Arisanschinins A-E, lignans from Schisandra arisanensis hay

Four new oxygenated dibenzocyclooctadiene lignans, arisanschinins A-D ( 1- 4), and a new 1,4-bis(phenyl)-2,3-dimethylbutane lignan, arisanschinin E ( 5), together with 15 known compounds, were isolated from the EtOAc-soluble fraction of the aerial parts of SCHISANDRA ARISANENSIS Hay. The structures of 1- 5 were elucidated on the basis of extensive spectroscopic analyses, including 2D NMR (HMQC, HMBC, and NOESY) experiments. The configurations of the biphenyl and octadiene moieties were deduced from circular dichroism (CD) and NOESY spectra, respectively. Compound 1 showed significant inhibition of α-glucosidase IN VITRO. The radical-scavenging activities of these compounds were evaluated using DPPH.

Frajunolides E-K, briarane diterpenes from Junceella fragilis

Chemical investigation of the gorgonian octocoral Junceella fragilis, collected in Taiwan, resulted in the isolation of seven new briarane-type diterpenes, frajunolides E-K (1-7), in addition to 14 known briaranes, praelolide, junceellin, junceellolides A-E, and K, 11a,20a-epoxy-4-deacetoxyjunceelolide D, umbraculolide A, junceellonoid A, and juncins Y, Z, and ZI, as well as ergosterol peroxide. The structures of 1-7 were determined by analysis of HRESIMS and 2D NMR spectroscopic data. Cytotoxicity and in vitro anti-inflammatory activities of compounds 1-7 were also evaluated.

Bioactive marine prostanoids from octocoral Clavularia viridis

Chemical investigation of the nonpolar extract of soft coral Clavularia viridis resulted in isolation of five new prostanoids, designated as claviridic acids A-E (1-5, resp.), in addition to the known clavulones I-III. Their structures were determined on the basis of spectroscopic techniques, especially HR-ESI-MS, CD, and 2D-NMR experiments. The isolated marine prostanoids exhibited potent inhibitory effect on PHA-induced proliferation of peripheral blood mononuclear cells (PBMC), as well as significant cytotoxic activity against human gastric cancer cells (AGS).

Triterpenoid saponins from the fruits and galls of Sapindus mukorossi

Six saponins, sapinmusaponin K (1) [hederagenin-3-O-(3-O-acetyl-alpha-L-arabinopyranosyl)-(1-->3)-alpha-L-rhamnopyranosyl-(1-->2)-alpha-L-arabinopyranoside], sapinmusaponin L (2) [hederagenin-3-O-(4-O-acetyl-alpha-L-arabinopyranosyl)-(1-->3)-alpha-L-rhamnopyranosyl-(1-->2)-alpha-L-arabino-pyranoside], sapinmusaponin M (3) [hederagenin-3-O-(2,3-O-diacetyl-beta-D-xylopyranosyl)-(1-->3)-alpha-L-rhamnopyranosyl-(1-->2)-alpha-L-arabinopyranoside], sapinmusaponin N (4) [hederagenin-3-O-(2,4-O-diacetyl-beta-D-xylopyranosyl)-(1-->3)-alpha-L-rhamnopyranosyl-(1-->2)-alpha-L-arabinopyranoside], sapinmusaponin O (5) [3,7,20(S)-trihydroxydammar-24-ene-3-O-alpha-L-rhamnopyranosyl-(1-->2)-beta-D-glucopyranoside], and sapinmusaponin P (6) [3,7,20(R)-trihydroxydammar-24-ene-3-O-alpha-L-rhamnopyranosyl-(1-->2)-beta-d-glucopyranoside], along with seven known saponins (7-13), were isolated from fruits and the galls of Sapindus mukorossi. Their structures were elucidated by 1D and 2D NMR spectroscopic techniques and acid hydrolysis. Biological evaluation indicated that saponins 1-4 and 7-13 showed moderate cytotoxicity against several human tumor cell lines.

Triterpenoidal saponins from Hydrocotyle sibthorpioides

Oleanane-type triterpenoidal saponins, hydrocosisaponins A-F (1-6), along with a known saponin, hydrocotyloside VII (7), were isolated from Hydrocotyle sibthorpioides. Their structures were established on the basis of spectroscopic analyses including NMR spectroscopic techniques ((13)C, (1)H, COSY, HMQC, HMBC, TOCSY and NOESY). Biological evaluation established that saponins possessing four sugar units (three d-glucoses and one l-arabinose) (4-7) exhibited moderate cytotoxicity against KB, Daoy and WiDr human tumor cell lines.

Anti-platelet aggregation triterpene saponins from the galls of Sapindus mukorossi

Bioassay-directed fractionation of an ethanolic extract of the galls of Sapindus mukorossi has resulted in the isolation of two new tirucallane-type triterpenoid saponins, sapinmusaponins Q (1) and R (2), along with three known oleanane-type triterpenoid saponins (3-5). Their structures were elucidated on the basis of spectroscopic analysis and chemical hydrolysis. Biological evaluation showed that both sapinmusaponins Q and R demonstrated more potent anti-platelet aggregation activity than aspirin.

Kadsuphilols A-H, oxygenated lignans from Kadsura philippinensis

Eight new oxygenated lignans, kadsuphilols A-H (1-8), were isolated from the leaves and stems of Kadsura philippinensis. Four of the isolated lignans (1-4) possess the normal C18-dibenzocyclooctadiene skeleton, while the other four lignans (5-8) are C19-homolignans possessing a substituted cyclohexadienone ring with a spiro-benzofuranoid moiety. The structures of the isolated metabolites were elucidated through spectroscopic analyses, including 2D NMR experiments. Compounds 1 and 4 are the first report of an R-biphenyl configuration with a beta-oxygenated substituent at the C-9 position. The in vitro radical-scavenging activities of these compounds using DPPH were tested and evaluated. Compound 3 exhibited more potent activity than vitamins C and E.

