Chemotherapy plus cyclosporine A for the treatment of intraocular retinoblastoma: The University of Miami Miller School of Medicine experience

20005

Background: In the past decade chemotherapy and focal control became the standard of care in retinoblastoma. The ideal chemotherapy regimen has not yet been determined. We analyzed the results of treatment at the University of Miami Miller School of Medicine using the regimen carboplatin (20 mg/kg, day 1), vincristine (0.05 mg. /kg, day 1), etoposide (5 mg / kg, days 1 and 2) with or without cyclosporine A (10 mg. /kg over 2 hours followed by 45 mg/kg over 31 hours) every 3–4 weeks. We attempted to maintain peak CSA levels between 2,400 and 6,000 and steady state levels between 2,400 and 4,200 ng/ml. When CSA was given, vincristine was started at 0.0125 mg /kg. The dose was escalated by 25% with each cycle of therapy, as tolerated. Methods: A retrospective analysis was performed in 41 patients diagnosed with bilateral retinoblastoma from Dec 1996 to Jan 2006. Only eyes with intraocular disease (76 eyes) were included in this analysis. Before each cycle of chemotherapy ophthalmologic examination under anesthesia was performed and active tumor and seeding were treated with local ablation using laser therapy. Eyes in which enucleation was planned at diagnosis were excluded from this analysis. Results: Most patients received 9 cycles of chemotherapy. Sixty percent (46/76) of the eyes were treated with chemotherapy and CSA. The eye salvage rate for eyes classified by the International Classification of Retinoblastoma (ICRB) as groups A, B, C and D was 100%. The eye salvage rate for the 21 eyes classified as ICRB group E was 29%. No difference in salvage rate was observed in eyes treated with or without CSA. One patient died from disease progression. Only one patient required radiation therapy to both eyes. To date there have been no reports of development of secondary malignancies. Conclusion: The addition of CSA to the treatment of the eyes classified as ICRB groups A, B, C and D made no difference in the eye salvage rate. Also, we were not able to demonstrate any benefit from the addition of CSA in patients with stage E eyes- although our sample size was quite small. Aggressive focal control and chemotherapy beginning at diagnosis may be the reason for the excellent EFS in group A, B, C and D eyes.

No significant financial relationships to disclose.

Pegaspargase-induced pancreatitis

BACKGROUND

The purpose of this study is to report the incidence of pancreatitis in patients treated with pegaspargase in our hospital during a 2-year period.

PROCEDURE

We identified episodes of pancreatitis related to the intramuscular administration of pegaspargase 2,500 IU/m(2) for the treatment of childhood hematological malignancies during a 2-year period (May 1996-April 1998). Patients were evaluated clinically and by sequential serum amylase and lipase determinations and radiographic examinations. For comparison, episodes of pancreatitis in patients who only received native Escherichia coli L-asparaginase were examined during the same time period.

RESULTS

Nine children with acute lymphoblastic leukemia (ALL) of 50 (18%) patients who received pegaspargase were diagnosed to have pancreatitis. All had prior therapy with native L-asparaginase. These children developed symptoms consisting of abdominal pain, nausea, vomiting, and decreased appetite within a median of 15 days from the onset of pegaspargase administration. Six patients became symptomatic after their initial dose. Seven patients developed severe or unacceptable toxicity (grades 3 and 4), measured by increased amylase (>2 times normal) and lipase levels or radiographic evidence of pancreatic inflammation or pseudocyst. One patient also developed hyperammonemia and encephalopathy. In contrast, only one out of 52 (1.9%) ALL patients who received native E. coli L-asparaginase during the same time period developed pancreatitis (P= 0.007).

CONCLUSION

Clinicians should be aware of a possible higher incidence of pancreatitis associated with pegaspargase.

Massive upper gastrointestinal hemorrhage due to cytomegalovirus infection in two patients with acquired immunodeficiency syndrome

Massive upper gastrointestinal (GI) hemorrhage is a rare manifestation of GI cytomegalovirus (CMV) infection. A review of the English language literature yielded 21 well-documented cases of gastric ulcers due to CMV, and 7 of these 21 cases were complicated by significant GI bleeding. This report describes two cases of massive upper GI hemorrhage due to CMV infection in patients with acquired immunodeficiency syndrome (AIDS).

Polymicrobial cholangitis and liver abscess in a patient with the acquired immunodeficiency syndrome

Cholangitis/cholangiopathy associated with the human immunodeficiency virus (HIV) infection is characterized by chronic abdominal pain, low-grade fever, cholestasis, and sometimes areas of focal or diffuse dilatation of the bile ducts that may be apparent on noninvasive imaging studies. Although the etiology of this biliary disease may be multifactorial, it appears to be the result of immunosuppression and/or secondary opportunistic infections rather than a direct cytopathic effect of HIV itself. Various opportunistic pathogens, including cytomegalovirus, Cryptosporidium, Campylobacter fetus, and Candida albicans, have been implicated as causes of HIV-associated cholangitis. We report an unusual case of polymicrobial cholangitis and liver abscess in a patient with HIV infection.

