Cerebral hemodynamics and stroke risks in symptomatic intracranial atherosclerotic stenosis with internal versus cortical borderzone infarcts: A computational fluid dynamics study

There may be different mechanisms underlying internal (IBZ) and cortical (CBZ) borderzone infarcts in intracranial atherosclerotic stenosis. In 84 patients with symptomatic, 50-99% atherosclerotic stenosis of M1 middle cerebral artery (MCA-M1) with acute borderzone infarcts in diffusion-weighted imaging, we classified the infarct patterns as isolated IBZ (n = 37), isolated CBZ (n = 31), and IBZ+CBZ (n = 16) infarcts. CT angiography-based computational fluid dynamics models were constructed to quantify translesional, post-stenotic to pre-stenotic pressure ratio (PR) in the MCA-M1 lesion. Those with IBZ infarcts were more likely to have a low PR (indicating impaired antegrade flow across the lesion) than those without (p = 0.012), and those with CBZ infarcts were more likely to have coexisting small cortical infarcts (indicating possible embolism) than those without (p = 0.004). In those with isolated IBZ or CBZ infarcts, low PR was independently associated with isolated IBZ infarcts (adjusted odds ratio = 4.223; p = 0.026). These two groups may also have different trajectories in the stroke risks under current medical treatment regimen, with a higher risk of same-territory ischemic stroke recurrence within 3 months in patients with isolated IBZ infarcts than isolated CBZ infarcts (17.9% versus 0.0%; log-rank p = 0.023), but similar risks later in 1 year.

Hemodynamic significance of intracranial atherosclerotic disease and ipsilateral imaging markers of cerebral small vessel disease

INTRODUCTION

Cerebral small vessel disease (CSVD) commonly exists in patients with symptomatic intracranial atherosclerotic disease (sICAD). We aimed to investigate the associations of hemodynamic features of sICAD lesions with imaging markers and overall burden of CSVD.

PATIENTS AND METHODS

Patients with anterior-circulation sICAD (50%-99% stenosis) were analyzed in this cross-sectional study. Hemodynamic features of a sICAD lesion were quantified by translesional pressure ratio (PR = Pressurepost-stenotic/Pressurepre-stenotic) and wall shear stress ratio (WSSR = WSSstenotic-throat/WSSpre-stenotic) via CT angiography-based computational fluid dynamics modeling. PR ⩽median was defined as low ("abnormal") PR, and WSSR ⩾ fourth quartile as high ("abnormal") WSSR. For primary analyses, white matter hyperintensities (WMHs), lacunes, and cortical microinfarcts (CMIs) were assessed in MRI and summed up as overall CSVD burden, respectively in ipsilateral and contralateral hemispheres to sICAD. Enlarged perivascular spaces (EPVSs) and cerebral microbleeds (CMBs) were assessed for secondary analyses.

RESULTS

Among 112 sICAD patients, there were more severe WMHs, more lacunes and CMIs, and more severe overall CSVD burden ipsilaterally than contralaterally (all p < 0.05). Abnormal PR and WSSR (vs normal PR and WSSR) was significantly associated with moderate-to-severe WMHs (adjusted odds ratio = 10.12, p = 0.018), CMI presence (5.25, p = 0.003), and moderate-to-severe CSVD burden (12.55; p = 0.033), ipsilaterally, respectively independent of contralateral WMHs, CMI(s), and CSVD burden. EPVSs and CMBs were comparable between the two hemispheres, with no association found with the hemodynamic metrics.

DISCUSSION AND CONCLUSION

There are more severe WMHs and CMI(s) in the hemisphere ipsilateral than contralateral to sICAD. The hemodynamic significance of sICAD lesions was independently associated with severities of WMHs and CMI(s) ipsilaterally.

Abstract WMP84: Symptomatic Intracranial Atherosclerotic Plaques: Different Morphological Features In The Anterior Versus Posterior Circulation

Introduction: We compared the morphology of intracranial atherosclerotic plaques in the anterior versus posterior circulation, using three-dimensional rotational angiography (3DRA).

Methods: We prospectively recruited adult patients with acute ischemic stroke or transient ischemic attack attributed to high-grade (60-99%), atherosclerotic intracranial stenosis as confirmed by 3DRA. We assessed the plaque morphology in 3DRA, including the percentage of luminal stenosis, smooth/irregular/ulcerative plaque surface contour, plaque thickness, length, eccentricity, upstream plaque shoulder angulation, longitudinal distribution of the maximal stenosis, and adjoining branch atheromatous disease (BAD). We compared characteristics of patients with middle cerebral artery-M1 (MCA-M1) and basilar artery (BA) plaques, and the plaque morphology in the two subgroups.

Results: Overall, 164 and 17 patients respectively with MCA-M1 and BA plaques were analyzed, with similar age (medians 60 versus 62 years), sex (male 64.6 versus 52.9%) and history of common vascular risk factors. The percentage of luminal stenosis (medians 77 versus 81%), proportion of smooth/irregular/ulcerative plaque surface contour, upstream plaque shoulder angulation (32.1 versus 25.8 °), longitudinal distribution of the maximal stenosis, and presence of adjoining BAD (56.7 versus 64.7%) were similar between MCA-M1 and BA plaques. However, BA plaques were thicker (1.5 versus 1.3mm; p=0.03) and longer (16.4 versus 8.4mm; p<0.001), but less likely eccentric (70.6 versus 88.4%; p=0.039).

Conclusions: There were differences in the morphology of symptomatic atherosclerotic plaques in anterior and posterior circulations, independent of demographics and common vascular risk factors. Different artery geometry and the hemodynamics may underlie such differences.

A cross-sectional study of COVID-19 vaccination patterns among patients with epilepsy in Hong Kong

OBJECTIVE

As Hong Kong faced the 5th wave of the COVID-19 pandemic, the facilitators and hurdles toward effective vaccination is important for healthcare professionals to understand the vaccination gap among patients with epilepsy.

METHODS

A cross-sectional, pragmatic study of COVID-19 vaccination was performed at a tertiary epilepsy center with regards to patterns of vaccination and any unusually high rate of adverse events. Patients having recent visits at the epilepsy center (4 months) had their anonymized electronic linkage records examined 12 months after the inception of vaccination program for types of vaccines, seizure demographics, and adverse events following immunization (AEFI).

RESULTS

A total of 200 patients with epilepsy and their anonymized data were analyzed. The vaccine uptake was approximately 60% of that of the general population. Twice as many patients with epilepsy chose to receive mRNA vaccine as compared with inactivated vaccine. The proportion of patients who kept up-to-date with all available dosing was 7%. Patients with epilepsy with genetic etiology were least likely to receive vaccination (13/38, 34%, P = .02). There was no unreasonably high rate of unacceptable side effects after vaccination among patients with epilepsy. Only 3 patients reported worsening of seizures without meeting the criteria for AEFI. Refractory epilepsy, allergy to antiseizure medications and elder age (≥65) did not confer any significant difference in vaccination patterns or adverse effects.

SIGNIFICANCE

A vaccination gap exists among epilepsy patients which calls for actionable strategies for improving vaccine uptake, including education and outreach programs.

