completely ablated at MRI. Local oedema was observed in three patients. No other side effects were observed. All patients were discharged 1-3 days after treatment.

CONCLUSIONS

According to our preliminary experience in a small number of patients, we conclude that HIFU ablation is a safe and feasible technique for locoregional treatment and is effective in pain control.

Porphyrin pattern and methemoglobin levels in Columba livia applied to assess toxicological risk by air pollution in urban areas

The study has explored two conservative biomarkers, porphyrin pattern in guano and methemoglobin levels in blood of Columba livia, in order to assay their potential use for monitoring toxic effects induced by exposure to urban air pollution. Fieldwork was conducted between October 2003 and June 2005 in the city of Milan, Italy, by sampling the pigeons in different areas almost twice a week. Six air contaminants, CO, PM10, NO(2), O(3), SO(2), and C(6)H(6), plus polycyclic aromatic hydrocarbons (PAHs) in fine particles, temperature, and UV index, were considered. Protoporphyrins from pigeon excreta sampled outdoors were always higher than in indoor animals, particularly in winter. A positive correlation (p < 0.001) of protoporphyrin with PAHs was observed. In terms of the values of methemoglobinemia, animals exposed to urban air showed significant differences from season to season but only in summer and autumn did the outdoor pigeons show higher values than indoor animals. In summer, a regression model with a positive correlation between O(3) and benzene was determined (p < 0.01). The use of Columba livia as a sentinel for urban air pollution as well as for detecting complex interactions between contaminants in the urban air pollutant mixture was discussed.

Best choice of central venous insertion site for the prevention of catheter-related complications in adult patients who need cancer therapy: a randomized trial

BACKGROUND

Central venous access is extensively used in oncology, though practical information from randomized trials on the most convenient insertion modality and site is unavailable.

METHODS

Four hundred and three patients eligible for receiving i.v. chemotherapy for solid tumors were randomly assigned to implantation of a single type of port (Bard Port, Bard Inc., Salt Lake City, UT), through a percutaneous landmark access to the internal jugular, a ultrasound (US)-guided access to the subclavian or a surgical cut-down access through the cephalic vein at the deltoid-pectoralis groove. Early and late complications were prospectively recorded until removal of the device, patient's death or ending of the study.

RESULTS

Four hundred and one patients (99.9%) were assessable: 132 with the internal jugular, 136 with the subclavian and 133 with the cephalic vein access. The median follow-up was 356.5 days (range 0-1087). No differences were found for early complication rate in the three groups {internal jugular: 0% [95% confidence interval (CI) 0.0% to 2.7%], subclavian: 0% (95% CI 0.0% to 2.7%), cephalic: 1.5% (95% CI 0.1% to 5.3%)}. US-guided subclavian insertion site had significantly lower failures (e.g. failed attempts to place the catheter in agreement with the original arm of randomization, P = 0.001). Infections occurred in one, three and one patients (internal jugular, subclavian and cephalic access, respectively, P = 0.464), whereas venous thrombosis was observed in 15, 8 and 11 patients (P = 0.272).

CONCLUSIONS

Central venous insertion modality and sites had no impact on either early or late complication rates, but US-guided subclavian insertion showed the lowest proportion of failures.

The management of colorectal liver metastases: Expanding the role of hepatic resection in the age of multimodal therapy

Colorectal cancer (CRC) caused nearly 204,000 deaths in Europe in 2004. Despite recent advances in the treatment of advanced disease, which include the incorporation of two new cytotoxic agents irinotecan and oxaliplatin into first-line regimens, the concept of planned sequential therapy involving three active agents during the course of a patient's treatment and the integrated use of targeted monoclonal antibodies, the 5-year survival rates for patients with advanced CRC remain unacceptably low. For patients with colorectal liver metastases, liver resection offers the only potential for cure. This review, based on the outcomes of a meeting of European experts (surgeons and medical oncologists), considers the current treatment strategies available to patients with CRC liver metastases, the criteria for the selection of those patients most likely to benefit and suggests where future progress may occur.

Institutional guidelines and ongoing studies in management of liver tumours: the experience of the European Institute of Oncology

BACKGROUND

An institutional task force on upper gastrointestinal tumours is active at the European Institute of Oncology (EIO). Members decided to collate the institutional guidelines on management of liver tumours (primary and metastatic) into a document. This article is aimed at presenting the current treatment guidelines as well as ongoing research protocols and trials in this field at the EIO.

