Hereditary persistence of alpha-fetoprotein. Case report and review of the literature

Persistently elevated alpha-fetoprotein (AFP) levels of 24 to 30 micrograms/ml (normal < 10 micrograms/ml) were found in a 38-year-old healthy man. Subsequently, AFP was found to be elevated in another five out of 13 family members within three generations. The pedigree is consistent with an autosomal dominant inheritance pattern. No discernible disease and no functional abnormality appears to be associated with this clinically benign disorder which has been recorded in the literature on four occasions to date. The reported AFP levels in these other cases ranged from 18 to 198 micrograms/ml. Physiologically, AFP is mainly produced in the liver and the yolk sac of human fetuses more than four weeks old, with peak values of up to 4 mg/ml at 12 to 16 weeks of gestation. After birth, AFP levels usually fall, within eight to 12 months, to a very low concentration of < 10 micrograms/ml and persist at low levels throughout life. However, AFP levels can rise above normal in both children and adults in distinct conditions and diseases which will be discussed. Hereditary persistence of alpha-fetoprotein (HPAFP) should be considered in both children and adults with unexplained and persistent elevation of AFP e.g., those screened for hepatocellular carcinoma or diagnosed for germ cell tumor. It should also be recognized in AFP screening for neural tube defects or Down's syndrome during pregnancy. Hereditary persistence of AFP can be easily confirmed by analyzing AFP levels in family members.

[Pain in tumor patients: assessment and pain drug therapy]

This review gives an overview over the diagnostic and pharmacological approach to pain in cancer patients. The work-up and the pharmaceutical treatment is detailed and several important points in the use of opiates are highlighted.

[Current aspects and problems relating to medical ethics in oncology]

A case history of a breast cancer patient is used to exemplify ethical dilemmas in medical oncology: information of a cancer patient and his family, ethical problems with genetic testing, ethical issues with do-not-resuscitate-orders, ethical dilemmas with limited resources, problems with insurance companies, ethical issues in clinical trials and questions in dying patients including physician-assisted suicide and active euthanasia. Medical oncologists have to develop skills in recognizing ethical dilemmas in patient care and must prepare to cope with the many and complex ethical issues in the care of oncology patients.

[Multimodal therapy concepts in esophageal carcinoma: importance of radio- and chemotherapy]

Five-year survival of surgically treated patients with operable oesophageal carcinoma does not exceed 20%. The results with curative radiotherapy are even worse, with < or = 10% alive after 5 years. New treatment strategies are needed. Pre- or postoperative radiotherapy and perioperative chemotherapy alone do not improve survival. A simultaneous radiochemotherapy with cisplatin is significantly more effective than radiotherapy alone. A subgroup of patients with pathological complete remission after preoperative treatment (radio- and/or chemotherapy) survives significantly longer. It seems likely that survival in oesophageal cancer is improved by multimodal therapy encompassing radiotherapy, chemotherapy and surgery. Further randomised trials are needed, possibly in combination with other potentially active drugs.

Comparative pharmacokinetics of oral and intravenous ifosfamide/mesna/methylene blue therapy

Oral treatment with ifosfamide results in dose-limiting encephalopathy. Methylene blue is effective in reversal and prophylaxis of this side effect. In the present study, the pharmacokinetics of ifosfamide after iv and po therapy in combination with prophylactic administration of methylene blue were investigated. Nine patients with metastatic non-small cell lung cancer were treated by a combination of ifosfamide (3 days), sodium 2-mercaptoethane sulfonate (4 days), and etoposide (8 days). Cycles were repeated every 28 days. Ifosfamide was administered orally, with the exception of one of the first two cycles, when it was administered as a short infusion (randomly assigned). The patients received methylene blue in doses of 50 mg po 3 times daily; an initial dose of 50 mg was given the evening before chemotherapy. Urine samples were collected over the entire treatment period, and concentrations of ifosfamide and its major metabolite, 2-chloroethylamine, were measured by gas liquid chromatography. By the same technique, 2- and 3-dechloroethylifosfamide were determined in plasma and urine. Overall alkylating activity in urine was assayed by reaction of the alkylating metabolites with 4-(4'-nitrobenzyl)-pyridine. The chemotherapeutic regimen was well-tolerated by all of the patients studied. There was no evidence of a shift in the metabolic pattern dependent on the route of administration. From the data, we conclude that methylene blue has a neuroprotective effect and that the pharmacokinetics of ifosfamide are not influenced by its comedication.

[Emergencies in oncology]

Emergencies in oncologic patients are common and diverse. Almost every cancer patient will develop at least one emergency situation at the beginning or in the further course of his disease. The cancer itself or cancer treatment typically give rise to otherwise rare emergency development. In this review detailed descriptions of spatial cord compression syndrome, superior vena cava obstruction as well as hypercalcemia are given. Finally problems due to cerebral metastases, pulmonary embolism, hyperviscosity and hyperuricemia are briefly summarized.

[Cardioprotection in chemo- and radiotherapy for malignant diseases--an echocardiographic pilot study]

AIM

Pilot study, examining the cardioprotective effect of an antioxidant regimen in patients with malignancies receiving high dose chemo- or radiotherapy.

PATIENTS AND METHODS

14 patients with chemotherapy and 10 patients with radiotherapy were randomized in a double-blind fashion (placebo versus vitamin E and C and N-acetylcysteine). Systolic and diastolic echocardiographic parameters were determined before and within three weeks of treatment completion.

RESULTS

Left ventricular ejection fraction fell significantly in patients receiving placebo (radiotherapy: 67 +/- 6 to 56 +/- 2%, p = 0.008, chemotherapy: 67 +/- 7 to 60 +/- 8%, p = 0.05). Patients on antioxidants showed no significant fall in EF (radiotherapy: 63 +/- 8 to 61 +/- 7%, chemotherapy: 67 +/- 5 to 64 +/- 6%).

CONCLUSION

The small number of patients in the study precludes a definitive statement. The preliminary results, however, suggest efficient cardioprotection by this cheap and safe antioxidant combination, so that larger studies are warranted for confirmation.

[Frequent errors in planning and clinical management of tumor therapy]

Frequent and important errors in the management of cancer patients are reviewed. Mistakes can occur during diagnostic work-up, treatment planning, the actual treatment phase, evaluation of the response and of treatment-related side effects, the continuation or termination of a therapy, follow-up of the cancer patient and on several other occasions. Despite the fact that human knowledge and human actions are less than perfect, the knowledgeable and alert physician can avoid many errors in caring for cancer patients.

[Medical ethos of Paracelsus]

450 years ago the Renaissance doctor Theophrastus von Hohenheim called Paracelsus (1493-1541) died. Inspite of a famous name and his renowned challenging nature, his way of thinking and his work remain in many parts unknown. His professional ethics revolve around mercy, charity and his passion for medical art. In his book 'Paragranum' he waves the ethics as a virtue into his succint concept of a 'new topical and veritable medical science'. It is the aim to show the Paracelsian professional ethics in its timeless fundamentals, as in its very personal character.

[New cytostatic drugs--indications and costs]

In the last decade six new chemotherapeutic agents including the vinca alcaloid vinorelbine, the taxanes paclitaxel and docetaxel, the antimetabolite gemcitabine and the two topoisomerase I-inhibitors irinotecan and topotecan were shown to be active in several phase II- and randomized phase III-trials. This article reviews their mode of action, their efficacy, their side effects and their indications. Their state of registration and reimbursement by insurance companies in Switzerland are summarized. Finally, their costs and cost-effectiveness in a time of increasing financial restraint in health care budgets are analyzed.