Abstract P678: Elevated Neutrophil to Lymphocyte Ratio Associated With Increased Risk of Recurrent Vascular Events in Older Minor Stroke or TIA Patients

Background: The risk of recurrent stroke following a minor stroke or transient ischemic attack (TIA) is high, when inflammation might play an important role. We aimed to evaluate the value of neutrophil-to-lymphocyte ratio (NLR) in predicting composite cardiovascular events in patients with minor stroke and TIA.

Methods: Consecutive patients with acute minor stroke or TIA admitted within 24 hours of symptoms onset during a 5-year period in a prospective stroke registry were analyzed. We calculated the NLR dividing absolute neutrophil count by absolute lymphocyte count tested within 24 hours of admission. NLR ≥ 4th quartile was defined as high NLR. A composite outcome was defined as ischemic stroke, acute coronary syndrome or vascular death within 1 year. We investigated associations between NLR and the composite outcome in univariate and multivariate analyses, among all patients and in those aged over 60 years (i.e., older patients).

Results: Overall, 841 patients (median age 68 years; 60.4% males) were recruited. No significant independent association was found between NLR and the composite outcome in multivariate analysis in the overall cohort. Among the 612 older patients (median age 73 years; 59.2% males), the median NLR was 2.76 (interquartile range 1.96-4.00) and 148 (24.2%) patients had high NLR. The composite outcome occurred in 77 (12.6%) older patients, who were more likely to have a high NLR (39.0% versus 22.1%; p=0.001) than those without a composite outcome. In multivariate logistic regression, high NLR (adjusted odds ratio 2.00; 95% confidence interval 1.07-3.75; p=0.031) was independently associated with the composite outcome in older patients.

Conclusions: In older patients with acute minor stroke or TIA, a higher NLR is an independent predictor of subsequent cardiovascular events, indicating inflammation as an important factor and potential therapeutic target for secondary prevention of such patients.

Steroids administered after vacuum-assisted biopsy in the management of idiopathic granulomatous mastitis

AIMS

The aetiology and treatment options for idiopathic granulomatous mastitis (IGM) are controversial. The aim was to study the clinical and diagnostic features and discuss medical and surgical treatment for IGM in our patients.

METHODS

Sixty-five patients who met the histological criteria for IGM were retrospectively studied. The diagnosis of IGM was confirmed using Mammotome (an ultrasound-guided, vacuum-assisted biopsy system), core needle biopsy, quadrantectomy or segmental resection. Forty-five patients were treated with prednisolone (69.2%). Immunohistochemical (IHC) staining for immune-related antigens (CD3, CD4, CD8, CD79a, IgG, and IgM) was performed.

RESULTS

Ultrasonography (USG) was carried out in all patients. Among them, 61 were considered to have an inflammatory mass and 15 had accompanying liquefaction. In four patients, the findings mimicked breast carcinoma (6.2%). The IHC results showed CD3, CD4, CD8 and CD79a lymphocytes diffusely distributed in the lesion. Stains for IgG and IgM were negative. Prednisolone was administered to the patients diagnosed with IGM. The success rate was 53 (81.5%) and the whole recurrence was 12 (18.5%). The median follow-up period was 12 months (range 4-42 months).

CONCLUSIONS

The aetiology of IGM remains uncertain. The disease has no propensity for the right or left breast. It is a local autoimmune disease, involving humoral and cell-mediated immunity. Hyperprolactinaemia may play a role in some patients. Corticosteroids administered after complete removal of the IGM lesion using the Mammotome biopsy system is an effective treatment option.

Abstract WP121: An Evaluation of Hemodynamics Across Intracranial Steno-occlusive Lesions by Computational Fluid Dynamics

Introduction: Intracranial atherosclerotic steno-occlusive disease (ICAS) is a major cause of stroke worldwide and portends a high risk of recurrence. Computational fluid dynamics (CFD) is a novel technique developed to solve and analyze the dynamic effects of fluid flow. We aimed to analyse hemodynamics across ICAS using CFD on processed CTA images and explore the correlation between the degree of arterial stenosis and hemodynamic flow status.

Methods: We recruited patients with symptomatic ICAS from Acute Stroke Unit, Prince of Wales Hospital. All patients received CTA and DSA as vascular workup. Using CFD analysis of processed CTA images, we first defined the hemodynamic parameters, including pressure difference, pressure ratio, pressure gradient, shear strain rate ratio (SSR), wall shear stress (WSS) ratio and velocity ratio, across the stenosed vessels, and then we correlated the severity of stenosis as defined by DSA, with these parameters.

Results: Among the 53 recruited patients (mean age 62.9 years, 69.8% males), 45 (85%) had lesions in the anterior circulation. The severity of stenosis showed a weak-to-moderate correlation with pressure difference (rs=0.392, p=0.004), pressure ratio (rs=-0.429, p=0.001) and pressure gradient (rs=0.419, p=0.002). There was no significant correlation between the severity of stenosis with SSR ratio, WSS ratio and velocity ratio. Among patients with anterior circulation stroke or TIA, the severity of stenosis showed a weak to moderate correlation with pressure difference (rs=0.381, p=0.01), pressure ratio (rs=-0.426, p=0.004) and pressure gradient (rs=0.407, p=0.005). For patients with posterior circulation stroke or TIA, the severity of stenosis was strongly correlated with pressure difference (rs=0.714, p=0.047) and pressure ratio (rs=-0.714, p=0.047); and very strongly correlated with velocity ratio (rs=0.833, p=0.01).

Conclusions: The severity of ICAS showed only weak-to-moderate correlation with hemodynamic parameters across the culprit lesion. Thus, risk stratification and treatment based solely on stenotic severity may be inadequate. Our findings may guide further research in estimating stroke risks and selection of high-risk patients who may benefit from adjunctive treatments.

Comparative genomic hybridization of esophageal squamous cell carcinoma: correlations between chromosomal aberrations and disease progression/prognosis

BACKGROUND

Esophageal carcinoma is a major cause of cancer-related deaths among males in Taiwan. However, to date, the genetic alterations that accompany this lethal disease are not understood.

METHODS

Chromosomal aberrations of 46 samples of esophageal squamous cell carcinoma (EC-SCC) were analyzed by comparative genomic hybridization (CGH), and their correlations with pathologic staging and prognosis were analyzed statistically.

RESULTS

In total, 321 gains and 252 losses were found in 46 tumor samples; thus, the average gains and losses per patient were 6.98 and 5.47, respectively. Frequent gain abnormalities were found on chromosome arms 1q, 2q, 3q, 5p, 7p, 7q, 8q, 11q, 12p, 12q, 14q, 17q, 20q, and Xq. Frequent deletions were found on chromosome arms 1p, 3p, 4p, 5q, 8p, 9p, 9q, 11q, 13q, 16p, 17p, 18q, 19p, and 19q. It was found that deletions of 4p and 13q12-q14 and gain of 5p were significantly correlated with pathologic staging. Losses of 8p22-pter and 9p also were found more frequently in patients with advanced disease. Gain of 8q24-qter was seen more frequently in patients with Grade 3 tumors. A univariate analysis found that pathologic staging; gains of 5p and 7q; and deletions of 4p, 9p, and 11q were significant prognostic factors. However, pathologic staging became the only significant factor in a multivariate analysis.

CONCLUSIONS

CGH not only revealed novel chromosomal aberrations in EC-SCC, but also found possible genotypic changes associated with disease progression. Despite all of the possible associations of chromosomal aberrations with disease progression, the most important prognostic factor for patients with EC-SCC was pathologic staging.