Mesenteric lipodystrophy with fever of unknown origin and mesenteric calcifications

Mesenteric lipodystrophy (ML) is a rare condition characterized by a nonspecific inflammatory process that involves the root of the mesentery in a lipoma-like lesion. Presenting features of ML include abdominal pain, weight loss, nausea, vomiting, diarrhea, and constipation. This case illustrates that ML should be included in the differential diagnosis of patients with fever of unknown origin and mesenteric calcifications.

Use of electron microscopy and other special techniques in the investigation of suspected specimen contamination

Contamination of a biopsy or surgical specimen with spurious tissue is an uncommon but potentially disastrous event. In this regard, the case of a 5-year-old boy referred for treatment of an abdominal tumor is presented. Sections made from paraffin blocks brought by the family showed both neuroblastoma and a spindle cell sarcoma, initially suggesting the possibility of divergent or mixed differentiation. However, the resemblance of the spindle cell component to well-differentiated leiomyosarcoma rather than rhabdomyosarcoma raised the suspicion that a specimen contamination had occurred. Electron microscopy was instrumental in confirming the smooth muscle nature of the sarcomatous component, leading to a fluorescence in situ hybridization study, which established that this component was incompatible with the patient's gender. This case illustrates that even when the light microscopic differential has been compromised by specimen mishandling, electron microscopy can at times provide useful information regarding specimen identity, as well as assist in sorting out the correct diagnosis.

Jejunal phlebectasia presenting with massive gastrointestinal hemorrhage

Our case report illustrates the clinicopathologic features of this rare vascular lesion and highlights that phlebectasia should be considered as a cause of gastrointestinal bleeding of undetermined etiology in adult patients.

Improvement of thrombocytopenia due to hypersplenism after transjugular intrahepatic portosystemic shunt placement in cirrhotic patients

Thrombocytopenia secondary to hypersplenism is a well-known complication of portal hypertension. The effects of transjugular intrahepatic portosystemic shunt (TIPS) on hypersplenism have not been adequately studied. In this report, we describe 11 patients who had significant improvement in their thrombocytopenia due to hypersplenism after TIPS. There was a statistically significant improvement in the platelet counts after TIPS placement, in virtually every case during the follow-up period, although some patients had platelet counts less than 100,000/mm3 at the end of the follow-up period. Statistically significant hemodynamic improvement in the gradient pressure was observed immediately after TIPS. Furthermore, all patients tolerated the procedure well, and TIPS-related complications were encountered during the follow-up period. Our data suggest that TIPS is an effective, noninvasive alternative to surgical interventions in the management of hypersplenism in cirrhotic patients, who are generally high-risk surgical candidates.

Jejunal diverticulitis manifesting with abdominal wall abscess

Jejunal diverticulosis is generally considered to be an innocuous condition, but serious complications can arise and lead to acute or chronic syndromes. In this report, we describe a case of jejunal diverticulitis presenting with an abdominal wall abscess. To our knowledge, this is the first documented case of jejunal diverticulitis complicated by fistula formation leading to the development of an abdominal wall abscess. Because jejunal diverticula generally localize at the mesenteric border and their perforation tends to result in intra-abdominal abscess formation, we speculate that the abdominal wall abscess described in our case here was due to adhesions of jejunal loops to the abdominal wall secondary to previous abdominal surgeries.

Transjugular intrahepatic portosystemic shunt placement for variceal bleeding: predictors of mortality

PURPOSE

To identify factors that predict survival in patients with variceal bleeding who have undergone transjugular intrahepatic portosystemic shunt (TIPS) placement.

PATIENTS AND METHODS

TIPS was performed in 64 of 65 patients. Indications were bleeding esophagogastric varices in 64 patients and hemorrhoidal bleeding in one. Child-Pugh classifications were A in two patients, B in 32, and C in 31. Acute bleeding was controlled before TIPS in 26 patients in stable condition but not in 39 patients whose condition was unstable.

RESULTS

Twelve patients died within 30 days of TIPS, and another 14 died thereafter. The cumulative survival rate was 67% at 6 months and 56% at 1 year. Cumulative 30-day survival was 96% for stable and 69% for unstable patients, a significant difference (P = .0135). Thirty-day survival was 91% for patients in Child-Pugh classes A and B combined and 71% for patients in class C (P = .042).

CONCLUSION

Efforts to control acute bleeding and improve a patient's metabolic status before TIPS are likely to improve 30-day survival.

Severe diarrhea due to Cokeromyces recurvatus in a bone marrow transplant recipient

Cokeromyces recurvatus, a sporangiola-forming dimorphic fungus, is a rare cause of urogenital infection in humans. We report here a case of severe watery diarrhea due to C. recurvatus, which was treated successfully with high-dose oral nystatin therapy. We speculate that our patient was probably predisposed to infections due to opportunistic organisms, such as C. recurvatus, because of post-transplantation immunosuppression. To our knowledge, our patient represents the first documented case of diarrhea due to C. recurvatus in man, and this case highlights the potential pathogenic capability of this opportunistic organism in immunosuppressed patients.