Four new nonaoxygenated C18 dibenzocylcooctadiene lignans from Kadsura philippinensis

Four new nona-oxygenated C18 dibenzocyclooctadiene lignans, kadsuphilins C-F (1-4), were isolated from the EtOAc soluble portion of the alcoholic extract of the aerial parts of Kadsura philippinensis. The structures of 1-4 were elucidated on the basis of extensive spectroscopic analyses, including 2D NMR (HMQC, HMBC, and NOESY) experiments, comparison of the spectral data with those of the related metabolites. The stereochemistries of the biphenyl and octadiene moieties were deduced from circular dichorism (CD) and the NOESY spectra, respectively. The in vitro antiplatelet aggregation activity of metabolites 1-4 also have been evaluated.

Isolation of aureol from Smenospongia sp. and cytotoxic activity of some aureol derivatives

The sesquiterpene aureol (1) was isolated by chromatographic fractionation of a non-polar extract from Smenospongia sp. Methylation of aureol yielded 5'-O-methyl-aureol (2) while the prepared acylation products of aureol were 5'-O-acetyl-aureol (3), 5'-O-benzoyl-aureol (4), 5'-O-(4-fluoro-benzoyl)-aureol (5), 5'-O-(4-chlorobenzoyl)-aureol (6), 5'-O-(4-methylbenzoyl)-aureol (7), 5'-O-nicotinoyl-aureol (8), aureol-N,N-dimethylthiocarbamate (9), 5'-O-(2-furoylcarbonyl)-aureol (10), 5'-O-(2-thienoylcarbonyl-aureol (11). The structures of aureol as well as its ten derivatives were established through spectral analysis. The in vitro cytotoxic activities of the eleven compounds were evaluated against Hepa59T/VGH, KB and Hela tumor cell lines.

C18 dibenzocyclooctadiene lignans from Kadsura philippinensis

Four new C18 dibenzocyclooctadiene lignans, kadsuphilins A (1) and B (3), 6-epi-gomisin (2), and 1-demethylkadsuphilin A (4), along with eight known related metabolites, were isolated from an EtOAc fraction of an alcoholic extract of the aerial parts of Kadsura philippinensis growing in Taiwan. The structures of 1-4 were elucidated on the basis of spectroscopic analyses, including 2D NMR (HMQC, HMBC, and NOESY) experiments, and by comparison of their spectroscopic data with those of related metabolites. The configurations of the biphenyl and cyclooctadiene moieties were deduced from circular dichroism (CD) and NOESY NMR spectra, respectively. Some of the compounds showed radical-scavenging activity in a DPPH-HPLC method.

Taiwankadsurins A, B, and C, Three New C19 Homolignans from Kadsura philippinensis

[structures: see text] Three novel C19 homolignans, designated taiwankadsurins A (1), B (2), and C (3), were isolated from the aerial parts of Taiwanese medicinal plant Kadsura philippinensis. The structures of 1-3, which have a 3,4-{1'-[(Z)-2''-methoxy-2''-oxo-ethylidene]}-pentano(2,3-dihydro-benzo[b]furano)-3-(2'''-methoxycarbonyl-2'''-hydroxy-2''',3'-epoxide) skeleton, were determined by spectroscopic analyses, especially 2D NMR techniques (HMBC and NOESY). Compound 2 exhibited mild cytotoxicity against human KB and Hela tumor cells.

Cytotoxic phenylpropanoid glycosides from the stems of Smilax china

Bioassay-guided fractionation of an ethanol extract of Smilax china led to the isolation of nine phenylpropanoids including six new compounds, smilasides A-F (1-6), and three known phenylpropanoids, smiglaside E, heloniosides B, and 2',6'-diacetyl-3,6-diferuloylsucrose. Structural elucidation of isolates 1-6 was based on spectroscopic data analysis. These new phenylpropanoids were evaluated against several human tumor cell lines.

Antihepatitis activity (anti-HBsAg and anti-HBeAg) of C19 homolignans and six novel C18 dibenzocyclooctadiene lignans from Kadsura japonica

Bioassay-directed fractionation of the EtOAc extract of Kadsura japonica has led to the isolation of six new C18 dibenzocyclooctadiene lignans, schizanrins I, J, K, L, M, N, along with four known C19 homolignans, taiwanschirins A, B, C, and heteroclitin F. The elucidations of the new structures were based on spectral analysis. Bioassay evaluation against human type B hepatitis revealed that taiwanschirins A and B showed strong activity for anti-HBsAg and a medium effect for anti-HBeAg at 25 microg/mL (12.9 and 11.9 microM for taiwanschirins A and B, respectively).

DNA topoisomerase I inhibitor, ergosterol peroxide from Penicillium oxalicum

Recently, we found that the MeOH extract of Penicillium oxalicum showed inhibitory activity towards DNA topoisomerase I. Subsequently, ergosterol peroxide, ergosterol, palmitoleic acid, and linoleic acid were isolated from the cultured mycelia of P. oxalicum. The structural determinations were based on physical and spectral analyses. Biological evaluation revealed that ergosterol peroxide inhibited the relaxation of supercoiled DNA (pBR322) induced by DNA topoisomerase I, and also showed marginal, selective cytotoxic activity against human colon tumor cells [COLO-205 (ED50=8.56 microg/mL].

Weekly high-dose 5-fluorouracil (5-FU), leucovorin (LV) and bimonthly cisplatin in patients with advanced gastric cancer

BACKGROUND

A phase II clinical trial was performed to evaluate the activity and toxicity of bimonthly cisplatin and weekly 24-h infusion of high-dose 5-fluorouracil and leucovorin in patients with advanced gastric cancer.

PATIENTS AND METHODS

From September 1997 to March 1998, 23 chemo-naive patients of advanced gastric cancer were enrolled in this study. The regimen consisted of weekly 24-h infusion of 5-FU (2,600 mg/m2) and LV 150 mg and bimonthly cisplatin (25-50 mg/m2) bolus for 12 weeks followed by a 2-week break.

RESULTS

There were 10 male and 13 female patients with a median age of 52 years. A total of 428 chemotherapy treatments were given with a mean of 11. Seventeen patients were evaluable for response. There were 41% (7/17) partial response, 18% (3/17) stable disease and 41% (7/17) progressive disease. The grade III or IV toxicity included anorexia 35% (8/23), fatigue 26% (6/23), vomiting 17% (4/23) and mucositis 9% (2/23). One patient developed perforated duodenal stump after chemotherapy. One patient died of hyperammonemia-related coma. The median times to disease progression and overall survival were 3.5 and 7 months, respectively.