Relapse of Graves' disease after successful allogeneic bone marrow transplantation

As shown in many reports, allogeneic BMT can help cure autoimmune diseases. Conversely, we present a 24-year-old woman with Graves' disease, which was diagnosed just before BMT for CML. The Graves' disease remitted immediately after BMT but relapsed 18 months later. Since the donor was free from thyroid diseases and the patient showed a rapid shift to complete donor chimerism after BMT, the autoimmune problem seemed neither to arise directly from the donor nor simply from the recipient's residual lymphocytes. On the contrary, it was most likely compounded by chronic GVHD as suggested by the accompanying GVHD symptoms and the absolute donor karyotype in bone marrow cells. A Graves' disease-susceptible HLA allele was also shared between recipient and donor, possibly enhancing the chances of this condition developing. Thus, allogeneic BMT may facilitate relapses in autoimmune diseases as well as alleviating them.

Comparative genomic hybridization of esophageal squamous cell carcinoma: correlations between chromosomal aberrations and disease progression/prognosis

BACKGROUND

Esophageal carcinoma is a major cause of cancer-related deaths among males in Taiwan. However, to date, the genetic alterations that accompany this lethal disease are not understood.

METHODS

Chromosomal aberrations of 46 samples of esophageal squamous cell carcinoma (EC-SCC) were analyzed by comparative genomic hybridization (CGH), and their correlations with pathologic staging and prognosis were analyzed statistically.

RESULTS

In total, 321 gains and 252 losses were found in 46 tumor samples; thus, the average gains and losses per patient were 6.98 and 5.47, respectively. Frequent gain abnormalities were found on chromosome arms 1q, 2q, 3q, 5p, 7p, 7q, 8q, 11q, 12p, 12q, 14q, 17q, 20q, and Xq. Frequent deletions were found on chromosome arms 1p, 3p, 4p, 5q, 8p, 9p, 9q, 11q, 13q, 16p, 17p, 18q, 19p, and 19q. It was found that deletions of 4p and 13q12-q14 and gain of 5p were significantly correlated with pathologic staging. Losses of 8p22-pter and 9p also were found more frequently in patients with advanced disease. Gain of 8q24-qter was seen more frequently in patients with Grade 3 tumors. A univariate analysis found that pathologic staging; gains of 5p and 7q; and deletions of 4p, 9p, and 11q were significant prognostic factors. However, pathologic staging became the only significant factor in a multivariate analysis.

CONCLUSIONS

CGH not only revealed novel chromosomal aberrations in EC-SCC, but also found possible genotypic changes associated with disease progression. Despite all of the possible associations of chromosomal aberrations with disease progression, the most important prognostic factor for patients with EC-SCC was pathologic staging.

Salvage therapy with single-agent paclitaxel by three-hour infusion in metastatic breast cancer: an experience in Taipei Veterans General Hospital

BACKGROUND

Paclitaxel is an active agent in the treatment of breast, ovarian, lung and head and neck cancers. In previous phase I and II trials, it exerted novel cytotoxic effect on several malignancies. Various doses and regimens of paclitaxel have been assessed in metastatic breast cancer, with responses between 20 and 62%. However, combination therapy with other anti-cancer drugs leads to a high incidence of side effects. Our aim was to evaluate the efficacy of paclitaxel given by 3 h infusion as salvage chemotherapy for patients with metastatic breast cancer.

METHODS

Between May 1999 and April 2000, 14 women with metastatic breast cancer were enrolled in this study and all the patients had to have measurable lesions. The median age of the patients was 48.7 years (range 39-56 years). All of them were definitely evidenced as having metastatic breast cancer and received complete courses of anthracycline-containing agents before applying paclitaxel. The protocol was single-agent paclitaxel (Anzatax, Faulding, Australia) at a moderate dosage of 175 mg/m(2) by 3 h intravenous infusion every 3 weeks.

RESULTS

A total of 75 cycles were administered to these 14 patients with a median of four delivered cycles (range 3-14) and the response rate was 28.6% (95% CI: 21-40%), including four partial remission, three stable disease and seven progressive disease. The median time to progression was 3 (range 3-7) months. Hematological toxicities were minimal with no evidence of severe (grade 3 or 4) leukopenia and thrombocytopenia. Hepatic toxicities were observed in 12 cycles with five in grade 3.

CONCLUSIONS

Our study indicates that utilizing single-agent paclitaxel exerts moderate activity on anthracycline-refractory metastatic breast cancer patients without excessive toxicities.

Molecular analysis of mucosa-associated lymphoid tissue (MALT) lymphoma of ocular adnexa

Lymphomas of mucosa-associated lymphoid tissue (MALT) are a distinct subgroup of extranodal B-cell non-Hodgkin's lymphomas. Most studies have failed to demonstrate the clonal rearrangement of BCL-1, BCL-2 or c-MYC genes for MALT lymphomas. Further, alteration of the p53 gene is rarely demonstrated in low-grade MALT lymphomas, but can be detected in high-grade disease. Lymphomas of the ocular adnexa represent approximately eight percent of all extranodal lymphomas, most of which are MALT lymphomas, but few studies had explored the alterations of BCL-1, BCL-2, c-MYC and p53 genes specifically for ocular MALT lymphomas. We investigated the changes to BCL-1, BCL-2, c-MYC and p53 genes in these lymphomas for Taiwanese patients. Clonal rearrangement for immunoglobulin heavy-chain (IgH), BCL-1, BCL-2, c-MYC and p53 genes was examined for 16 cases of ocular MALT lymphoma. Restriction-length polymorphism and polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP) of the DNA, corresponding to exons 5 through 9, followed by DNA sequencing, were utilized to analyze the possible mutations of the p53 gene for these tumors. Thirteen of the cases revealed rearranged IgH genes using Southern blotting or PCR. No rearrangement of BCL-1, BCL-2, c-MYC or p53 genes was discovered, with point mutation of the p53 gene in one case. As for other types of MALT lymphomas, BCL-1, BCL-2 and c-MYC genes are not implicated in the pathogenesis of the ocular sub-group. Although alteration of the p53 gene is rare for low-grade ocular MALT lymphoma, its role in disease progression merits further research.

Complete atrio-ventricular block as a major clinical presentation of the primary cardiac lymphoma: a case report

It is uncommon for malignant lymphomas to present primarily with cardiac invasion as the main clinical feature. What we are interested in is not only where the disease is, but also those symptoms that it may induce. Sudden onset of complete atrio-ventricular block is one of the most common clinical presentations. Cardiac tamponade is another common disease entity which, if it locates over outlets of great vessels, may also exert symptoms of obstructive vessels. Diagnosis can be made by needle aspiration under the guidance of transcutaneous or transesophageal echocardiography. Both CT scan and MRI play positive roles in the diagnosis of cardiac lymphomas, and the latter can even provide much more image information than the former. We report a 70-year-old male with primary cardiac lymphoma with initial clinical pictures of sudden onset of complete atrio-ventricular block. Chemotherapy was utilized with cyclophosphamide, vincristine and prednisolone (COP) initially for four courses and followed by adding doxorubicin (CHOP) for another three courses. The patient was still in remission status after treatment for 2 years.