METHODS

A steering committee convened to assign tasks to individual members. Contributions from experts in each treatment area were collated in a single document, in order to produce a draft for subsequent review from the aforementioned committee. Six drafts have been discussed and the final version approved.

RESULTS

Surgical, medical oncology, interventional radiology, nuclear medicine and radiation therapy approaches, their roles in management of liver tumours and ongoing research trials are presented and discussed in this article.

CONCLUSIONS

At the EIO a multi-disciplinary integrated approach to liver tumours is standard and several ongoing research projects are currently active in this field.

Surgical 'damage control' treatment of a large retroperitoneal liposarcoma encasing a horseshoe kidney

Damage control is a surgical strategy for severely compromised trauma patients based on speed control of life-threatening injuries that aims to rapidly resuscitate patients in an intensive care unit (ICU). We report on the use of such therapeutic strategy in a patient affected by a retroperitoneal sarcoma concomitant to a horseshoe kidney, a relatively rare anatomical malformation.

Resection of colorectal liver metastases following neoadjuvant chemotherapy

Background/aims:

Hepatic resection in metastatic disease from colorectal cancer offers the best chance in selected cases for long-term survival. Neoadjuvant chemotherapy (NACT) has been advocated in some cases initially deemed irresectable, with few reports of the efficacy of such a strategy and the influence of the response to chemotherapy on the outcome of radical hepatic resection.

Methodology:

Between December 1995 and May 2005, 27 patients with colorectal liver metastases (seven males, 20 females, mean age: 58 ± 8 years; range: 40–75) were treated with neoadjuvant chemotherapy. A seven-year survival analysis was performed. Chemotherapy included mainly 5-fluorouracil, leucovorin and either oxaliplatin or irinotecan for a median of eight courses.

Results:

A total of 16 patients (59%) had synchronous and 11 (41%) metachronous metastases. During pre-operative chemotherapy, tumour regression occurred in ten cases (37%), stable disease in a further ten patients (37%) and progressive disease developed in seven cases (26%). The five-year overall survival for NACT responders was 64% and only 15% for non-responders (p=0.044).

Conclusions:

The response to chemotherapy is likely to be a significant prognostic factor affecting survival after liver resection for cure.

Hepatic intra-arterial chemotherapy in patients with metastatic breast cancer

10581

Background: Hepatic intra-arterial chemotherapy has been reported to produce higher response rate than systemic in patients (pts) with metastatic colorectal cancer. In breast cancer the liver is involved in up to 60% of cases and often conditions the prognosis. Nevertheless, only rare hepatic arterial infusion studies were published. Therefore, based on our previous experience in hepatic metastatic colorectal malignancies, we evaluated efficacy and toxicity of hepatic intra-arterial chemotherapy in pts with metastatic breast cancer. Methods: A three-day continuous arterial infusion (CAI) of fluorouracil 1000 mg/m2 q 24 hrs, with cisplatin 10 mg/m2 twice daily, and mitomycin-c 1 mg/m2 twice daily, was performed through a percutaneous radiological temporary trans-subclavicular catheter. Pts with responsive disease received up to four cycles every six weeks. Pts still responding could carry on with cisplatin and fluorouracil, without mitomycin-c. Pts were hospitalized and the catheter was removed upon end of infusion. Results: From 9.2000 to 6.2005, 25 pts with progressive liver metastases from breast cancer were treated. Nine had more than 50% of liver involvement. Fifteen had also extra-hepatic metastases. All had received antracyclines and 22/25 taxanes. Pts had a median of five previous chemotherapy lines. Median time from diagnosis of liver metastases to first CAI was 33 months (range: 7–110). Sixty-four total courses were administered, with a median of 2 (range: 1–7) per pts. Epigastric pain was the main clinical toxicity (54%) and iatrogenic gastro-duodenal ulcer, the main complication (28%). No relevant catheter-related complications occurred. Fifteen partial responses (60%) and eight stable diseases (32%) were observed. Response duration was 5.4 months (range: 2 - 27), time to progression 5.1 months (range: 2.5–29+), and median overall survival 13 months (range: 3.5+–32+). Conclusions: Hepatic arterial infusion of chemotherapy in heavily pre-treated pts with metastatic breast cancer is feasible and effective. A specific evaluation of quality of life should be performed to verify a real clinical benefit. An earlier timing during course of liver disease, and a shift to radiological implanted arterial port (allowing out-patient treatment), will be investigated.

