Design of a prognostic index score for metastatic nasopharyngeal carcinoma

The survival outcome of patients with systemic cancer differs significantly between individuals even within the same tumour type. We set out to illustrate this by analysing the factors determining survival in patients with metastatic disease from nasopharyngeal carcinoma (NPC) and to design a scoring system based on these prognostic factors. Patients referred between January 1994 and December 1999 were retrospectively analysed. Factors analysed included patient (age group, gender, performance status (BS) at diagnosis of metastases), disease (number of metastatic sites, specific metastatic sites, disease-free interval (DFI), metastases at presentation, presence of locoregional recurrence), and laboratory factors (leucocyte count, haemoglobin level, albumin level). Univariate and multivariable analyses were performed using the Cox proportion hazards model. A numerical score was derived from the regression coefficients of each independent prognostic variable. The prognostic index score (PIS) of each patient was calculated by totalling up the scores of each independent variable. Independently significant, negative prognostic factors were liver metastasis, lung metastasis, anaemia, poor PS, distant metastasis at initial diagnosis, and a DFI of <6 months. Three prognostic groups based on the PIS were obtained: (i) good risk (PIS=0-6); (ii) intermediate risk (7-10); (iii) poor risk (>or=11). The median survivals for these groups were 19.5, 10, and 5.8, months, respectively, (log rank test: P<0.0001). The variable prognosis of patients with disseminated NPC can be assessed by using easily available clinical information (patient, disease and laboratory factors). The PIS system will need to be validated on prospectively collected data of another cohort of patients.

A multicenter phase II study of the efficacy and safety of docetaxel plus cisplatin in Asian chemonaïve patients with metastatic or locally advanced non-small cell lung cancer

AIMS

To evaluate the efficacy and safety of docetaxel-cisplatin in patients with metastatic or locally advanced non-small cell lung cancer (NSCLC).

METHODS

Chemotherapy-naïve patients with histologically confirmed TNM stage III or IV NSCLC were recruited from 12 Asian trial centers. Patients received docetaxel (75 mg/m2) and cisplatin (75 mg/m2) every 3 weeks for 6 cycles.

RESULTS

130 of 146 patients were evaluable for efficacy (60% stage IV). Three complete and 58 partial responses were observed (overall response rate: 46.9%; 95% CI: 38.3-55.5%). Median time to progression was 6.9 months and median survival was 14.0 months; 1-year survival was 59.5%. Grade 3/4 neutropenia, thrombocytopenia and anemia occurred in 69.2%, 6.2% and 18.5% of patients, respectively. Grade 3/4 vomiting was observed in 13.7% and grade 3/4 neurosensory effects were observed in 2.7% of patients. There was one case of treatment-related death due to sepsis.

CONCLUSION

Docetaxel-cisplatin is an effective and well-tolerated treatment in Asian patients with NSCLC.

Measuring quality of life in Chinese cancer patients: a new version of the Functional Living Index for Cancer (Chinese)

INTRODUCTION

Since its translation into Chinese, the Functional Living Index for Cancer (FLIC) has not been widely received due to some of its difficulties. We modified its visual analogue scale (VAS) to an ordered categorical scale and changed some of the wording in the instrument. This study examined the measurement properties of the modified FLIC.

MATERIALS AND METHODS

The modified version of FLIC and the Functional Assessment of Cancer Therapy (FACT-G Chinese version 4) were filled in by 140 patients recruited from the National Cancer Centre Singapore. The patients' FLIC scores were compared with their clinical characteristics to establish known-group validity. Convergent and divergent validity of FLIC were examined by correlation analysis with FACT-G and its sub-scales. Cronbach's alpha and relative efficiency were also examined.

RESULTS

FLIC and most of its sub-scales could indicate a clear and statistically significant difference of quality of life (QOL) according to patients' performance status and treatment status. FLIC strongly correlated with FACT-G. The Physical, Psychological, and Symptoms sub-scales of FLIC converged to and diverged from FACT-G sub-scales as conceptually expected. Cronbach's alpha indicated a satisfactory level of reliability. FLIC appeared to be more efficient than FACT-G, meaning that a smaller sample size will be required for FLIC than for FACT-G to achieve the same research purpose.

CONCLUSIONS

The modified version of FLIC was found to have achieved satisfactory measurement properties. This is a user-friendly alternative to the original FLIC.