Tamoxifen and colchicine-modulated vinblastine followed by 5-fluorouracil in advanced renal cell carcinoma: a phase II study

OBJECTIVES

Chemotherapy resistance of renal cell carcinoma (RCC) has been attributed in large part to multidrug resistance (MDR). Reported MDR-modulated chemotherapy for RCC, however, has resulted in only marginal response benefits. In this study, the MDR-modulated effect of paired tamoxifen and colchicine on vinblastine and the possible additive effect of 5-fluorouracil (5-FU) were investigated in the treatment of advanced RCC.

METHODS

Chemotherapy was administered every 4 weeks with biweekly vinblastine (4 mg/m(2)/day, intravenously on days 1 and 15) modulated by oral tamoxifen (100 mg/day) and colchicine (1 mg/day) from days -1 to 2 and from days 13 to 16. 5-FU (800 mg/m(2)/day from days 2 to 5) was administered after vinblastine administration as a continuous infusion.

RESULTS

Of 17 eligible patients with advanced RCC available for evaluation, 1 achieved a complete response (CR) and 3 a partial response (PR), with an overall response (CR plus PR) rate of 23.5%. The median overall survival time of all patients was 10 months (95% confidence interval [CI] 3.5 to 16.5); that of our patients with poor, intermediate, and favorable risks as stratified by Motzer's model was 6 (95% CI 1.7 to 10.3), 10 (95% CI 7.9 to 12.2), and 26 (95% CI 24.4 to 27.6) months, respectively. These results are encouraging in view of the poor efficacy of chemotherapy in RCC observed previously. Additionally, the treatment toxicity was limited: toxicity of grade 3 or greater occurred in only 1 patient with leukopenia, and no treatment-related mortality was found.

CONCLUSIONS

The encouraging response rates and overall survival with limited toxicity warrant further investigation of this combination therapy as an integrated part of immunochemotherapy for RCC.

Carcinoembryonic antigen in monitoring of response to systemic chemotherapy in patients with metastatic colorectal cancer

The response to chemotherapy of solid tumors is generally assessed by measuring tumors visualized by imaging. However, the response assessment based on imaging is not always feasible because patients often have disease not measurable by imaging, such as diffuse peritoneal dissemination. We evaluated the correlation between the change on imaging and change in CEA levels for assessing chemotherapeutic response of patients with metastatic colorectal cancer. Between July 1993 and August 1999 we retrospectively examined 136 patients with metastatic colorectal carcinoma, all of whom had measurable lesions. Forty patients received oral tegafur-uracil (300 mg/m2/day) plus folinic acid (60 mg/day) for 4 weeks, repeated every 5 weeks, as the firstline treatment. Another 96 patients received either a weekly intravenous bolus injection of 5-fluorouracil (400 mg/m2) plus folinic acid (20 mg/m2), or an intravenous bolus injection of 5-fluorouracil (425 mg/m2) plus folinic acid (20 mg/m2) for 5 consecutive days every month. Responders, based on CEA assessment, were defined as those with a greater than 50% drop in CEA level for more than 4 weeks. The pretreatment CEA levels were elevated beyond the normal cutoff value in 110 (81%) patients. A response rate of 18.4% (95% CI, 11.9-24.9%), including 8 complete remissions and 17 partial remissions, was achieved according to imaging studies. The response rate assessed by CEA was 25% (34/136). Sixteen responders (47%) based on CEA had no remission on imaging. The sensitivity of change in CEA levels in the prediction of true responders and progressive diseases on imaging were 72% and 81%, respectively. In terms of the positive predictive value, change in CEA levels in the prediction of true responders and progressive disease on imaging were 53% and 85%, respectively. Patients with remarkable falls on CEA levels survived significantly longer than nonresponders (P < 0.001, log-rank test). At follow-up of 48 months the median survival for responders and nonresponders assessed by CEA was 28 months and 13 months, respectively. These data suggest that measurement of CEA levels might be helpful in monitoring chemotherapeutic response when imaging study is unsuitable for assessing the response in clinical practice. Furthermore, measurement of CEA levels may be helpful in determining the prognosis of patients with metastatic colorectal cancer receiving chemotherapy.

Single agent paclitaxel as a first-line therapy in advanced urothelial carcinoma: its efficacy and safety in patients even with pretreatment renal insufficiency

BACKGROUND

Cisplatin-based chemotherapy is the mainstay of the treatment for advanced urothelial cancer, but patients with renal insufficiency before therapy are usually contraindicated to receiving platinum-based chemotherapy. Paclitaxel is one of the most promising agents against advanced urothelial carcinoma in recent trials and it can be easily tolerated even in patients with compromised renal function. We conducted a study in order to evaluate the efficacy and safety of paclitaxel as a first-line therapy in advanced urothelial carcinoma patients.

METHODS

Thirteen advanced chemo-naive urothelial carcinoma patients with a median age of 71 years were studied, seven of them demonstrating renal insufficiency (pretreatment serum creatinine > or = 1.5 mg/dl). All 13 patients received a minimum of two cycles of paclitaxel 175 mg/m2, delivered by intravenous infusion for 3 h every 3 weeks.

RESULTS

Four of the 13 patients responded to treatment, a response rate of 30.8%, with two of these achieving complete remission and two showing partial responses. The median overall survival period of all 13 patients was nine months (95% Cl: 6.51-11.49) and our study revealed a statistical tendency in the difference of median overall survival time between responders and non-responders (13 months versus 7.5 months, log-rank p = 0.038), although the number of cases was limited. The differences in response rate and median overall survival time, comparing patients with renal insufficiency and those with normal renal function, were not significant. Treatment-related toxicity was mild, with only two (15.4%) patients suffering from grade 3-4 leukopenia. No treatment-related mortality was noted.

CONCLUSIONS

Single-agent paclitaxel can be used as a first-line therapy in advanced urothelial carcinoma patients, and is especially suitable for those with pretreatment renal insufficiency, since the antitumor activity is significant while toxicity is well tolerated.

Randomized trial comparing weekly bolus 5-fluorouracil plus leucovorin versus monthly 5-day 5-fluorouracil plus leucovorin in metastatic colorectal cancer

BACKGROUND/AIMS

The purpose of this study was to compare the efficacy and toxicity profiles of weekly intravenous (i.v.) bolus injection of 5-fluorouracil plus low-dose leucovorin with the Mayo Clinics' monthly 5-day schedule of 5-fluorouracil and leucovorin in the treatment of metastatic colorectal cancer.

METHODOLOGY

A total of 96 patients with previously untreated metastatic colorectal cancer were randomized to receive either a weekly i.v. bolus injection of 5-fluorouracil 400 mg/m2 plus leucovorin 20 mg/m2 (weekly arm), or i.v. bolus injection of 5-fluorouracil 425 mg/m2 plus leucovorin 20 mg/m2 for 5 consecutive days every 4 or 5 weeks (monthly arm). Therapy was continued until disease progression or unacceptable toxicity appeared. In the presence of disease progression, the study regimen was stopped and second-line treatment was instituted after the patient was discontinued from this study.