No significant financial relationships to disclose.

Exposure to the organophosphorus pesticide chlorpyrifos inhibits acetylcholinesterase activity and affects muscular integrity in Xenopus laevis larvae

The effect of organophosphate pesticide chlorpyrifos (CPF) on acetylcholinesterase (AChE) activity and on skeletal muscle development in Xenopus laevis larvae was studied. To achieve our purpose embryos were exposed to 100, 250 and 3000 microg/l CPF concentrations from late blastula stage (8 h postfertilization, p.f.) to stage 47 (120 h p.f.) and the appearance of AChE activity was monitored every 24 h. Compared with control, CPF treated larvae showed a dose dependent AChE inhibition during the early stages (beginning from 24 h until 120 h p.f.) that are crucial for neuromuscular development. The amount of AChE activity that can still be measured in treated larvae at stage 47 relative to that of the control, ranged from 28% in CPFs 100 microg/l to 4% in CPFs 3000 microg/l. These low AChE activities were associated with muscular damages such as reduced myotome size and hypertrophies coupled with extensive vacuolated regions in myocytes. The occurrence of this tissue-specific injury was related to CPF concentrations and was most pronounced in CPFs 3000 microg/l which revealed a very severe AChE inhibition during the exposure. Since AChE is the major neurotransmitter of the neuromuscular system, this initial descriptive study will be an useful starting-point to ongoing and future subcellular/molecular studies that correlate the morphological damage with changes in AChE activity.

Percutaneous Treatment of Uretero-Intestinal Stenosis with Acucise®: Preliminary Experience

The incidence of stenosis of uretero-intestinal anastomoses is about 5–10%. The most relevant effect of this post-surgical complication is the progressive renal function deterioration. Infections, ureteric ischemia, perianastomotic urinary extravasation and apposition of two different types of mucosa are the main causes of this complication. Several options are available for the treatment of these strictures: surgery, ureteral stenting, balloon dilation, endoscopic electrocautery or laser incision. The Acucise® catheter system combines diatermic incision with balloon dilation.

Material and methods

9 stenosis of uretero-intestinal anastomoses have been treated with Acusise® endoureterotomy in 7 patients. All the patients underwent to radical cistectomy with urinary diversion for oncological disease. The diagnosis has been obtained with US and/or CT examination. Residual renal function has been assessed with sequential renal scintigraphy. The procedure includes two parts: percutaneous pleacement of nephrostomic catheter with distal part inside the neo-bladder and, after 15 days, treatment with Acucise®. The incision was performed with 75W activation of the cutting wire during inflation of the balloon at the level of stenosis.

Results

Mean follow-up is about 5 months so we can't consider the long term effects of the treatment but our preliminary results are interesting, with an adequate patency of the anastomoses in 8/9 cases at CT scan. The procedure, performed under fluoroscopic control and local anaesthesia, resulted ease and safe with low procedural complications.

Conclusions

If long term results will be confirm, Acucise® could be suggested as first-line treatment in these situations; surgery should be indicated in case of minimally invasive procedure approach.

Comparative teratogenicity of chlorpyrifos and malathion on Xenopus laevis development

The embryotoxic potential of chlorpyrifos (CPF) and malathion (MTN), two organophosphorus insecticides (OPs), was evaluated by modified Frog Embryo Teratogenesis Assay-Xenopus (FETAX). CPF and MTN were not embryolethal even at the highest concentration tested (6000 microg/l), but both exhibited a powerful teratogenicity. The probit analysis of malformed larva percentages showed a TC(50) of 161.54mug/l for CPF, and a TC(50) of 2394.01 microg/l for MTN. Therefore, CPF teratogenicity was about 15 times higher than MTN. Larvae of both exposed groups were mainly affected by ventral and/or lateral tail flexure coupled with abnormal gut coiling. Histopathological diagnosis displayed abnormal myotomes and myocytes with marked hypertrophies localized at the cell extremity, probably due to a break away of myofibril extremities at the intersomitic junction level. We speculate that this muscular damage was related to inhibition of acetylcholinesterase that showed a clear concentration-response in CPF and MTN exposed larvae. The teratogenic effects of these anti-cholinesterase compounds on Xenopus laevis myogenesis suggest a possible role played by OPs on induction of congenital muscular dystrophy.