CONCLUSIONS

This regimen showed modest activity against gastric cancer. However, there was no survival advantage and there was greater toxicity than with weekly high-dose 5-FU-LV alone.

Gender discrepancy observed between chemotherapy-induced emesis and hiccups

The aim of this paper was to describe striking gender differences observed between emesis and hiccups in patients receiving cisplatin-based chemotherapy (CT) and one of two dexamethasone-containing anti-emetic regimens. Four hundred patients were evaluated in a crossover study with two arms. Patients in arm A received three doses of ondansetron 8 mg i.v. at 4-h intervals plus dexamethasone 20 mg i.v. from the start of CT, followed by dexamethasone 5 mg i.v. every 12 h, until CT was complete, after which dexamethasone was discontinued. For patients in arm B the treatment was the same as in arm A except that the three doses of ondansetron 8 mg i.v. were given at 24-h intervals. There were 363 patients in arm A and 358 patients in arm B. Vomiting/nausea/hiccups were observed in 30.3%/41.6%/23.7% of patients in arm A and 28.8%/39.1%/23.7% of patients in arm B, respectively. Comparison showed that the rates for complete control of vomiting and nausea on days 1 through 6 were significantly lower in women (P<0.0001 and =0.0004 in arm A and P<0.0001 and <0.0001 in arm B, respectively). Men had a significantly higher incidence of hiccups (P<0.0001 in both arms), but no apparent associations with age, cisplatin dose, tumor type, and the presence of vomiting and nausea during CT were found. Hiccups usually began 24 h after cisplatin administration and persisted for some days. Women had significantly higher rates of vomiting and nausea. The cause of the gender discrepancy is unknown.

Single-agent docetaxel in metastatic breast cancer patients pre-treated with anthracyclines and paclitaxel: partial cross-resistance between paclitaxel and docetaxel

The purpose of this study was a retrospective analysis of docetaxel in a cohort of anthracyclines and paclitaxel pretreated patients with metastatic breast cancer. From July 1998 to June 1999, 24 consecutive patients were included for this study. The regimen consisted of docetaxel 75 mg/m2 in combination with a 3-day schedule of dexamethasone every 3 weeks until disease progression or unacceptable toxicity. The median age of patients was 53 (ranged 32-67) years with a median performance status of 2. Twenty of the 24 patients (84%) had measurable disease. The median number of organs involved was 2 (range 1-4). A total of 146 cycles chemotherapy were given with a mean of 6. There was a 25% (six of 24) overall response rate including one complete response, 37.5% stable disease and 37.5% progressive disease. The major toxicity included grade 3-4 leukopenia (41.7%) and eight episodes of infection. No treatment-related death was observed. The responders included patients refractory to or resistant to prior paclitaxel treatment. The median survival and median time to disease progression was 12 and 9 months, respectively. We conclude that docetaxel has a modest activity in breast cancer patients pre-treated with anthracyclines and paclitaxel, indicating a partial cross-resistance between paclitaxel and docetaxel.

Prevention of acute and delayed cisplatin-induced nausea and vomiting with intravenous ondansetron plus intravenous dexamethasone

BACKGROUND

We conducted a prospective study to evaluate the anti-emetic effect of cisplatin-induced nausea and vomiting with intravenous (i.v.) ondansetron plus i.v. dexamethasone.

METHODS

One hundred forty-six chemotherapy (CT)-naive patients were enrolled in the study. They were scheduled to receive cisplatin 50 to 100 mg/m2 (mean, 53 mg/m2) on day 1 followed immediately by continuous infusion of 5-fluorouracil with or without other CT agents on the subsequent days. Three 8 mg doses of ondansetron i.v. were given at 4-hour intervals plus 20 mg dexamethasone i.v. infusions from the start of CT, followed by 5 mg dexamethasone i.v. every 12 hours, and the administration of dexamethasone was discontinued after the completion of CT.

RESULTS

The rates of complete protection from acute and delayed vomiting/nausea obtained in these patients were 97.3%/93.2% and 71.2%/60.3%, respectively. The rates of complete protection from both acute and delayed nausea were 70.5% and 58.9%, respectively. By comparison, the total control rate of vomiting was less in female patients than in male patients (p = 0.017), and the total control rate of nausea was lower in the age group less than 50 years (p = 0.045). The time from the start of CT to the onset of nausea appeared to be earlier than that for vomiting (log-rank test, p = 0.045). Adverse events tended to be minor, with constipation and hiccups as the most common.

CONCLUSION

These results indicate that i.v. ondansetron plus i.v. dexamethasone is a feasible anti-emetic therapy in an inpatient setting. I.v. ondansetron plus i.v. dexamethasone is highly effective in preventing acute cisplatin-induced nausea and vomiting.

Control of cisplatin-induced emesis with intravenous ondansetron plus intravenous dexamethasone: a crossover study of triple 8-mg dose of ondansetron

Two hundred seventy-five patients were enrolled in one of two arms in a crossover fashion. Arm A: three 8-mg doses of ondansetron intravenous (IV) were given at 4-hour intervals plus dexamethasone 20 mg IV from the start of chemotherapy followed by dexamethasone 5 mg IV every 12 hours. Arm B: as in arm A but with three 8-mg doses of ondansetron IV were given at 24-hour intervals substituted for ondansetron IV given at 4-hour intervals. There were 237 patients in arm A and 223 patients in arm B. Complete protection from acute and delayed vomiting/nausea obtained in arm A was 94.5%/90.3% and 71.3%/57.8%, respectively; protection obtained in arm B was 92.7%/91.0% and 71.7%/60.5%, respectively. No differences were observed in control of acute emesis after the addition of dexamethasone to ondansetron, given as either a triple 8-mg dose at 4-hour intervals or a single 8-mg dose. The triple dose of ondansetron given at 24-hour intervals was also not more effective than ondansetron given at 4-hour intervals in preventing delayed emesis when dexamethasone was added. However, the former improved control of delayed nausea on day 2. Adverse events tended to be minor, with constipation and hiccup the most common.