RESULTS

There was no significant difference of response rates between both regimens. The response rate were 14.3% in the weekly arm (2 CR and 5 PR, 95% CI: 2.6-25.2%) and 10.6% in the monthly arm (1 CR and 4 PR; 95% CI: 6.5-32.3%), respectively (P = 0.8957). The survival times were also similar between the two (P = 0.4207, log-rank test). The median survival were 15.8 months in the monthly arm and 18.4 months in the weekly arm. Hematologic toxicity was minimal in both arms. However, the monthly arm produced a higher toxicity in severe (grade 3-4) diarrhea (14.9% vs. 2%; P = 0.029) and stomatitis (8.5% vs. 0; P = 0.054).

CONCLUSIONS

Weekly bolus injection of 5-fluorouracil and low-dose leucovorin achieved a similar response rate and survival as compared with the Mayo Clinics' monthly 5-day schedule, but severe toxicity was less commonly seen using the weekly regimen. As current chemotherapeutic treatment for metastatic colorectal cancer is largely palliative rather than curative, the weekly bolus regimen may be a more favorable approach in managing metastatic colorectal cancer.

Phase II study of oral tegafur-uracil and folinic acid as first-line therapy for metastatic colorectal cancer: Taiwan experience

BACKGROUND

Tegafur-uracil has become an important regimen in the treatment of metastatic colorectal cancer. Tegafur is a prodrug that is converted to 5-fluorouracil (5-FU) and has been reported to be less toxic and to have a higher therapeutic index. The additional advantage of tegafur is oral administration, an important consideration to improve the quality of life in these patients. Tegafur in combination with uracil is thought to have greater anti-tumor activity due to the inhibitory effect of uracil on the degradation of 5-FU by hepatic dihydropyrimidine dehydrogenase. Tegafur with folinic acid has been reported with modest efficacy and acceptable toxicity. The purpose of this study was to evaluate the effectiveness and toxicity profile of oral tegafur-uracil plus folinic acid in Chinese patients with metastatic colorectal cancer.

METHODS

Between May 1998 and August 1999, 40 patients with metastatic colorectal carcinoma were enrolled in this study. All the patients had to have measurable lesions. The initial dose of tegafur-uracil was 300 mg/m2/day for 28 days, followed by a 7-day rest period. Folinic acid was administered orally at a dose of 60 mg/day concurrently with tegafur-uracil. For patients with neutrophil count <1500/microl or a platelet count <100,000/microl after treatment, the treatment was postponed for a maximum of 2 weeks. After that time, if the neutrophil count was 1000-1500/microl and the platelet count was 70,000-100,000 microl, the dose of tegafur-uracil was reduced by 50%, and if lower values resulted, the treatment was discontinued.

RESULTS

Forty patients received a total of 318 courses of treatment and a response rate of 32.5% (95% CI, 18-47%), including five complete remissions and eight partial remissions, was achieved. Toxicity was mild and generally tolerable. Gastrointestinal toxicities, including diarrhea, nausea and vomiting, were the major side effects. Seven incidences (17.5%) of grade 3-4 gastrointestinal toxicity were observed. Hematological toxicities were minimal with no evidence of severe (grade 3 or 4) leukopenia and thrombocytopenia. No episode of hepatic, renal, cardiac or neurological toxicity occurred. Two patients (5%) developed transient painful fissuring erythroderma over their palms and soles (the hand-foot syndrome).

CONCLUSIONS

The data from our study indicate that oral tegafur-uracil plus folinic acid is an active and tolerable first-line treatment for Chinese patients with metastatic colorectal cancer, with the additional advantage of being easily administered at home.

Vincristine-induced dysphagia suggesting esophageal motor dysfunction: a case report

Transient esophageal motor dysfunction with dysphagia was observed in a 62-year-old man receiving vincristine-containing chemotherapy for non-Hodgkin's lymphoma. Neurological examinations, including muscle strength of extremities, deep tendon reflexes and cranial nerves, were normal. However, the patient complained of severe numbness in the fingertips and toes. The results of esophagogram and esophagoscopy were unremarkable. However, a significantly prolonged esophageal transit time was observed. Vincristine was considered as the causative agent. Empirical vitamin and metoclopramide were prescribed for his neurological symptoms but there was no improvement. The symptoms of dysphagia subsided spontaneously 2 weeks later. However, prompt recurrence of severe dysphagia was observed again after administration of the second and third courses of treatment, which again disappeared upon discontinuation of the drug. Peripheral nerves and the gastrointestinal tract are often affected by vincristine. Common gastrointestinal tract symptoms of vincristine neuropathy may be colicky abdominal pain and constipation. However, vincristine-induced esophageal motor dysfunction with dysphagia is uncommon but generally reversible. The oncologist and chemotherapist should be aware of this complication.

Factors predictive of survival in patients with node-positive colorectal cancer in Taiwan

BACKGROUND/AIMS

Preoperative CEA levels, depth of tumor penetration, and the number of positive lymph nodes were reported as independent factors prognostic of survival in colorectal cancer patients. This study was carried out in an effort to evaluate the prognostic significance of these three factors in patients with Dukes' C colorectal cancer in Taiwan.

METHODOLOGY

Between 1992 and 1994, a total of 112 patients with node-positive colorectal cancer were evaluated retrospectively at the Veteran General Hospital-Taipei. All patients underwent potentially curative surgery and received 5-fluorouracil based adjuvant chemotherapy. Reference to the Dukes' classification was according to the classical criteria described in 1932 for carcinoma of the rectum and adapted for use in colonic tumors. Data on the location of the tumor, depth of penetration, number of positive lymph nodes, degree of tumor differentiation, and preoperative CEA levels were analyzed to understand their association with survival. Blood samples for CEA measurement were taken a few days before operation. A multivariate analysis using the Cox's proportional hazards regression model was then performed to determine the most important independent predictors of survival among all the possible variables.

RESULTS

Using univariate analysis the number of positive lymph nodes (P < 0.001), penetration of the bowel wall (P < 0.001), and preoperative CEA levels (P < 0.001) were found as significant prognostic factors, while the degree of tumor differentiation, location of the tumor, age and sex were not significant. Using multivariate Cox analysis the number of positive lymph nodes, penetration of the bowel wall, and preoperative CEA levels were still found as independent prognostic factors in node-positive colorectal cancer patients.

CONCLUSIONS

Data obtained from our study indicates that preoperative CEA levels, depth of tumor penetration, and the number of positive lymph nodes were independent prognostic factors in Dukes' C colorectal cancer patients. They could serve as appropriate modifications of the initial Dukes scheme in node-positive diseases.

Lack of mutations of BCL6 and BCL10 genes in mucosa-associated lymphoid tissue lymphomas of the orbital adnexa

Knowledge regarding the molecular pathogenesis and progression of mucosa-associated lymphoid tissue (MALT) lymphomas of ocular adnexa is limited. Eleven cases of ocular MALT lymphoma were analyzed by clonal rearrangement of antigen receptor genes using Southern blot hybridization. Polymerase chain reaction-single stranded conformational polymorphism analysis and DNA sequencing was utilized to analyze the mutations of BCL6 and BCL10 genes. Clonal rearrangement of immunoglobulin heavy genes was found in all 11 patients. No point mutation was found in BCL6 or BCL10 genes in any of the samples analyzed. We suggest that mutations of BCL6 and BCL10 genes are rare in low-grade MALT lymphoma of ocular adnexa and are unlikely to be involved in the pathogenesis of the disease. But the role of alterations of both BCL6 and BCL10 genes in the disease progression of low-grade MALT lymphoma require additional study.