Effect of levamisole administration on bluetongue vaccination in sheep

Levamisole is an anthelmintic drug with immunostimulant properties when administered at repeated doses of 2.5 mg/kg prior to a vaccine being administered. In order to assess the effect of levamisole administration on bluetongue (BT) vaccination in sheep, four groups of unvaccinated pregnant sheep (8 sheep per group) were used. Group A received vaccine only; Group B received levamisole+vaccine; Group C received Levamisole only; Group D was a non-treated control. Levamisole (Citarin L-10%) was administered three times weekly at an initial dose of 5.0 mg/kg of body weight and subsequently at 2.5 mg/kg of body weight. There was a significant decrease in faecal egg count of gastrointestinal strongyles in Groups B and C. At the beginning of the trial, all animals were serologically negative for BT antibodies; after vaccination, there was a difference in antibody response in animals in the treated groups. Significantly, more animals in Group B developed BT antibodies following vaccination than those in Group A. In conclusion, levamisole appeared to have an immunostimulating effect on the response of sheep to BT vaccination.

Factor V Leiden and G20210A prothrombin mutation and the risk of subclavian vein thrombosis in patients with breast cancer and a central venous catheter

BACKGROUND

To analyze the influence of the prothrombotic gene mutation factor V G1691A (factor V Leiden) and prothrombin G20210A on the risk of a first episode of catheter-related deep venous thrombosis (DVT) in a group of patients with breast cancer treated with chemotherapy.

PATIENTS AND METHODS

Between January 1999 and February 2001, the occurrence of a first symptomatic DVT was investigated in a cohort of 300 consecutive patients with locally advanced or metastatic breast cancer treated at a single institution with fluorouracil-based chemotherapy, administered continuously through a totally implanted access port. A nested case-control study included 25 women (cases) with catheter-related DVT and 50 controls without DVT matched with cases for age, identical chemotherapy, stage of disease and prognostic features. The G1691A factor V and G20210A prothrombin mutation genotypes were analyzed.

RESULTS

Five cases [20%; 95% confidence interval (CI) 9% to 39%)] and two controls (4%; 95% CI 1% to 14%) were heterozygous carriers of G1691A factor V (P = 0.04). The age-adjusted odds ratio for catheter-related DVT was 6.1 (95% CI 1.1-34.3). Only one patient (case) had the G20210A prothrombin gene mutation. Time from start of chemotherapy infusion to DVT was not significantly different between patients with (median 31 days) and without (median 43 days) G1691A factor V mutation (P = 0.6).

CONCLUSIONS

Factor V Leiden carriers with locally advanced or metastatic breast cancer have an increased risk of developing catheter-related DVT during chemotherapy.

Hepatic intra-arterial chemotherapy using a percutaneous catheter in pretreated patients with metastatic colorectal carcinoma

BACKGROUND

Hepatic intra-arterial chemotherapy (HIAC) leads to a higher response rate than systemic administration in untreated patients with liver metastases from colorectal cancer (CRC). The aim of this study was to evaluate the activity and safety of giving HIAC through a percutaneous catheter in pre-treated patients.

PATIENTS AND METHODS

Forty-five CRC patients with liver-only or liver-dominant metastases, resistant or refractory to previous systemic therapy, were treated using a temporary trans-subclavian catheter. A 3-day chemotherapy regimen of daily 5-fluorouracil (5-FU) 1000 mg/m2/day + heparin 5000 IU/day given as a 24-hour continuous infusion, and twice daily bolus injections of cisplatin (CDDP) 10 mg/m2 and mitomycin C (MMC) 2 mg/m2, was administered every six weeks.

RESULTS

One hundred and seventeen courses were administered to 45 patients (a median of three per patient: range 1-5). Of the 44 patients evaluable for response, 16 (35%) had a partial response, 15 (33%) stable disease and 12 (26%) progressive disease. Eleven of the 16 responding patients had been refractory to a previous 5-FU-based systemic therapy. The most relevant grade 3-4 toxicities included neutropenia (22%) and thrombocytopenia (15%). Gastro-duodenal ulcers occurred in nine patients. Catheter displacement was recorded during 22 out of 117 (18%) courses.

CONCLUSION

HIAC with 5-FU, CDDP and MMC given through a temporary percutaneous catheter is safe and active in pretreated patients with metastatic CRC. Iatrogenic gastroduodenal ulcers are a serious but manageable complication.