GLOB-1: a prospective randomised clinical phase III trial comparing vinorelbine-cisplatin with vinorelbine-ifosfamide-cisplatin in metastatic non-small-cell lung cancer patients

BACKGROUND

The standard doublet, vinorelbine-cisplatin, was compared with a triplet of vinorelbine-ifosfamide-cisplatin, in terms of survival, in patients with advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

From February 1998 to June 1999, 259 chemonaïve patients entered the study and were randomised to receive either vinorelbine-cisplatin (NP; vinorelbine 30 mg/m(2) on days 1, 8 and 15 with cisplatin 80 mg/m(2) on day 1) or vinorelbine-ifosfamide-cisplatin (NIP; vinorelbine 25 mg/m(2) on days 1 and 8, ifosfamide 3 g/m(2) on day 1 and cisplatin 75 mg/m(2) on day 1), with both regimens being repeated every 3 weeks. All patients had stage IV or relapsed disease and a performance score of 0 or 1.

RESULTS

The overall response rate was 34.6% for NP and 35.7% for NIP. Median and 1-year survival rates were 10.0 months and 38.4% for NP, and 8.2 months and 33.7% for NIP, respectively. A median of four cycles was administered in each arm. The major World Health Organization grade 3-4 toxicities for NP and NIP, respectively, were: neutropenia (20.3% compared with 9% of cycles), anaemia (4.1% compared with 5% of cycles), nausea and vomiting (22.2% compared with 19.4% of patients) and alopecia (5.6% compared with 29.8% of patients). Four toxic deaths occurred in the NP arm and eight in the NIP arm.

CONCLUSIONS

The different schedules of vinorelbine in the two arms led to a greater survival in the NP arm without impairing the tolerance profile, although this is not statistically significant. This confirms that the two-drug combination NP is a reference treatment for metastatic NSCLC. The role of three-drug combinations remains questionable in this subset of patients.

Gastric carcinoma presenting with cellulitis-like cutaneous metastasis

INTRODUCTION

A case of carcinoma of the stomach presenting with cellulitis-like cutaneous metastasis is reported.

CLINICAL PICTURE

This patient was diagnosed to have early stage carcinoma of the prostate (T1bN0M0), which was treated with radiotherapy and hormonal therapy. He presented with an erythematous area of induration over the right neck a few weeks after the completion of radical radiotherapy. The CT scan of the neck showed features suggestive of cellulitis of the right cervical region. Due to the lack of response to intravenous antibiotics, a fine needle aspiration biopsy of the indurated area was done. This confirmed the presence of adenocarcinoma. Due to the presence of iron-deficiency anaemia and the positive occult blood test in the stool, an upper gastrointestinal endoscopy was done. This confirmed the presence of adenocarcinoma of the stomach of the signet-ring cell type.

OUTCOME

He had a rapid downhill course after the diagnosis and died four weeks after the diagnosis was made.

CONCLUSION

Carcinoma of the stomach can rarely present with cutaneous metastasis as a cellulitis-like picture.

Gemcitabine in metastatic nasopharyngeal carcinoma of the undifferentiated type

BACKGROUND

We conducted two parallel phase II trials in chemonaïve and previously treated patients with metastatic nasopharyngeal carcinoma (NPC) to evaluate the tumour response, progression-free and overall survival, and toxicity of gemcitabine.

PATIENTS AND METHODS

Gemcitabine 1250 mg/m2 was given on days 1 and 8 of a 21-day cycle. Patients with an Eastern Cooperative Oncology Group performance status <2, adequate renal, hepatic and bone marrow function, and radiologically measurable NPC were eligible.

RESULTS

Twenty-five chemonaïve and 27 previously treated patients were enrolled. The overall response rate was 28% [95% confidence interval (CI) 14% to 48%] for the chemonaïve and 48% (95% CI 31% to 66%) for previously treated patients. Toxicities greater than or equal to grade 3 occurred in 15 (60%) chemonaïve and 13 (48%) previously treated patients. Neutropenia was uncommon in chemonaïve patients, but occurred in 37% of previously treated patients. The median time to progression was 3.6 months (range 0.9-7.9) for chemonaïve and 5.1 months (0.9-13.1) for previously treated patients. Median overall survival time was 7.2 months (1.4-15.6) and 10.5 months (2.4-15.0) for chemonaïve and previously treated patients, respectively.

CONCLUSIONS

Gemcitabine has moderate activity in NPC with minimal toxicity, and is also an effective salvage agent for patients who have failed or progressed after treatment with other agents.