Immunophenotypic and genotypic characteristics of chronic myelogenous leukemia in blast crisis

BACKGROUND

Chronic myelogenous leukemia (CML) may transform into blast crisis (BC) if not properly treated. Among patients with transformation, 20% to 30% will develop BC with lymphoid-associated antigens (Ly-BC), and the remaining cases with myeloid-associated antigens (My-BC) or with both (Mix-BC). In this study, we investigated the lineage of blast cells in CML-BC using immunophenotypic and genetic analyses and analyzed the prognostic significance of genotypic change in CML-BC.

METHODS

Twenty-one patients with CML-BC diagnosed at the Taipei Veterans General Hospital from 1982 to 1992 were included. Immunophenotyping was done by using the avidin-biotin immunoperoxidase technique. Genetic analyses were carried out by using Southern Blot hybridization. The prognostic influence of genotypic change was analyzed.

RESULTS

Thirteen patients (61.9%) expressed myeloid-associated antigens, one patient (4.8%) expressed megakaryoblast-associated antigens, four patients (19%) expressed B lymphoid-associated antigens and three patients (14.3%) expressed both myeloid and B lymphoid antigens. Clonal rearrangement of the immunoglobulin heavy chain (IgH) gene was found in six cases. Among them, four expressed B lymphoid markers only and two expressed both myeloid and B lymphoid markers. Patients with clonal IgH gene rearrangement tended to have a better response to chemotherapy (50% vs 8.3%, p = 0.08) and significantly longer survival (median survival, 5 months vs 3 months, p < 0.05) than did those with a germline configuration.

CONCLUSIONS

Clonal rearrangement of the IgH gene was found mostly in cases of Ly-BC and Mix-BC. We found that CML-BC with clonal rearrangement of the IgH gene had a more favorable prognosis than in cases with a germline configuration.

Comparison of the efficacy and safety of oral granisetron plus dexamethasone with intravenous ondansetron plus dexamethasone to control nausea and vomiting induced by moderate/severe emetogenic chemotherapy

BACKGROUND

Chemotherapy-induced nausea and vomiting can affect cancer patients' compliance with cytotoxic chemotherapy. Currently, there are some new antiemetic therapies for the treatment of chemotherapy-induced emesis. A single institution, randomized, open, parallel trial was done to compare oral granisetron plus intravenous (i.v.) dexamethasone with intravenous ondansetron for the prevention of moderate or severe emetogenic chemotherapy-induced acute and delayed emesis.

METHODS

Fifty-one cancer patients were treated with moderate/severe emetogenic chemotherapy and randomized to receive either oral granisetron 1 mg twice daily or i.v. ondansetron 8 mg every 8 hours combined with i.v. dexamethasone 10 mg on the day of chemotherapy. The efficacy and safety of the two antiemetic regimens were compared.

RESULTS

Oral granisetron plus i.v. dexamethasone had comparable antiemetic efficacy for the prevention of nausea in the first 24-hour period after initiation of chemotherapy compared with intravenous ondansetron plus i.v. dexamethasone. The complete response of antiemesis in the first 24-hour period after initiation of antiemetic therapy between granisetron and ondansetron were 84.0% (95% CI, 62.9%-95.6%) and 84.6 (95% CI, 64.0%-97.5%). The complete response for delayed emesis after initiation of antiemetic therapy between granisetron and ondansetron were 16.0% (95% CI, 4.5%-36.1%) and 19.2% (95% CI, 6.8%-40.7%0. There was diarrhea in 12% of patients receiving granisetron therapy and constipation in 23.1% of the ondansetron group.

CONCLUSIONS

Oral granisetron plus i.v. dexamethasone and i.v. ondansetron plus i.v. dexamethasone are potentially equally effective antiemetic agents in the prevention of moderate or severe emetogenic chemotherapy-induced acute or delayed emesis. Oral granisetron with dexamethasone appears to be a suitable alternative antiemetic agent in cancer patients who receive moderately or severely emetogenic chemotherapy.

Venous gangrene in a patient with adenocarcinoma of the lung

Cancer-related thromboembolism is a severe but not uncommon paraneoplastic syndrome in mucinous cancer patients. However, cancer-induced venous gangrene is extremely rare and has never been reported in the English literature. Here, we present a case of lung cancer complicated with venous gangrene of the left foot. An elevated serum anticardiolipin level was detected during hospitalization, but the patient's clinical condition stabilized after heparinization. We suggest that in cancer patients, an elevated serum anticardiolipin antibody level might be a warning sign of an impending thrombotic event and that low-molecular-weight heparin is a sensible choice in treating this kind of cancer-related thromboembolism.

Preoperative carcinoembryonic antigen level as an independent prognostic factor in colorectal cancer: Taiwan experience

BACKGROUND

Preoperative carcinoembryonic antigen (CEA) level is considered as a factor predictive of survival in colorectal cancer patients. Patients with normal (<5 ng/ml) or lower preoperative CEA levels were reported to have significantly longer survival. This study was carried out in an effort to evaluate the prognostic significance of preoperative CEA levels of patients with colorectal cancer in Taiwan.

METHODS

Between 1990 and 1994, 218 patients with histologically confirmed colorectal cancers were evaluated retrospectively at the Veterans General Hospital-Taipei. All the patients had undergone potentially curative surgery. Patients with metastatic diseases were not included. 5-Fluorouracil-based adjuvant chemotherapy was administered if the patients had Dukes' C disease. Reference to the Dukes' classification was according to the classical criteria described in 1932 for carcinoma of the rectum and adapted for use in colonic tumors. Data on gender, age, degree of tumor differentiation, location of the tumor, tumor size, lymph node metastasis, penetration of the bowel wall and preoperative CEA levels were analyzed to determine their association with survival. Blood samples for CEA measurement were taken a few days before operation and were analyzed using the radioimmunoassay method. Multivariate analysis by Cox's proportional hazards regression model was performed to determine the most important predictors of survival among all of the possible variables.

RESULTS

By univariate analysis, the size of the tumor (p = 0.012), lymph node metastases (p = 0.007), penetration of the bowel wall (p < 0.001) and preoperative CEA levels (p < 0.001) were found to be significant prognostic factors, while gender, age, degree of tumor differentiation and location of the tumor were not significant. By multivariate Cox analysis, lymph node metastases (p = 0.003), penetration of the bowel wall (p = 0.0001) and preoperative CEA levels (p = 0.0001) were found to be independent prognostic factors in colorectal cancer patients.

CONCLUSIONS

The data from our study indicate that in addition to lymph node metastases and penetration of the bowel wall, the preoperative CEA levels are also an independent prognostic factor in non-metastatic colorectal cancer patients after curative surgery. This could serve as an appropriate modification to the initial Dukes' scheme in colorectal cancer.