Tuberculosis presenting with pelvic mass, peritoneal lesions, and elevation of serum CA125 mimicking malignant tumor: a case report

Tuberculosis is a curable infective disease which can mimic a malignant tumor. We report on a young woman who presented with abdominal fullness, body weight loss, and microcytic anemia. A pelvic mass and peritoneal lesions were found. The serum CA125 level was high. The initial gynecologic echo and abdominal CT scan revealed bilateral ovarian mass with peritoneal lesions, and malignancy was highly suspected. Diagnostic laparoscopy was performed, and peritoneal tuberculosis was pathologically proven. Combination anti-tuberculosis therapy was prescribed for one year. She was followed up in the outpatient clinic regularly with symptom improvement, body weigh gain, and improvement of anemia. We suggest that in cases of a pelvic mass and peritoneal lesions, with elevation of the serum CA125 level, tuberculosis should always be kept on the list of differential diagnoses. A tissue diagnosis should always be obtained before treatment, regardless of initial image study and laboratory findings.

New annonaceous acetogenins from Rollinia mucosa

Four new compounds, a mixture of 20,23-cis-2,4-trans-bullatalicinone (1) and 20,23-cis-2,4-cis-bullatalicinone (2), rollimusin (3), and rolliacocin (4), along with eight known acetogenins, were isolated from an ethyl acetate extract of the unripe fruits of Rollinia mucosa. The structures and stereochemistry of 1-4 were determined on the basis of spectral data and chemical evidence.

The effects of two different cisplatin-based chemotherapy regimens on advanced non-small cell lung cancer

BACKGROUND

Many different cisplatin-based regimens have been used on advanced non-small cell lung cancer (NSCLC) in previous studies but there have been few such references in Taiwan. In this study, we evaluated the efficacy and toxicity of two different regimens including 5-Fluorouracil, Leucovorin, Etoposide and cisPlatin (FLEP) and cisPlatin, Etoposide and Mitomycin (PEM) in the treatment of patients with advanced NSCLC.

METHODS

We retrospectively analyzed the records of 44 patients with NSCLC who met the selection criteria from February 1995 through April 1998. All of them were confirmed, using histologic tests, that they were in advanced stages, i.e. stage IIIB or IV. Twenty-two patients received FLEP and 22 patients received PEM.

RESULTS

Three patients with FLEP therapy and 3 patients with PEM therapy had partial response. No patient had complete response. The response rate was 13.6% in both groups, respectively. The median survival was 160 +/- 30 (median + SD) days for patients with FLEP therapy and 263 +/- 104 days for patients with PEM therapy. The factors that were associated with longer survival in all patients included response (Stable Disease vs Disease Progression p = 0.004, Partial Response vs Disease Progression p = 0.047) and regimen of chemotherapy (PEM vs FLEP p = 0.008). The major clinically significant toxicity was myelosupression.

CONCLUSION

The responses to regimens, FLEP and PEM, were low in our study groups that might be due to the low dose of cisplatin and etoposide in our regimens. The patients with response to chemotherapy and PEM therapy had longer median survival than those who underwent FLEP therapy.

Successful surgical treatment of solitary adrenal metastases from non-small cell lung cancer: case report

Lung cancer is one of the most common types of maligancies and has been one of the leading causes death due to cancer for a long time. Although surgery is the treatment of choice for patients with non-N2 localized disease, most of the lung cancer patients are found to have metastatic lesions at the same time as initial diagnosis. The median survival of patients with metastatic lung cancer is less than one year even when systemic chemotherapy is given. We present a patient with non-small cell lung cancer with no initial evidence of metastasis. He underwent curative resection of the primary tumor followed by local radiotherapy. Adrenal gland metastasis was found fours years after the first surgery. After surgical resection of this metastatic lesion, followed by adjuvant chemotherapy, this patient's survival was prolonged with no evidence of disease recurrence until now. The prolonged survival of this patient may be due to a slow rate of progression of the primary tumor.

Gastric adenocarcinoma with tonsil and submaxillary gland metastases: case report

Local invasion, hematogenous and lymphatic metastases are the major modes of spreading gastric cancer. The most common sites of metastases in patients with gastric cancer are liver, peritoneum, omentum, lungs and mesentery. Of the two pathological types of gastric cancer, intestinal-type gastric cancer showed preferential metastasis to the liver, whereas the diffuse-type showed a preference for peritoneal involvement and lymph node metastasis. However, metastases of gastric cancer to the head and neck regions are not common. The hematogenous route appears to account for a great majority of metastases to the head and neck regions. Malignant neoplasm metastases to major salivary glands or tonsils are not common. Several patients with cancers from the infraclavicular area have been reported with parotid gland or tonsil metastases. However, metastasis of gastric adenocarcinoma to the tonsils or submandibular glands is rare. We present a patient with recurrent gastric adenocarcinoma with both tonsil and submandibular gland metastases which is even rarer.

Risk of transient hyperammonemic encephalopathy in cancer patients who received continuous infusion of 5-fluorouracil with the complication of dehydration and infection

From 1986 to 1998, 29 cancer patients who had 32 episodes of transient hyperammonemic encephalopathy related to continuous infusion of 5-fluorouracil (5-FU) were identified. None of the patients had decompensated liver disease. Onset of hyperammonemic encephalopathy varied from 0.5 to 5 days (mean: 2.6 +/- 1.3 days) after the initiation of chemotherapy. Plasma ammonium level ranged from 248 to 2387 microg% (mean: 626 +/- 431 microg%). Among the 32 episodes, 26 (81%) had various degrees of azotemia, 18 (56%) occurred during bacterial infections and 14 (44%) without infection occurred during periods of dehydration. Higher plasma ammonium levels and more rapid onset of hyperammonemia were seen in 18 patients with bacterial infections (p=0.003 and 0.0006, respectively) and in nine patients receiving high daily doses (2600 or 1800 mg/m2) of 5-FU (p=0.0001 and < 0.0001, respectively). In 25 out of 32 episodes (78%), plasma ammonium levels and mental status returned to normal within 2 days after adequate management. In conclusion, hyperammonemic encephalopathy can occur in patients receiving continuous infusion of 5-FU. Azotemia, body fluid insufficiency and bacterial infections were frequently found in these patients. It is therefore important to recognize this condition in patients receiving continuous infusion of 5-FU.