Primary intrathoracic malignant effusion: a descriptive study

BACKGROUND

Patients who present with malignant pleural/malignant effusion without a definite primary site are not well described in the medical literature. In the course of our clinical practice, we have observed certain traits that are peculiar to patients with such a presentation. We have applied the term primary intrathoracic malignant effusion (PIME) to describe this condition.

STUDY OBJECTIVES

Patients must fulfill the following criteria before a diagnosis of PIME can be made: clinical presentation dominated by pleural/pericardial effusion; histologic proof of malignancy obtained from the pleura and/or pericardium; no definite primary site in the lungs or elsewhere from CT scan of the chest, chest radiograph, or physical and endoscopic examination; no history of malignancy; and no history of asbestos exposure. Exposure to environmental tobacco smoke (ETS) among the nonsmokers was examined in a case-control setting.

METHODS

We conducted a retrospective search of our database of patients who were referred to the Department of Medical Oncology with a diagnosis of pleural/pericardial effusion from January 1993 to January 2000.

RESULTS

Seventy-one of 200 patients from our database met the criteria. A significant majority of the patients were women (65%) and nonsmokers (72%). All patients had adenocarcinoma shown on biopsy. The majority of patients (63%) had disease localized to the intrathoracic serosal surfaces; the rest had distant metastases involving the lung (50%), bone (27%), liver (19%), brain (8%), and skin (4%). Six patients had two or more sites of distant metastases. There was a significant association with ETS exposure when compared to a control group comprised of patients with colonic cancer, matched for sex and age. The median survival was 10 months for patients with disease localized to the pleura/pericardium and 7 months for those with distant metastases. Thirty-eight patients (54%) received chemotherapy. All had platinum-based chemotherapy, except for three patients. The median survival for patients treated or not treated with chemotherapy was 12 months and 5 months, respectively. This difference in survival was statistically significant (p = 0.003).

CONCLUSIONS

PIME should be viewed as a distinct entity. Its etiology remains largely unknown, although exposure to environmental tobacco smoke may play a part. Platinum-based chemotherapy may have a positive biological effect on this disease. More studies are required to elucidate the epidemiology, possible etiologic factors, and treatment options for this group of patients.

Recurrent nasopharyngeal carcinoma presenting as diffuse dermal lymphatic infiltration in the neck: three case reports

BACKGROUND

Any malignancy has the propensity to metastasize to skin. The frequency of skin metastases vary in different tumors and occur in about 0.7% to 10% of all patients diagnosed with cancer. It is rare in nasopharyngeal carcinoma.

METHOD

Three cases of relapsed nasopharyngeal carcinoma with diffuse dermal involvement were described. Their clinical presentation, results of investigations, and response to treatment were reviewed. Literature review of similar forms of presentation was done by means of a MEDLINE search.

RESULTS

At the time of dermal relapse, all three patients had a uniform clinical picture of facial, periorbital, and lip swelling associated with stridor and dysphagia. Histologic findings showed dermal infiltrates of malignant cells, and CT scan showed diffuse infiltration of the subcutaneous tissue. Despite chemotherapy, the clinical course was relentless.

CONCLUSION

This report describes a presentation of disease that is underdiagnosed and heightens awareness of oncologists to this form of recurrence in nasopharyngeal carcinoma.

Induction chemotherapy followed by concurrent chemoradiotherapy in stage III unresectable non-small cell lung cancer

The favourable experience with the combination regimen of vinorelbine, ifosfamide and cisplatin (NIP) in patients with metastatic non-small cell lung cancer (NSCLC) has led to a protocol assessing this regimen as an induction treatment in patients with stage III unresectable NSCLC, followed by thoracic radiotherapy with concurrent daily cisplatin as a radiosensitizer. Two cycles of NIP were administered 21 days apart; each cycle comprised i.v. vinorelbine 25 mg/m2 on days 1 and 8, i.v. ifosfamide 3 g/m2 on day 1 with MESNA as uroprotection, and i.v. cisplatin 50 mg/m2 on day 1. Radical thoracic radiotherapy commenced on day 43 to a total dose of 64 Gy and i.v. cisplatin 6 mg/m2 was given concurrently prior to each fraction of radiation as a sensitiser. Two more cycles of NIP were given to patients who responded favourably to the induction treatment about 2 weeks after completion of radiation. Between July 1995 and July 1997, 44 patients were treated with this protocol. This treatment schedule was generally well tolerated. Grade 3-4 neutropenia occurred in 50% of the patients and neutropenic sepsis was seen in 8. Grade 3-4 oesophagitis was uncommon. Most of the patients were able to complete the induction and concurrent chemoradiotherapy phase. Major response occurred in 75% of the patients with 2 (4.5%) complete responses (CR). A total of 6 patients achieved CR after chemoradiotherapy. At a median follow-up of 35 months, the median overall survival for all patients was 15 months with a 3-year survival rate of 24%. The median overall survival for stage IIIA patients was 19 months with a 3-year survival rate of 39% in contrast to 13 months' median overall survival and only 15% 3-year survival rate for stage IIIB. The NIP regimen results in a high response rate in NSCLC and this treatment programme seems to benefit selected patients with stage III disease.