Prognostic significance of immunoglobulin and T cell receptor gene rearrangements in patients with acute myeloid leukemia: Taiwan experience

We investigated the prognostic significance of lymphoid antigen receptor gene rearrangement in patients with newly diagnosed acute myeloid leukemia (AML). Thirty-nine patients were included in the study. Clonal gene rearrangement of immunoglobulin heavy chain (IgH) and T cell receptor beta chain (TCRbeta) was found in leukemic cells in 11 (28.2%) and 10 (25.6%) patients, respectively. Five (12.8%) had both IgH and TCRbeta gene rearrangements. Three of the seven (42.9%) B-lymphoid marker-positive and eight of the 32 (25%) B-lymphoid marker-negative patients had clonal IgH gene rearrangements. Five of the 11 (45.5%) T-lymphoid marker-positive and 5 of the 28 (17.9%) T-lymphoid marker-negative patients had clonal TCRbeta gene rearrangements. All patients were treated with similar regimens. The complete remission rate (62.5% vs 65.2%, p=1.000) and median survival (13 vs 14 months, p=0.366) were similar in patients with and without clonal IgH or TCRbeta gene rearrangements. In conclusion, while clonal rearrangements of IgH or TCRbeta genes were found in AML patients, they did not appear to effect the prognosis.

Fulminant hepatitis is significantly increased in hepatitis B carriers after allogeneic bone marrow transplantation

BACKGROUND

Bone marrow transplantation (BMT) is effective treatment for many hematologic disease, but performed in a population with a high endemic hepatitis B virus carrier rate, the incidence of liver function impairment and fulminant hepatitis (FH) is expected to be raised.

METHODS

Forty-three hepatitis B virus carriers received high-dose chemotherapy and BMT, 32 patients received an allogeneic graft, and 11 patients autologous marrow. Acute graft-versus-host disease prophylaxis consisted of methotrexate on day 1, 3, 6, and 11 and cyclosporine for 6 months.

RESULTS

After a median follow-up period of 68 months (range: 1-11.5 years), 26 (81.3%) allogeneic BMT patients developed impaired liver function (LF), 5 progressed to FH on day 93, 169, 170, 180, and 468, respectively, and died after an average of 13.8 days (range: 1-45 days). Whereas only 4 (36.4%) autologous BMT patients developed impaired LF, and none FH. Impaired LF (P=0.026, chi-square), and FH (odds ratio=12.86, P=0.009 for coefficient) were significantly related to an allogeneic marrow graft, and the timing of liver function impairment coincided with cyclosporine withdrawal. Hepatitis B surface antigen (HbsAg) disappeared from the serum in 4/14 (28.6%) patients receiving a marrow graft from an HbsAg+ donor. HbsAg was not detected in the serum after BMT in 2/11 (18.2%) autologous BMT patients.

CONCLUSIONS

Hepatitis B virus carriers receiving a marrow graft from an HbsAg+ donor have a significantly increased risk of FH.

p53 gene mutations and rearrangements in non-Hodgkin's lymphoma

BACKGROUND

Alterations of the p53 gene have been associated with the progression of certain human malignancies. To establish further the correlation between p53 gene alterations and progression of non-Hodgkin's lymphomas (NHLs), the authors analyzed both mutations and rearrangements of the p53 gene in a cohort of 84 NHLs.

METHODS

Eighty-four NHLs were analyzed for p53 gene alterations. Point mutations of exons 5-9 were studied by polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP), and DNA rearrangements were studied by Southern blot analysis. RESULTS. Point mutations and DNA rearrangements of the p53 gene were detected in 6 (7.2%) and 3 (3.6%) patients, respectively. All p53 gene abnormalities were found exclusively in B-cell NHLs. Taken together, patients with p53 gene alterations had poorer survival than other patients (P = 0.024). However, of the three patients with p53 gene rearrangements, the two who appeared to have one normal allele showed a relatively better response to chemotherapy and had longer survival (27 and 47 months). In contrast, the remaining patient who had rearranged bands much stronger than the germline, and thus appeared to have both alleles rearranged, was refractory to chemotherapy and had poorer survival (6 months).

CONCLUSIONS

Patients with NHLs of intermediate and high grades who carried point mutations or rearrangements of p53 genes had worse outcomes than other patients. Patients with one abnormal p53 allele and one residual normal allele had a more favorable prognosis than those with two abnormal alleles.

ESHAP as salvage therapy for refractory non-Hodgkin's lymphoma: Taiwan experience

BACKGROUND

The ESHAP regimen, a combination of the chemotherapeutic drugs etoposide, methylprednisolone (solumedrol), high-dose cytarabine (ara-C) and cisplatin, has been shown to be active against refractory non-Hodgkin's lymphoma in therapeutic trials. We were interested in determining whether this regimen would be effective and tolerable for Chinese patients.

METHODS

Thirty-two patients with refractory/relapsed non-Hodgkins lymphoma (23 intermediate-grade and nine high-grade) were enrolled in this study. Etoposide was administered at a dose of 40 mg/m2/day as a 1 h intravenous infusion from day 1 to day 4, solumedrol 500 mg/day was given as a 15 min intravenous infusion from day 1 to day 5, ara-C 2 g/m2 was given as a 2 h intravenous infusion on day 5 and cisplatin was given at a dose of 25 mg/m2/day as a continuous infusion from day 1 to day 4. Clinical efficacy and toxicity were assessed on the basis of the WHO criteria.

RESULTS

Ten patients (31.3%, 95% Cl 15.2-47.4%) attained complete remission (CR) and seven had partial remission (PR). The overall response rate was 53.1% (95% Cl 35.8-70.4%). In eight of the 10 CR patients, the remission lasted for more than 8 months. The remaining two patients had CR of 5 and 6 months. The median duration of CR was 12.2 months (range 5-22 months). Myelosuppression with subsequent infections was the major toxicity. Severe leukopenia (WBC < 1000/microliter) lasted for an average of 12 days and thrombocytopenia (< 25,000/microliter) 18 days. One patient (3.1%) died of neutropenia-associated sepsis within 4 weeks after treatment. Non-myeloid toxicities included alopecia in 66% (28% grade 2, 22% grade 3), stomatitis in 72% (25% grade 2, 28% grade 3, 13% grade 4), hepatotoxicity in 9% (3% grade 2), renal toxicity in 13% (6% grade 2, 3% grade 3) and infection in 56% (18% grade 2, 25% grade 3, 13% grade 4). The majority of the responders relapsed within 2 years after ESHAP treatment. Median survival for all patients was 8.6 months.

CONCLUSIONS

ESHAP is an active and tolerable regimen in Chinese patients with relapsed/refractory lymphoma, but the duration of remission is brief and without significant impact on survival.

Toxic cardiogenic shock in a patient receiving weekly 24-h infusion of high-dose 5-fluorouracil and leucovorin

A 54-year-old man was treated with weekly 24-h infusion of high-dose 5-fluorouracil (2600 mg/m2) and leucovorin (100 mg/m2) for metastatic colon cancer. At first, he tolerated the treatment well and no significant toxicity was identified. After a total of eight courses of treatment, a stable disease was observed, but mild shortness of breath was found on occasion. The patient had no previous history of cardiac disease and the heart performance assessed by left ventricular ejection fraction before treatment was normal. Unfortunately, acute pulmonary edema with lethal cardiogenic shock occurred during the ninth course of treatment, in spite of intensive medical treatment. The chest X-ray showed extreme cardiomegaly. Repeated assessment of his heart function by echocardiogram and ventricular ejection fraction revealed a very poor cardiac performance. Toxic cardiogenic shock during weekly 24-h infusion of high-dose 5-fluorouracil and leucovorin is extremely rare. To the best of our knowledge, no case has been reported in the English literature. We report a case and the relevant literature about the incidence, clinical picture and possible pathophysiology on 5-fluorouracil-related cardioxicity is reviewed.