Tumor fever in patients with nasopharyngeal carcinoma: clinical experience of 67 patients

From 1982 through 1996, 67 patients with nasopharyngeal carcinoma (NPC) proven to have tumor fever (TF) were analyzed. All were in metastatic stage when TF occurred. Forty-five patients (67%) had recurrent disease. Thirty-eight (57%) had fever before metastatic lesions were detected. The metastatic sites were: 84% in bone, 69% in liver, and 19% in lung. Multiple-organ metastases were found in 64% of the patients. Nine patients (13%) had bone-marrow invasion. When TF was present, 22 (33%) patients had other paraneoplastic syndromes, of which leukemoid reaction (LR) was seen most frequently. After the initiation of naproxen or indomethacin, most patients had complete lysis of the fever within 48 hours. Of the six patients receiving chemotherapy as the initial therapy, all of their temperatures returned to normal range after the treatment. Some patients, particularly those with tumor progression, developed TF again when antipyretic drugs were discontinued. The median survival time was 5 months. In conclusion, TF in NPC is usually a manifestation of metastatic disease. Tumor fever often associates with other paraneoplastic syndromes. Naproxen, indomethacin, and systemic chemotherapy all had effectiveness in ameliorating TF. Systemic metastases should be suspected in NPC patients with fever of unknown origin.

Gastric cancer with obstructive uropathy: clinical experience with 17 cases

BACKGROUND

Gastric cancer can spread to either the paraaortic area or pelvis causing ureteral obstruction.

METHOD

Between 1984 and 1996, 17 patients with gastric cancer were proven to have obstructive uropathy (OU). Of these, 12 (70%) had poorly differentiated adenocarcinomas.

RESULTS

The obstructed levels were at the proximal ureter (7 cases), distal ureter (7 cases), and at multiple sites in the ureter (3 cases). The mucosa of the ureter tended to be spared. In 3 cases, OU was the initial presentation. Peritoneal carcinomatosis was noted in all cases. Most cases demonstrated obvious paraaortic lymph node and/or pelvic metastases. Management of ureteral obstruction included percutaneous nephrostomy (PCN) in 8 cases, and cystoscopic placement of a ureteral stent in 9 cases with double-J stents used in 8. Insertion of the double-J stent failed in 1 case initially. Four cases using double-J stents resulted in occlusion within 1 month, of which 3 subsequently were successfully changed to PCN.

CONCLUSION

Gastric cancer with OU can obstruct the ureter at any level. Double-J stents exhibited a high failure rate in these patients necessitating a switch to PCN. We could also choose PCN as the initial procedure to preserve renal function.

Concurrent 5-fluorouracil, leucovorin, etoposide, cisplatin and radiotherapy for locally advanced non-small cell lung cancer

BACKGROUND

The prognosis of Stage III unresectable non-small cell lung cancer may be improved by concurrent chemoradiotherapy. In this study, we attempted to evaluate the feasibility, tolerance, efficacy and toxicities of the combination of thoracic radiation and chemotherapy with a novel regimen that included 5-fluorouracil, leucovorin, etoposide and cisplatin (the FLEP regimen) in the treatment of this group of patients.

PATIENTS AND METHODS

From July 1995 to September 1996, 20 untreated patients with locally advanced non-small cell lung cancer were enrolled in the study. Radiation at a dose of 44 Gy was initially delivered in daily fractions of 2 Gy 5 days a week to the tumor and mediastinum, followed by a boost to the tumor (20 to 26 Gy according to patients tolerance). Concurrently with thoracic irradiation, patients were treated with chemotherapy consisting of cisplatin at the dose of 60 mg/m2/d for 1 day, etoposide at the dose of 60 mg/m2/d for 2 days, and 5-FU 500 mg/m2/d plus leucovorin 50 mg/d infusion for 48 hours. Cycles of chemotherapy were repeated every 3 weeks for a maximum of 3 cycles.

RESULTS

Seventeen of 20 patients were assessable. The overall response rate was 70.6% (95% confidence interval = 49-92%). No complete response was achieved. The median response duration for all responding patients is not yet estimable, with a range of 3.5 to 15.5+ months. Eleven patients remain progression-free for 4 to 15 months. The median survival for the entire group is not estimable. The major toxicity was esophagitis. Other grade 3 or 4 toxicities were not frequently observed.

CONCLUSION

Combined-modality therapy with FLEP regimen and radiation is a promising treatment with a high response rate and acceptable toxicity for locally advanced non-small cell lung cancer.

Enteric intussusception due to metastatic intestinal tumors

Enteroenteric intussusception caused by metastatic tumors is a very rare condition. Because of its rarity and rather mild abdominal physical presentation, preoperative diagnosis is not easily made. Two cases of enteric intussusception due to metastatic intestinal tumors, with the main symptom of melena, are reported. Intussusception was caused by metastatic liposarcoma in one patient and metastatic melanoma in the other. Both patients had long histories of malignant disease, for 15 and 8 years, respectively. They had undergone repeated surgical treatment for metastatic lesions. The diagnosis of enteric intussusception was initially made by computed tomographic scans and small bowel series and was confirmed by laparotomy and pathologic findings. We suggest that tumor metastasis to the small intestine with intussusception should be considered in patients with recurrent tumors and tarry stools.

Serum lactate dehydrogenase level in patients with nasopharyngeal carcinoma

Serum lactic dehydrogenase (LDH) levels of 465 patients with nasopharyngeal carcinoma (NPC) were assayed retrospectively. Four cohorts were selected in order to investigate the enzymes: 1) stage IV disease (118 cases) with pretreatment measurement, 2) relapse cases (159 cases) with pretreatment measurements, 3) no evidence of disease (217 cases) with spotting or serial measurements, and 4) monitoring of response to cytotoxic chemotherapy (34 cases). Higher serum LDH levels and more cases with elevated values were found in metastatic disease, especially relapse cases with liver and/or multiple organ site metastases. Serum LDH levels in locoregional disease were rarely found to be greater than two times the normal level. The value of serial serum LDH measurement for detecting disease relapse in the follow-up of patients with NPC is limited. Twelve percent of cases with no evidence of disease demonstrated elevation in serum levels. Serum LDH levels were found to correlate with the clinical responsiveness to systemic chemotherapy. Cases with normal serum LDH before treatment had a better chance of survival than those with elevated levels (median: 53 vs. 10 months, p = 0.008).