Concurrent chemoradiotherapy followed by adjuvant chemotherapy in Asian patients with nasopharyngeal carcinoma: toxicities and preliminary results

PURPOSE

Nasopharyngeal carcinoma (NPC) is endemic in Singapore. Nearly 60% of the patients diagnosed with NPC will present with locally advanced disease. The North American Intergroup study 0099 reported improved survival outcome in patients with locally advanced NPC who received combined chemoradiotherapy when compared to radiotherapy alone. Hence we explored the feasibility and efficacy of a similar protocol in our patients.

METHODS AND MATERIALS

Between June 1996 and December 1997, 57 patients were treated with the following schedule as described. Radical radiotherapy (RT) of 66-70 Gy to the primary and neck with cisplatin (CDDP) 25 mg/m2 on days 1-4 given by infusion over 6-8 hours daily on weeks 1, 4, and 7 of the RT. This is followed by a further 3 cycles of adjuvant chemotherapy starting from week 11 from the first dose of radiation (CDDP 20 mg/m2/d and 5-fluorouracil [5-FU] 1 gm/m2/d on days 1-4 every 28 days).

RESULTS

The majority of patients (68%) had Stage IV disease. About 54% of patients received all the intended treatment; 75% received all 3 cycles of CDDP during the RT phase and 63% received all three cycles of adjuvant chemotherapy. The received dose intensity of CDDP and 5-FU of greater than 0.8 was achieved in 58% and 60% of the patients respectively. Two treatment-related deaths due to reactivation of hepatitis B and neutropenic sepsis respectively, were encountered. At median follow-up of 16 months, 14 patients had relapsed, 12 systemically and 2 loco-regionally.

CONCLUSION

Due to the acceptable tolerability of such a protocol in our cohort of patients, we have embarked on a Phase III study to confirm the results of the 0099 Intergroup study in the Asian context.

Vinorelbine, ifosfamide and cisplatin in advanced non-small cell lung cancer

Between September 1994 and July 1997, 78 patients with advanced/metastatic, non-small cell lung cancer (NSCLC) were selected for the NIP (vinorelbine, ifosfamide, and cisplatin) protocol. The study group included 43 males; age range 34-74 years; median age 56 years; median follow-up for all patients was 14 months and for surviving patients, 30 months. Histological distribution included 55 adenocarcinomas (70.5%), 8 squamous cell carcinomas, and 9 large cell carcinomas. Stage distribution was 14 stage IIIB (malignant effusions) and 64 stage IV or recurrent metastatic; sites of metastasis were lungs, -26; liver-19; bones-27; brain-7; adrenals-3; distant nodes-2; skin-2. The NIP regimen was well tolerated by most of the patients but nausea/vomiting was noted in 55% of the cycles administered, most of them of grade 1-2 severity. Fifteen neutropenic episodes (5%) were encountered. Response to NIP was: 44 partial responses (56%); 1 complete response (1%); overall response, 58%. For stage IIIB, overall response was 36%, while for stage IV/metastatic, overall response was 63%. The median time to progression was 7 months for stage IIIB and 8 months for stage IV/metastatic disease and the overall median survival achieved was 14 months, with 60% of patients alive after one year. No significant difference in survival outcome was noted between patients with metastatic disease and those with stage IIIB (malignant effusion) disease. The NIP regimen has produced encouraging results in advanced NSCLC, as well as a favourable toxicity profile. The efficacy of NIP as a palliative tool should be assessed. A randomized trial to compare NIP with a two-drug combination of vinorelbine and cisplatin has been initiated.