Inhibition of collagenolytic activity and metastasis of tumor cells by a recombinant human tissue inhibitor of metalloproteinases

Metalloproteinases secreted by tumor cells play an important role in metastasis. In the present study, we determined whether an inhibitor of these proteinases could inhibit the ability of tumor cells to degrade collagen and to metastasize. Metalloproteinases with degradative activities for type I collagen, type IV collagen, gelatin, and casein were secreted by a highly metastatic rat embryo cell line (4R) transfected by c-Ha-ras1 (also known as HRAS1). These metalloproteinases were identified by sodium dodecyl sulfate substrate-polyacrylamide gel electrophoresis as 92-kilodalton and 68-kilodalton gelatinolytic enzymes and 48-kilodalton and 45-kilodalton caseinolytic proteinases. A recombinant human tissue inhibitor of metalloproteinases (rTIMP) completely inhibited the proteolytic activities of these enzymes and was also a potent inhibitor of the proteolytic degradation of collagen by intact c-Ha-ras1-transfected cells. The ability of these cells to colonize the lungs after intravenous injection into nude mice was inhibited by 83% when rTIMP was repeatedly injected intraperitoneally into the animals. These data demonstrate that rTIMP is a potent inhibitor of the metalloproteinase activities of these cells and can also inhibit their metastatic potential.

Permeability of barnacle muscle fibers to water and nonelectrolytes

The permeability of isolated muscle fibers of the giant barnacle Megabalanus psittacus to water and nonelectrolytes was studied by determining their reflection and permeability coefficients. Reflection coefficients were obtained by comparing the osmotic fluxes produced by a test molecule to that produced by the impermeant sucrose molecule. Permeability coefficients were determined for measurements of tracer uptake. The results indicate that, in these fibers, nonelectrolyte permeability is closely related to lipid solubility and molecular size. A value of 2.16 X 10(-12) cm3/sec dyne for the hydraulic conductivity and a value of 10.45 X 10(-4) cm/sec for 3HHO permeability coefficient were obtained. The effect of membrane surface invaginations and clefts on the determination of permeability coefficients is discussed.

Heart capillary permeability to lipid-insoluble molecules

1. A study has been made, in the isolated, beating dog heart perfused with blood, of the transcapillary exchange of the following substances: [(3)H]water, (22)Na, (86)Rb, (36)Cl, [(14)C]urea, [(3)H]glycerol, [(3)H]glucose, [(14)C]sucrose and [(3)H]inulin.2. The method used to study the exchange was the ;indicator diffusion' technique. It consists in a rapid arterial injection of a mixture containing a diffusible and a non-diffusible molecule, followed by a rapid split collection of the venous outflow, up to 30 sec. The fractional extraction, E, of the diffusible substance was obtained by comparing the relative concentrations of both tracers in injected medium and in each venous sample.3. E for [(3)H]water was the highest (0.90 +/- 0.3), and it did not vary with flow. All other molecules had values for E that decreased as flow increased.4. Capillary permeability constant, P, was estimated from PS = - F ln (1 - E), in which S is the surface area of exchange and F is the blood perfusion rate. To test the validity of the equation, E was measured at different blood perfusion rates. It was found that the equation did not apply at relatively low flows for the more diffusible substances.5. The average values of P estimated for inulin, sucrose, glucose, glycerol and urea were 0.27, 0.8, 1.0, 1.5 and 3.1 x 10(5) (cm/sec), respectively. The ratio P/D (in which D is the free diffusion in water constant) was the same for all these substances. This can be interpreted as showing that if pores exist in the capillary endothelium, they must be larger than 80-100 A diameter. It is concluded that the pores could actually be the intercellular slits as previously suggested by electron microscope studies. Endothelial cell participation in the exchange appears to be small except for [(3)H]water.

Fractional extraction and transcapillary exchange during continuous and instantaneous tracer administration

The relation between extraction fraction, E, measured by the multiple-tracer, instantaneous intra-arterial injection method and by single-tracer, continuous injection was studied by experiments on gastric wall, liver, and skeletal muscle of anesthetized dogs. E was calculated from ratios of diffusible to nondiffusible tracer concentrations in successive samples of venous blood. Initial extraction, E(0), was the same by instantaneous or continuous injection. E diminished with time due to back-diffusion. In liver, E(0) for water- 3 H, mannitol- 3 H, and glucose- 3 H remained close to unity, indicating that transcapillary transport was flow-limited. E(0) for 22 Na, 36 Cl, and mannitol- 3 H in gastric wall, and for 22 Na and 86 Rb in skeletal muscle were less than unity and decreased with increasing blood flow, indicating diffusion limitation. E for 86 Rb in skeletal muscle eventually reached a plateau level, due to the large "sink" for 86 Rb in cell K. Both E(0) and plateau E for 86 Rb in muscle increased during exercise. Permeability surface products PS were calculated from measured E's and blood flows, Q, by the relation PS = -Q ln (1 - E). Their values suggest that E(0) reflects relative capillary permeabilities to different tracers, but only for capillaries of fastest arteriovenous transit. Plateau E's, such as for 86 Rb in skeletal muscle, represent all the capillaries, but are influenced also by extracapillary barriers.