Correlation between computed tomographic density of lymph node metastases and response to cisplatin-based chemotherapy in patients with head and neck squamous cell carcinoma in an area in which betel quid chewing is prevalent

BACKGROUND

Identifying the factors predicting response to chemotherapy is important for patients with head and neck squamous cell carcinoma (HNSCC). It allows more rational selection of subsets of patients who may benefit from multidisciplinary treatment. Correlation of lymph node density in contrast-enhanced computed tomographic (CT) scans of HNSCC with response to chemotherapy was observed in the recent literature. This prospective study was designed to validate this clinical issue.

METHODS

From January 1992 to March 1995, 71 patients with untreated HNSCC were included in this study in which the following criteria were met: 1) a lymph node > 3 cm by physical examination or > or = 2 cm by scanographic examination; 2) clinically evaluable disease treated by cisplatin-based neoadjuvant chemotherapy; and 3) availability of a pretherapeutic contrast-enhanced CT scan showing the cross-sections of relevant lymph node metastases. The density of the largest lymph node was compared with that of the nuchal muscles by a radiologist blinded to the patient's therapeutic outcome. A lymph node was classified as hypodense if more than 33% of the lymph node surface area was comprised of a hypodense zone, and isodense if less than a third of the lymph node surface area was comprised of a hypodense zone.

RESULTS

Fifty-one patients (72%) had the largest lymph node classified as hypodense, and 63 patients (89%) were found to have extranodal spread (ENS) in the relevant lymph nodes. Fifty-nine patients were betel quid chewers. Lymph node density was not related to T classification, primary site, or histologic differentiation of the primary tumor. There was also no correlation between lymph node density and lymph node N classification. The lymph node chemotherapy response rate was 35% (7 of 20) of the isodense group and 47.1% (24 of 51) of the hypodense group (P = 0.36). ENS was found to have no impact on the chemotherapy response.

CONCLUSIONS

Computed tomographic density of lymph node metastases did predict chemotherapy response in the HNSCC patients in the current study from an area in which betel quid chewing is prevalent.

Prognostic factors of locoregionally recurrent nasopharyngeal carcinoma--a retrospective review of 182 cases

Locoregional relapse is the major cause of failure of nasopharyngeal carcinoma (NPC) after radical radiation therapy. The prognosis of such patients is dismal, and the factors related to the outcome are not well identified. Between January 1983 and December 1989, 1,168 new patients with biopsy-proven NPC were seen at this hospital. Eight hundred and eighty-three of these patients were treated uniformly with radical external irradiation and intracavitary treatment with or without chemotherapy. The clinical courses, retreatment outcomes, and prognostic factors for locoregional relapse and subsequent distant metastasis were analyzed. During the follow-up period of 3-10 years or until death, 182 patients (20.6%) developed locoregional relapses without distant metastasis initially. T stage and age were significant prognostic factors for locoregional recurrence. In contrast, histopathologic subtype, N stage, sex, and systemic chemotherapy were not. There were 36 patients (19.8%) who developed subsequent distant metastasis with or without retreatment. The median time from locoregional relapses to distant metastasis was 6 months in this study, and bone was the most frequent and the earliest site of distant metastasis. The N stage at diagnosis, the initial disease-free interval, the presence of neck nodal disease at relapse, and age were the significant factors for predicting the subsequent distant metastasis in locoregionally recurrent NPC patients. We recommend that additional systemic chemotherapy should be considered for retreatment of locoregional relapsed NPC, not only for enhancement of local control but also for eradicating microscopic metastasis as anticipated.

Tumor-associated hypereosinophilia: report of four cases

Hypereosinophilia is a rare manifestation of cancer. We reported four cases of tumor-associated hypereosinophilia. These cases presented with peripheral hypereosinophilia and disseminated metastatic malignancies. All cases were male, including two cases with cancer of unknown primary site, one with hepatocellular carcinoma, and one with a liver tumor. The age ranged from 27 to 55 years. They all had liver involvement. Two cases had bone marrow metastases. The leukocyte counts ranged from 78,600/microliters to 190,000/microliters. The percentage of eosinophils ranged from 20% to 77%. The eosinophil counts ranged from 15,720 to 126,350/microliters with a mean of 74,700/microliters. The first three cases died within 8 days after the malignancies were pathologically confirmed. We suggest that peripheral hypereosinophilia is a poor prognostic sign which is frequently associated with disseminated cancer.

Osteosarcoma of jaw: the experience of Chang Gung Memorial Hospital

Seven cases with Osteosarcoma (OS) of the jaw were retrospectively reviewed. There were five female and two male patients. Their ages ranged from 14 to 57 years with a mean of 39 years. Seventy-one percent of the patients were older than 30 years old. Jaw swellings were the most frequent complaints occurring on an average of 3 months before diagnosis. Four cases occurred in mandible and three cases developed from maxilla. Most cases were lytic lesions on roentgenography. Four were osteoblastic, 2 were chondroblastic, and 1 was histologic classification. Six of the 7 cases received surgery. Postoperatively, 3 of them received both radiotherapy and chemotherapy, 1 received chemotherapy only and 1 received radiotherapy only. One case received palliative chemotherapy only because of the locally far advanced disease. Four cases died of regional failure without any metastatic lesions (survival ranged from 5 months to 22 months). Two cases survived more than 4 years without any recurrence. The median survival time was 22 months. We concluded that OS of the jaw has different natural courses from OS of the long bones and the regional failure seems to be the main problem in jaw OS.

