Non-centralised service for palliative stenting of malignant gastric outlet obstruction

INTRODUCTION

Malignant gastric outlet obstruction (GOO) is a common, debilitating and frequently pre-terminal symptom of intra-abdominal malignancies. Traditional 'gold standard' treatment has been palliative surgical gastro-enterostomy. Over the past two decades, use of self-expanding metallic stents (SEMSs) to relieve malignant GOO has become first-line treatment. We present the results from a single district general hospital in the UK in which malignant GOO was treated with SEMSs over a six-year period.

METHODS

All patients who underwent palliative stenting for malignant gastro-duodenal tumours in our centre for six years up to January 2013 were assessed retrospectively. Outcomes were assessed with regard to: technical and clinical success; return to oral nutrition; prevalence of complications and re-intervention; and overall survival.

RESULTS

Thirty-two stents were implanted in 29 patients. Technical success was 100%. Clinical success and return to oral nutrition were both 91%. The prevalence of complications was 16%. The prevalence of re-intervention was 13%. Mean survival was 91 (range, 5-392) days. Median wait from decision to implant a stent to stent implantation was 1 (range, 0-14) day. Overall, 25 covered and nine uncovered stents were implanted.

CONCLUSION

Stent implantation for GOO in this patient group is an established and preferable alternative to surgical intervention. Much of the treatment for malignancies of the upper gastrointestinal tract has now been centralised. Our data showed comparable results with published data for these procedures, with a high prevalence of success and low prevalence of major complications. It is of considerable benefit to these patients not to have to travel to a regional centre for stent implantation.

A phase II study of bosentan, a dual endothelin receptor antagonist, as monotherapy in patients with stage IV metastatic melanoma

There is no effective systemic therapy for disseminated metastatic melanoma. Data suggest that endothelin may play a role in pathophysiology of melanoma and that the dual endothelin receptor antagonist bosentan may have anti-tumor activity. This multicenter, open-label, single-arm, prospective, proof-of-concept study assessed the effects of bosentan monotherapy (500 mg oral tablets, bid) on tumor response in patients with stage IV metastatic melanoma. Patients were treated until disease progression, death or serious adverse event leading to premature study drug discontinuation. Tumor response was assessed at 6-weekly intervals using the Response Evaluation Criteria in Solid Tumors (RECIST). Among the 35 patients included in this study with stage IV metastatic melanoma, 21 (60%) were stage M1C, 10 (29%) stage M1B and 4 (11%) stage M1A (American Joint Committee on Cancer [AJCC] classification). Nine patients (26%) had received prior therapy for stage IV melanoma. Disease stabilization was observed in 6 of the 32 patients analyzed per protocol at week 6 with confirmatory evaluation at week 12, 5 of whom were still stable at > or =24 weeks. Of the 6 patients with disease stabilization, 2 were stage M1A, 1 was stage M1B and the remaining 3 were stage M1C. Partial or complete response was not observed. Progressive disease was observed in 17 (49%) patients at week 12 and in 25 (71%) patients at the end of the study (data base closure). The most frequent adverse events were typical for the underlying disease or known to be associated with bosentan: headache (43%), fatigue (34%), nausea (31%), back pain (23%) and abnormal hepatic function (23%). Bosentan might have benefit in disease stabilization in certain patients with metastatic melanoma and deserves further investigation in combination with other anticancer drugs.