Concurrent chemoradiotherapy in patients with locally advanced nasopharyngeal carcinoma of the undifferentiated type

The result with radiotherapy alone in patients with locally advanced nasopharyngeal carcinoma (NPC) was disappointing. Encouraging results have been reported with the use of concurrent chemoradiotherapy in patients with locally advanced squamous cell carcinoma of the head and neck. Hence, we decided to explore the use of this treatment schedule in patients who presented with locally advanced disease (UICC/AJCC classification system). Between July 1995 and March 1996, 14 patients with locally advanced NPC were treated with the following schedule: radiation therapy was given conventionally to a total of 66 to 70 Gy to both the nasopharynx and neck with or without parapharyngeal/intracavitary boost; chemotherapy consisted of intravenous cisplatin at 20 mg/m2/day and intravenous 5-flurouracil 1000 mg/m2/day, infused over 8 hours on days 1 to 4 during the first and fifth week of radiation therapy. Depending on the patient's tolerability and clinical assessment of toxicity, a third cycle of chemotherapy was planned 4 to 5 weeks after the second cycle, upon the completion of the radiotherapy. Twelve patients completed all intended treatment. Two patients failed to do so due to treatment-related mortality. The median follow-up duration was 30 months. Limiting toxicities were myelosuppression and oropharyngeal mucositis. The overall response rate was a 100% at both the primary and nodal sites of disease. The median disease-free survival was 21 months. Forty per cent of the patients were alive at 3 years. This treatment schedule was associated with an unacceptable treatment-related death rate. As a result, this protocol was terminated.

Phase II trial of a paclitaxel and carboplatin combination in Asian patients with metastatic nasopharyngeal carcinoma

PURPOSE

An earlier phase II trial of paclitaxel in patients with metastatic nasopharyngeal carcinoma (NPC) demonstrated a response rate of 22%. Hence we proceeded to study the combination of paclitaxel and carboplatin in these patients.

PATIENTS AND METHODS

The 21-day regimen was as follows: i.v. paclitaxel 175 mg/m2 over three hours preceded by standard premedications, followed by i.v. carboplatin dosed at AUC of six infused over one hour. Only chemotherapy-naive patients with histological diagnoses of undifferentiated carcinoma of the nasopharynx, systemic metastases and radiologically measurable lesions were eligible.

RESULTS

Thirty-two patients were accrued to this study. Twenty patients (62%) had at least two sites of metastasis. The main grade 3-4 toxicity was neutropenia (31%). Nine patients (28%) developed neutropenic sepsis, which caused the demise of one of them. Twenty-four patients (75%) responded to treatment, with one (3%) attaining a complete response. The median time to progression of disease was seven months and the median survival was 12 months. At one year, 52% of the patients were alive.

CONCLUSIONS

The combination of paclitaxel and carboplatin is an active regimen in NPC. Its convenience of administration and good tolerability make it an attractive alternative regimen to consider for patients with metastatic disease.

Mitomycin, ifosfamide and cisplatin in advanced non-small cell lung cancer

BACKGROUND

Chemotherapy can be used to palliate the symptoms in patients with advanced non-small cell lung cancer.

PATIENTS

Twenty-four chemo-naive patients with stage IIIB and IV non-small cell lung cancer were treated with the MIC regimen (mitomycin, ifosfamide and cisplatin).

RESULTS

The overall response rate was 33% (partial response) and median duration of response was 7 months (range 5 to 10 months). At median follow-up of 26 months, the median survival was 8 months, and 1-year survival was 29%. Toxicities were tolerable.

CONCLUSION

This appears to be a reasonable regimen for palliating advanced non-small cell lung cancer.

Activity of paclitaxel by three-hour infusion in Asian patients with metastatic undifferentiated nasopharyngeal cancer

BACKGROUND

Despite its moderate anti-tumour activity in head and neck cancers there have been no reports on the activity of paclitaxel in patients with nasopharyngeal cancer, a highly chemosensitive tumour. A phase II study was thus initiated to determine the objective response rate and toxicity of paclitaxel in patients with previously untreated metastatic nasopharyngeal cancer.

PATIENTS AND METHODS

Twenty-four patients with previously untreated measurable metastatic nasopharyngeal carcinoma were accrued, one of them ineligible because of concomitant beta-blocker usage. Male:female ratio was 19:5, with a median age of 46 years. All had previously received radiotherapy but were chemotherapy-naïve. The great majority (20 of 24) had undifferentiated carcinoma. Paclitaxel (Anzatax, Faulding Pharmaceuticals) 175 mg/m2 was given intravenously over three hours every 21 days after premedication with oral dexamethasone and intravenous diphenhydramine and cimetidine.