Cisplatin and 5-fluorouracil as neoadjuvant chemotherapy: predicting response in head and neck squamous cell cancer

In order to prospectively evaluate the efficacy, toxicity and predictive factors of response to neoadjuvant chemotherapy, a total of 120 patients with head and neck squamous cell cancer diagnosed from January 1992 to November 1993 were enrolled in this study. There were 118 male and 2 female patients, with a median age of 51 years (range 30-74 years). The primary sites were the oral cavity (77), oropharynx (15), hypopharynx (25) and larynx (3). Betel quid chewing was habitual in 91% of patients. All patients were previously untreated, and 94% had stage III or IV disease. Chemotherapy was given in two or three courses to 96 patients who were then assessed for response rate and predictive factors. The chemotherapy regimen consisted of cisplatin 100 mg/m2/day on day 1 and 5-fluorouracil (5-FU) 1 g/m2/day intravenous infusion continuously for 4 to 5 days for 4 weeks. The overall chemotherapy response rate was 56%, with a 3% complete response. By univariate analysis, both the T-stage and tumor volume were significant for predicting the response of the primary site. The age, histologic differentiation, tumor location and N-stage were unpredictive for response. The nodal response (43%) was less than that of the primary site (68%). By multivariate analysis, only the tumor volume (> or = 50 cm3) and the presence of nodal metastases were predictive for the combined TN response. Based on the World Health Organization toxicity criteria, 49 patients experienced grade 3 to 4 mucositis, and 24 patients had grade 3 to 4 vomiting.(ABSTRACT TRUNCATED AT 250 WORDS)

Transient neurological disturbances induced by the chemotherapy of high-dose methotrexate for osteogenic sarcoma

Temporary neurologic abnormalities were observed in one out of 23 patients undergoing chemotherapy with high-dose methotrexate (HD-MTX) for osteogenic sarcoma. This patient developed sequential symptoms including alternative hemiparesis, dysarthria and altered consciousness 5 days after the second course of HD-MTX (8 gm/m2 by 6 h continuous infusion) with leucovorin rescue. Laboratory evaluations disclosed normal electrolytes, hemograms and non-toxic serum MTX levels at the onset of the symptoms. Computed tomography of the brain was normal but electroencephalography showed focal theta and delta slow waves over the right temporal-parietal-occipital area. The neurological symptoms resolved completely within 72 h.

Nasopharyngeal carcinoma with brain metastasis: a case report

We report a case of nasopharyngeal carcinoma with brain metastasis of a 69-year-old man. The patient presented with blindness and a huge mass over right upper neck. The magnetic resonance imaging (MRI) showed right nasopharyngeal tumor and metastatic lesion in bilateral occipital regions. The bony x-ray showed diffuse osteoblastic metastases. The brain lesion was pathology-proven through the computed-tomographic guidance stereotactic biopsy.

Spontaneous gastroduodenal perforation in patients with cancer receiving chemotherapy and steroids. Report of four cases combining 5-fluorouracil infusion and cisplatin with antiemetics dexamethasone

BACKGROUND

Spontaneous gastroduodenal perforation is an uncommon but life-threatening complication of systemic chemotherapy and/or steroids. Here, the authors reported four cases of gastroduodenal perforation following combined chemotherapy with steroids.

METHODS

The chemotherapeutic regimens all included 5-fluorouracil (5-FU) by continuous infusion and cisplatin. The authors used dexamethasone as an antiemetic. All patients took analgesics for pain relief. No patient had a history of peptic ulcer disease.

RESULTS

Severe epigastralgia occurred 3-5 days after the start of chemotherapy. The peptic ulcer perforations were diagnosed within 3 days of onset of symptoms. All patients had an emergency laparotomy. Three of the perforations were located in the duodenum and one was located in the stomach. Pathologic examination of one patient revealed a chronic peptic ulcer. Two patients with preoperative shock died in the postoperative period.

CONCLUSIONS

The cause of spontaneous gastroduodenal perforation is not known, but the etiology can be complex. Either 5-FU or steroids can induce the perforation. An asymptomatic peptic ulcer may be aggravated by 5-FU, cisplatin, or dexamethasone. The authors suggest that patients receiving 5-FU infusion and cisplatin with dexamethasone for antiemesis who complain of epigastric pain should be mentioned for a gastroduodenal ulcer or even a perforation.

Spontaneous gastroduodenal perforation in patients with cancer receiving chemotherapy and steroids. Report of four cases combining 5-fluorouracil infusion and cisplatin with antiemetics dexamethasone

BACKGROUND

Spontaneous gastroduodenal perforation is an uncommon but life-threatening complication of systemic chemotherapy and/or steroids. Here, the authors reported four cases of gastroduodenal perforation following combined chemotherapy with steroids.

METHODS

The chemotherapeutic regimens all included 5-fluorouracil (5-FU) by continuous infusion and cisplatin. The authors used dexamethasone as an antiemetic. All patients took analgesics for pain relief. No patient had a history of peptic ulcer disease.

RESULTS

Severe epigastralgia occurred 3-5 days after the start of chemotherapy. The peptic ulcer perforations were diagnosed within 3 days of onset of symptoms. All patients had an emergency laparotomy. Three of the perforations were located in the duodenum and one was located in the stomach. Pathologic examination of one patient revealed a chronic peptic ulcer. Two patients with preoperative shock died in the postoperative period.

CONCLUSIONS

The cause of spontaneous gastroduodenal perforation is not known, but the etiology can be complex. Either 5-FU or steroids can induce the perforation. An asymptomatic peptic ulcer may be aggravated by 5-FU, cisplatin, or dexamethasone. The authors suggest that patients receiving 5-FU infusion and cisplatin with dexamethasone for antiemesis who complain of epigastric pain should be mentioned for a gastroduodenal ulcer or even a perforation.

Transient hyperammonemia related to chemotherapy with continuous infusion of high-dose 5-fluorouracil

Hyperammonemic encephalopathy has been reported in patients receiving chemotherapy (CT). It is characterized by abrupt alteration in mental status with markedly elevated plasma ammonium levels in the absence of obvious liver disease. This paper reports seven patients who developed transient hyperammonemia during chemotherapy. The regimens all included continuous infusion of high-dose 5-fluorouracil (5-FU). The onset of hyperammonemic encephalopathy was 1.5-4 days after the start of CT. Five cases had infection and six had prerenal azotemia at the time of hyperammonemia. After management, plasma ammonium levels all returned to the normal range within 2 days. Except for one persistent coma, status of consciousness cleared completely. The true mechanism of transient hyperammonemia is unclear. The excess production of ammonium due to metabolites of 5-FU added to precipitating factors such as infection, hypovolemia or constipation may be the explanation for transient hyperammonemia in our study.