Differential modulation of cytochrome P-450 1A and P-glycoprotein expression by aryl hydrocarbon receptor agonists and thyroid hormone in Xenopus laevis liver and intestine

Several defence mechanisms, such as cytochrome P450 1A (CYP1A) enzymes and P-glycoprotein (Pgp), may influence the intracellular concentration and consequently the toxicity of xenobiotics. The parallel expression of CYP1A and Pgp has been investigated in mammals and, to a lesser extent in fish, in search for evidence of co-ordinated responses to xenobiotic exposure. The aryl hydrocarbon receptor (AHR) agonists are well known CYP1A inducers but some of them resulted not to have a uniquely defined action on Pgp levels in mammalian and fish species. To the best of our knowledge, no detailed studies have been carried out so far on amphibians Xenopus laevis. For this reason, in this work, the time dependent responses of the hepatic CYP1A and Pgp, to the prototypical CYP1A inducers, benzo(a)pyrene (B(a)P), 3-methylcholanthrene (3MC) and 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) in X. laevis have been assessed at the protein level and compared. The responsiveness of Xenopus intestinal Pgp to these compounds has also been analysed, as the epithelial cells lining the lumen of intestine represent another preferential site of Pgp expression. In addition, since the thyroid hormone has been demonstrated to down regulate the mdr gene during Xenopus development and in primary culture of Xenopus intestinal epithelial cells, the effects of 3,3',5-triiodo-L-thyronine (T(3)) on CYP1A and Pgp protein levels have been investigated in adult organisms. Western blot evidenced that a single injection of B(a)P (100 mg/kg), 3MC (20 mg/kg), and TCDD (3 microg/kg) elicited a statistically significant induction of hepatic CYP1A at all time points considered (72, 120 and 168 h) which decreased in time. The same trend of liver CYP1A induction was observed in T(3) treated Xenopus (15 microg/kg). Unlike CYP1A induction, the modulation of hepatic and intestinal Pgp expression exhibits an heterogeneous pattern. The basal levels of hepatic and intestinal Pgp were not statistically significant affected by treatments. In particular, the hepatic Pgp levels seem not to be induced by TCDD and T(3) at all times considered in comparison to control. For the first time the modulation of CYP1A and Pgp levels by B(a)P, 3MC and in particular by TCDD and T(3) in Xenopus has been demonstrated and the results herewith indicate that the two target defence mechanisms respond to AHR agonists in a dissimilar way in terms of proteins induction in Xenopus. Moreover, these data suggest additional experiments in order to clarify the complex mechanism, which adjusts the parallel expression of CYP1A and Pgp in Xenopus.

Iatrogenic gastroduodenal ulcers during hepatic intra-arterial chemotherapy

BACKGROUND/AIMS

Various percentages of iatrogenic gastroduodenal ulcers during hepatic intra-arterial chemotherapy have been reported in the literature. The aim of this study was to analyze a homogeneous cohort of patients in order to evaluate the evolution and management of this complication.

METHODOLOGY

We retrospectively reviewed the clinical charts of 80 patients with primary or metastatic liver tumors who received 186 hepatic arterial infusion chemotherapy courses of 5-fluorouracil, cisplatin and mitomycin-C. All of the patients complaining of upper gastrointestinal symptoms during or after hepatic arterial infusion underwent esophagogastroduodenoscopy.

RESULTS

Esophagogastroduodenoscopy was performed in 14 patients, all of whom had gastroduodenal ulcers. Two of ten investigated patients were Helicobacter pylori positive. All of the patients were treated with a proton pump inhibitor and five also received major analgesics. All of the ulcers healed without complications. Six patients did not continue with hepatic arterial infusion for reasons other than ulcers. Eight patients received a subsequent hepatic intra-arterial chemotherapy course, five despite the persistence of an active ulcer.

CONCLUSIONS

Iatrogenic gastroduodenal ulcers are probably due to ischemia and the direct toxicity of the anticancer agents. They are Helicobacter pylori independent and do not represent an absolute contraindication for the continuation of hepatic intra-arterial chemotherapy.