RESULTS

There were five (21.7%) partial responses while eight patients remained stable. Median response duration was 7.5 months and median survival was 12 months. The main toxicity was haematological, with grade 1-2 neutropenia in 19% and grade 3-4 neutropenia in 4.5% of cycles. Three cycles were complicated by grade 3-4 anaemia and one patient required a blood transfusion. No thrombocytopenia was seen. Peripheral neuropathy was frequent (20 of 23 patients) but mild. Alopecia was complete in 14 patients. There were no cardiac toxicity or hypersensitivity reactions.

CONCLUSIONS

Paclitaxel is well tolerated even in previously irradiated patients with metastatic nasopharyngeal cancer. Single-agent activity was 22% and its inclusion into combination chemotherapy regimens should be studied.

Concurrent chemoradiotherapy for salvage in relapsed squamous cell head and neck cancer

The results in 9 patients with unresectable recurrent squamous cell cancer of the head and neck who were treated with aggressive concurrent chemoradiotherapy are reported. Treatment consisted of one or two courses of chemotherapy with 5-fluorouracil 1000 mg/m2/day and cisplatin 20 mg/m2/day, both given as 4-day continuous intravenous infusions, concurrent with radiation therapy. Salvage radiation doses between 30 and 70 Gy were administered. Seven patients had previously undergone an attempt at curative surgery, and 7 had been treated with radiation doses between 52 and 72 Gy. The recurrent disease was locally confined in 3, locoregional in 5, and locoregional with metastases in 1 of the 9 patients. Treatment toxicity was significant and included mucositis, nausea/vomiting, and granulocytopenia, but there were no toxic deaths. Complete tumor clearance was possible in 6 of these 9 patients, and 5 patients remain disease-free at 41+, 43+, 45+, 47+, and 50+ months. Of these 5 patients, 4 had previously been treated with both surgery and radiation, while 1 had only undergone surgery. We conclude that aggressive chemotherapy and concurrent (re)irradiation can be given to patients with unresectable, recurrent, squamous cell cancer of the head and neck. Treatment is tolerable, and disease-free long-term survival is possible. Careful patient selection, however, is required.

Squamous cell head and neck cancer in nonsmokers

Tobacco and alcohol abuse are the major known risk factors for the development of squamous cell head and neck cancer (SCHNC). Information about this disease in nonsmokers, however, is limited. We retrospectively studied a group of 59 tobacco nonusers with SCHNC, diagnosed since 1986 at the Cleveland Clinic Foundation (CCF). Two objectives were defined: (a) to characterize this nonsmoking population of patients and identify any significant differences compared with a control population consisting of all patients diagnosed with SCHNC at the CCF between 1986 and 1993 and (b) to determine the prevalence of exposure to environmental tobacco smoke in this nonsmoking group of patients with SCHNC and compare it with the environmental tobacco-smoke exposure in a second, control population of non-SCHNC, nonsmoking patients matched for age, race, sex, and alcohol use. The group of nonsmoking patients with SCHNC was notable for only rare alcohol abuse, a preponderance of whites, and relatively fewer laryngeal primary tumors. There were significantly more women and more tongue primaries. When compared with the control population without cancer, the nonsmoking patients had a significantly higher risk of exposure to environmental tobacco smoke both in the home and in the workplace. We conclude that the tobacco nonuser who develops SCHNC is likely to be female and white and to have a primary tongue cancer. A significant association with environmental tobacco smoke exposure is suggested by our data.

Burkholderia pseudomallei infection in the Singapore Armed Forces from 1987 to 1994--an epidemiological review

Between 1987 and 1994, twenty-three cases of Burkholderia pseudomallei infection (melioidosis) were diagnosed in persons serving in the Singapore Armed Forces. There were four deaths resulting from complications of the infection. Unlike the situation in the general population, where the affected are mainly the elderly with underlying illness, the majority of cases in the Singapore Armed Forces were otherwise fit and healthy young servicemen. Serological surveys have shown the prevalence of the infection in Singapore to be 0.2% in the military as well as civilian population. As physical contact with soil is an unavoidable part of military training, military personnel continue to be at risk of exposure to this soil-related disease.