Prognosis of thymic carcinoma: analysis of 16 cases

Primary thymic carcinoma is a rare malignant neoplasm which arises from the thymic epithelium. Between May 1982 and September 1990, 16 patients with thymic carcinomas, diagnosed at Chang Gung Memorial Hospital, were reviewed. Their ages ranged from 19 to 75 years, with a median of 40 years. Males predominated (male to female ratio was 11:5). The most common presenting symptoms were chest pain, cough, body weight loss and dyspnea. No paraneoplastic syndromes were seen. Chest roentgenograms of 15 patients revealed a mediastinal mass, but a definitive diagnosis could not be made until surgery. Adjacent mediastinal tissues were invaded, or adhered to, by all the tumors. Six distinct histologic types were found, squamous cell carcinoma being the most common (seven cases). The primary treatment of surgical resection was attempted in 14 patients, but only in five cases could the tumors be completely resected; two had a biopsy only. Radiotherapy, with or without chemotherapy, given postoperatively, achieved additional local control in seven of the nine partially resected patients (77%). Distant metastasis occurred in nine of 16 patients (56%). Lymph nodes, bone and lung were the most common metastatic sites. Chemotherapy with cisplatin and/or adriamycin-based regimens was given to patients who had distant metastasis, but the responses were unsatisfactory. The overall survival at one, three and five years was 88%, 51% and 31%, respectively. The median survival was 30 months. The median survival of patients with pure squamous cell carcinoma (> 49 months) was superior to that of patients with other histologic types (18 months; p < 0.01).

Meningeal carcinomatosis from solid tumors: clinical analysis of 42 cases

From January 1984 to June 1990, we observed 42 patients with meningeal carcinomatosis, 20 men and 22 women, aged 21 to 80 years (median age, 53 years). The two most common primary malignancies were lung cancer (50%) and breast cancer (31%). Sixty-four per cent was adenocarcinoma. On the first lumbar puncture, 86% had malignant cells in the cerebrospinal fluid. The findings of brain computed tomography were hydrocephalus (62%), contrast enhancement in the cerebral sulci or basal cisterns (31%), concomitant parenchymal metastases (15%) and normal scan (18%). In five out of seven cases, myelography showed irregular filling defects over the spinal cord or cauda equina. Treatment results were evaluated in 24 patients. Eight received radiation therapy (RT) alone, and 16 had combined therapy with RT plus intrathecal methotrexate (IT MTX). Of the patients who received RT alone, only one patient with lung carcinoma was stabilized clinically. Of the cases receiving combined therapy, seven improved clinically. Six of these were patients with breast carcinoma who received IT MTX via Ommaya reservoir. The latter had a median survival of 23 weeks. The follow-up period of the entire group of patients ranged from one day to 50 weeks. The median survival was four weeks. Based on this study, combined therapy with RT and IT MTX is indicated for breast carcinoma with meningeal carcinomatosis, but the therapeutic effects are uncertain for lung carcinoma and other malignancies.

Prognostic factors of nasopharyngeal carcinoma: a multivariate analysis

Between 1979 and 1985, 561 patients with nasopharyngeal carcinoma were reviewed to determine prognostic factors that may influence survival. Sex (p = 0.294) and histopathology (p = 0.677) had no correlation to the actuarial survival, whereas the site of cervical metastasis (p = 0.001) and the radiation doses to the nasopharynx and regional lymph nodes (p = 0.03) were both significant when one used univariate analyses. Cox's multivariate regression model revealed that the presence rather than the site of distant metastases was the single most important independent factor influencing the treatment outcome (p less than 0.0001). The addition of chemotherapy, on the other hand, did not show a survival benefit even when one took available confounding factors into account. There are, however, survival advantages associated with: (a) young age (less than or equal to 40 years), (b) asymptomatic status, (c) Stage I or II lesions, and (d) biopsy via nasopharynx instead of neck nodes. These favorable prognostic factors may be used for therapeutic guidance and end-result reporting.

[Leiomyosarcoma associated hypoglycemia--report of two cases]

We report 2 cases of leiomyosarcoma associated hypoglycemia. Case 1 had had a tumor over his left thigh area for 13 years and a few episodes of hypoglycemia occurred when the tumor grew rather large (10 cm x 10 cm x 6 cm). Abdominal sonogram showed metastatic masses in the left lobe of liver. Hypoglycemia syndrome improved after chemotherapy, but relapse was noted later. Another case suffered from progressive abdominal distension for about one year and a huge mass (19 cm x 15 cm x 12 cm) over small intestine was found. Although surgical resection of the tumor and adjuvant chemotherapy was performed, recurrence of the tumor with hypoglycemia was noted. Both of the cases produced hypoglycemia in a fasting state rather than postprandial hypoglycemia. Hypoglycemia associated with non-islet cell tumor is one of the endocrinologic paraneoplastic Syndromes. The most common tumor found in this syndrome is sarcoma and such tumors are usually large when hypoglycemia is noted. Treatment of paraneoplastic hypoglycemia initially requires glucose infusion for acute symptomatic relief, then treatment of the underlying tumor. Reduction of tumor, radiotherapy or chemotherapy can improve the hypoglycemia syndrome, but it readily relapses.

Hepatocellular carcinoma presenting as bone metastasis

In a consecutive series of 395 patients with pathologically verified hepatocellular carcinoma, 20 patients (5%) had bone metastasis at initial presentation. Of these, 16 were men and four women ranging from 26 to 64 years of age (median, 50 years). The age, sex, hepatitis B surface antigen seropositivity, alpha-fetoprotein level, and frequency of associated cirrhosis were not statistically different from those in patients without initial bone metastasis. Initial presentation was usually the result of spinal lesion with neurologic compression, and chest wall or scalp mass. Metastasis most commonly involved spine and ribs, and occurred as osteolytic lesions or extrapleural mass. Computed tomography proved best for demonstrating an expansile soft tissue mass with bony destruction. Angiography showed hypervascular appearance over the destructive bone area. Treatment results were poor. The follow-up period ranged from 3 weeks to 14 months with a median survival of 5 months. The data suggested that hepatocellular carcinoma be ruled out in patients with osteolytic lesions.