Adjuvant VHF therapy in locally recurrent and primary unresectable rectal cancer

In a prospective randomized study, 434 mHz microwave therapy combined with external beam radiotherapy (VHF + RT) was compared with standard external beam radiotherapy (RT) in controlling locally recurrent or unresectable primary adenocarcinoma of the rectum. Independent assessors documented quality of life scores, performance status, toxicities, local response to treatment, and systemic disease progression before treatment and after treatment and every 8 weeks thereafter. Of 75 patients randomized, 73 were eligible for inclusion in the study. Forty-three of these patients had local pelvic tumour recurrence only and 21 also had distant metastases. In addition, nine patients had primary inoperable carcinomas, two of whom also had metastases. Thirty-seven patients were randomized to RT and 36 to VHF + RT. The median dose of radiation in the VHF+RT arm was 4275 cGy with a median fraction size of 150 cGy and median duration of therapy of 48.5 days versus 4500 cGy in the RT-only arm with a median fraction size of 180 cGy and median duration of therapy of 38 days. These doses are unlikely to be significantly different in biological effect. No significant difference between the two groups was observed in extent and duration of local control, measures of toxicity or quality of life scores. Additionally, survival and cumulative incidence of pelvic site of first progression did not differ significantly between the groups. We conclude that VHF microwave therapy in conjunction with radiotherapy produces no therapeutic advantage over conventional radiation therapy alone in the treatment of locally recurrent rectal carcinoma.

Syncope: a clue to malignant compression of the glossopharyngeal nerve

Three patients who were admitted to hospital because of syncope were found to have malignant head and neck tumours. A patient who presented with malignant external otitis with syncope and postural hypotension is also described. It is postulated that the syncope and postural hypotension result from compressive irritation of the glossopharyngeal nerve either in the neck or at the base of the skull.

Possible infectious etiology of six cases of Ewing's sarcoma in Western Australia

Six cases of Ewing's sarcoma occurring in Western Australia during a 2-year period are reported. All six patients lived in rural habitats and reported exposure to farm animals. There was evidence of direct contact between two patients over a 3-year period preceding the diagnosis of their tumors. These features raise the possibility that Ewing's sarcoma has an infectious etiology.

High creatine kinase MB isoenzyme activity associated with a rhabdomyosarcoma

A 20-year-old man was found to have high plasma creatine kinase (EC 2.7.3.2) activity in association with a rhabdomyosarcoma of the prostate. There was a very high proportion of the MB isoenzyme. Clinical findings and changes in creatine kinase activity with time showed that this increase was not ascribable to myocardial disease. We believe that the high proportion of CK-MB, confirmed by a combination of electrophoretic and immunoinhibition studies, originated from the tumor.

High creatine kinase MB isoenzyme activity associated with a rhabdomyosarcoma

A 20-year-old man was found to have high plasma creatine kinase (EC 2.7.3.2) activity in association with a rhabdomyosarcoma of the prostate. There was a very high proportion of the MB isoenzyme. Clinical findings and changes in creatine kinase activity with time showed that this increase was not ascribable to myocardial disease. We believe that the high proportion of CK-MB, confirmed by a combination of electrophoretic and immunoinhibition studies, originated from the tumor.

Problems of the oncology outpatient: role of the liaison health visitor

A survey by a liaison health visitor of outpatients attending an oncology department has identified and enumerated the principal problems with which she is confronted, and defined her role. The main medical symptoms of concern to the patient at home and needing attention by the liaison health visitor were anorexia, nausea, vomiting, and constipation: inadequate pain control due to poor drug compliance was also common. Other functions of the liaison health visitor include providing nursing aids and prostheses, support for bereaved relatives, and liaison with the community health care team.

Faecal bile acids and clostridia in the aetiology of colorectal cancer

This study was undertaken in an attempt to confirm the increased bile-acid concentration in association with nuclear dehydrogenating Clostridia (NDC) in the faeces of colorectal cancer patients. We have studied 37 patients with colorectal cancer and 36 control patients with no known gastrointestinal disease. Stool specimens were obtained for biochemical analysis (total faecal bile acid (FBA), lithocholic deoxycholic and cholic acids) and NDC isolation. The mean total FBA concentration (mumol/g) in the control group was 20.5 +/- 2.2 (s.e.) significantly higher (P < 0.001) than the colorectal-cancer group (11.8 +/- 0.7). There was no statistically significant difference in the percentage distribution of the individual FBAs measured. NDC were isolated from the faeces of 64% of colorectal-cancer patients and 15% of control patients, this difference being statistically significant (P < 0.001). These results suggest that bacteria capable of metabolizing steroids may be implicated in the aetiology of colorectal cancer. However, the relationship between FBA and colorectal cancer requires further evaluation.