O6-alkylguanines, dietary N-nitroso compounds, and their precursors in gastric cancer

Several N-nitroso compounds, present in foods and beverages or formed in the stomach from their precursors, act as alkylating agents. By using a highly reliable technique (high-resolution gas chromatography-mass spectrometry with negative-ion chemical ionization and selected ion recording), we measured a series of specific O6-alkylguanines in snap-frozen paired stomach tissue samples (tumor and noninvolved mucosa) obtained at surgery from 24 gastric cancer patients identified in Florence, Italy. Samples of noninvolved mucosa had higher levels of total O6-alkylguanines and more frequently detectable levels (54%) than tumor samples (29.2%). O6-propylguanine and O6-methylguanine were the single adducts most frequently detected in noninvolved mucosa and tumor tissue, respectively. Tumor samples showed higher levels of total O6-alkylguanines in female patients (p = 0.03) and among those with a diffuse histological type (p = 0.06) or seronegative for Helicobacter pylori CagA antibodies (p = 0.06). Mean dietary nitrate intake was significantly higher in patients with detectable levels of adducts in tumor samples (p = 0.03). Estimated intakes of dimethylamine and N-nitrosodimethylamine correlated with total levels of O6-alkylguanines in noninvolved gastric mucosa. These findings, although based on a small series of cases, support a role for N-nitroso compounds from dietary sources in the etiology of gastric cancer.

Determinants of 4-aminobiphenyl-DNA adducts in bladder cancer biopsies

Exposure to 4-aminobiphenyl (4-ABP) is an important determinant of urinary bladder cancer in humans. We have analyzed by gas chromatography-mass spectrometry the DNA adducts of 4-ABP in 75 bladder cancer biopsies. The purpose was to understand whether smoking, N-acetyltransferase 2 (NAT2) polymorphism, diet or tumor grade were determinants of 4-ABP-DNA levels. 4-ABP-DNA adducts were above the detection limit of 0.1 fmol/microg DNA for 37/75 patients. Overall the level of adducts was 2.7 +/- 0.7 (mean +/- SE) fmol/microg DNA (86 +/- 22 adducts/10(8) normal nucleotides, mean +/- SE). A strong association with grade was observed. In the group of patients with detectable 4-ABP-DNA adducts the odds ratio for having a tumor grade of 2 or 3 was respectively 4.3 (95% CI 0.8-21.9) and 6 (1.3-27.5), compared with grade 1. A non-statistically significant association was found between adduct levels and the deduced slow acetylator phenotype in grades 2 and 3. The intake of fruit and vegetables produced a lower frequency of detectable adducts, though the association was not statistically significant. Detectable 4-ABP-DNA adducts were clearly associated with current smoking in higher tumor grades (grade 3 versus grades 1 + 2, odds ratios 10.4; 95% CI 1.7-63.1). Overall, our findings indicate that higher levels of DNA adducts characterize more invasive tumors (higher tumor grades). This seems to be facilitated by smoking and contrasted by the intake of fruit and vegetables.

Receptor-mediated radiotherapy with 90Y-DOTA-D-Phe1-Tyr3-octreotide

A newly developed somatostatin radioligand, DOTA-[D-Phe1-Tyr3]-octreotide (DOTATOC), has been synthesised for therapeutic purposes, because of its stable and easy labelling with yttrium-90. The aim of this study was to determine the dosage, safety profile and therapeutic efficacy of 90Y-DOTATOC in patients with cancers expressing somatostatin receptors. We recruited 30 patients with histologically confirmed cancer. The main inclusion criterion was the presence of somatostatin receptors as documented by 111In-DOTATOC scintigraphy. 90Y-DOTATOC was injected intravenously using a horizontal protocol: patients received equivalent-activity doses in each of three cycles over 6 months. The first six patients received 1.11 GBq per cycle and the four successive groups of six patients received doses increasing in 0.37-GBq steps. Toxicity was evaluated according to WHO criteria. No patient had acute or delayed adverse reactions up to 2.59 GBq 90Y-DOTATOC per cycle (total 7.77 GBq). After a total dose of 3.33 GBq, one patient developed grade II renal toxicity 6 months later. The maximum tolerated dose per cycle has not yet been reached, although transient lymphocytopenia has been observed. Total injectable activity is limited by the fact that the maximum dose tolerated by the kidneys has been estimated at 20-25 Gy. Complete or partial tumour mass reduction occurred in 23% of patients; 64% had stable and 13% progressive disease. It is concluded that high activities of 90Y-DOTATOC can be administered with a low risk of myelotoxicity, although the cumulative radiation dose to the kidneys is a limiting factor and requires careful evaluation. Objective therapeutic responses have been observed.