Phase II study of the modified regimen of etoposide, leucovorin and 5-fluorouracil for patients with advanced gastric cancer

BACKGROUND

The efficacy of the treatment of advanced gastric cancer is not very good. The response rate to the original etoposide--leucovorin--5-fluorouracil (ELF) treatment is 53% with tolerable side effects. Whether increasing the dose intensity by prolonging the duration of infusion with 5-fluorouracil (5-FU) and leucovorin (LV) from 3 to 5 days for advanced or metastatic gastric cancer patients would enhance the efficacy but not increase side effects is still unknown.

METHODS

Thirty-six advanced or metastatic gastric cancer and chemotherapy-naïve patients with measurable or evaluable diseases were scheduled to receive intravenous etoposide 100 mg/m2/day on days 2-4, LV 300 mg/m2/day intravenously and 5-FU 500 mg/m2/day intravenously on days 1-5, every 4 weeks. All patients who received at least two courses of chemotherapy were evaluated for tumor response, survival and response duration and toxicity according to the WHO criteria.

RESULTS

Thirteen patients showed a response, including five with complete response (CR). The overall response rate was 36% (95% confidence interval, CI, 20-52%) in the whole group and 46% (95% CI 28-66%) in the 28 patients with measurable disease. The median progression-free interval and overall median survival time were 5 and 7 months, respectively. The most frequent toxicity was alopecia (grade I/II 56.3%). The incidence of grade III or greater myelosuppression was 5.9%. No treatment-related death occurred.

CONCLUSIONS

The efficacy of the modified ELF by increasing the dosages of 5-FU and LV is not superior to the results of the original regimen, yet it is a relatively safe and tolerable combination regimen for advanced gastric cancer.

Molecular cloning and characterization of a human brain-specific gene implicated in neuronal differentiation

A 2.5 kb human cDNA clone containing a CAG trinucleotide repeat, designated HB20, was isolated from a human fetal brain library. Northern analysis on multi-tissue blots and various cell lines confirmed that HB20 is specifically expressed in the brain. Its expression is low in two glioma cells, moderate in a neuron precursor cell, NT2, but absent in lymphoma, cervical carcinoma, or colonic carcinoma cells. Significant increase of HB20 mRNA was shown along with retinoic acid-induced terminal differentiation of NT2 cells into neuron cells, hNT. Homology comparison of the predicted HB20 amino acid sequence with the current database revealed that it belongs to a newly recognized protein family composed of nucleosome assembly proteins and SET proto-oncogene, which has been shown to interact specifically with B-type cyclins involved in the control of cell proliferation. Together with the detection of nuclear localization signals and apparent nuclear distribution of expressed protein, HB20 is likely to be a brain-specific nuclear protein, functioning in the process of neuronal differentiation.

Weekly 24-hour infusion of high-dose 5-fluorouracil and leucovorin in patients with advanced colorectal cancer: Taiwan experience

Between January 1994 and November 1995, 41 patients with metastatic colorectal carcinoma were enrolled in this study. All these patients had recurrent disease after a prior 5-fluorouracil based adjuvant chemotherapy or failed to achieve response by prior chemotherapy that included 5-fluorouracil. 5-Fluorouracil, 2600 mg/m2, was administered concurrently with 100 mg/m2 leucovorin over 24 hours of continuous intravenous infusion. The treatment was repeated every week until progressive disease was documented. Forty-one patients received a total of 810 courses of treatment. The overall response rate was 17.1% (95% confidence interval 5.6-28.6%). In two patients who achieved complete response, the liver was the metastatic site. The median survival was 18.4 months for responders and 12.6 months for non-responders. Gastrointestinal toxicities including diarrhea, stomatitis, nausea and vomiting were the major side-effects. Sixteen incidences (39.0%) of grade 2-3 gastrointestinal toxicities were observed. One patient (2.4%) developed a grade 3 cardiac toxicity, and another one (2.4%) had a grade 2 neurotoxicity. Hematological toxicities were minimal with no evidence of severe (grade 2 or more) leukopenia or thrombocytopenia. We conclude that in patients with pretreated metastatic colorectal cancer, weekly 24-hour infusion of high-dose 5-fluorouracil and leucovorin is associated with higher efficacy and tolerable toxicity. This regimen is a good option as a second-line treatment for those whose diseases are recurrent from or refractory to prior 5-fluorouracil, and deserves a longer period of follow-up.

Factors predictive of response and survival in patients with metastatic colorectal cancer in Taiwan

5-Fluorouracil in combination with leucovorin has been shown to be active in therapeutic trials of metastatic colorectal carcinoma. In this study, we administered these drugs to 72 patients with metastatic colorectal carcinoma. Thirty-six of them without previous exposure to 5-fluorouracil were treated with weekly bolus injections of 5-fluorouracil (425 mg/m2) and leucovorin (25 mg/m2) supplemented with oral levamisole. Another 36 patients with or without prior 5-fluorouracil treatment received 5-fluorouracil 3,000 mg/m2 and leucovorin 300 mg/m2 in a 48-hour continuous infusion every two weeks. Clinical efficacy and toxicity were assessed by WHO criteria. Variables were tested for relations to response and survival by univariate and multivariate analysis. The response rate was 19.4% in weekly bolus arm and 13.9% in biweekly high-dose infusion arm (P = 0.527). Median survivals in the two arms were 18.4 months (weekly) and 21 months (biweekly) respectively (P = 0.708). Gastrointestinal side effects including nausea, vomiting, diarrhea and mucositia were the major toxicities of these regimens. By multivariate analysis, the only factor to influence response rate was the site of metastases (P = 0.009). The only factor to affect survival was performance status of the patient (P = 0.0001). We concluded that the two 5-fluorouracil based regimens are well-tolerated and shown to have a response rate comparable with previous reports of similar regimens in patients with metastatic colorectal cancer. Only liver metastases seemed to have a better response to therapy. Performance status is the most important prognostic factor in patients with metastatic colorectal cancer.

Trisomy 21 in acute myeloid leukemia

We report two cases of acute myeloid leukemia (AML), constitutionally normal, with trisomy 21. Trisomy 21 does not often occur as a sole numerical karyotypic abnormality in AML leukemia. The possible prognostic significance of the finding in acute leukemia is discussed.

Intramedullary spinal cord metastasis: a case report

Intramedullary spinal cord metastasis is a rare condition of systemic malignancy. We report a case of breast cancer with thoracic spinal cord intramedullary metastasis. The patient suffered from neurological deficit in both lower extremities. Magnetic resonance imaging (MRI) examination showed two soft tissue lesions located in the medullary region of thoracic spinal cord at T3 to T5 vertebral level. She was treated with local radiotherapy and systemic corticosteroid treatment with much improvement of the symptoms.

Comparison of intravenous granisetron with metoclopramide in the treatment of chemotherapy-induced emesis

BACKGROUND

It is well known that chemotherapy-induced nausea and vomiting not only produce undesirable physical effects but also reduce patients' willingness to continue chemotherapy. The effect of a 5HT3 receptor antagonist, granisetron, on antiemesis was studied in patients who were receiving cisplatin-based chemotherapy.

METHODS

Forty patients with malignant diseases, who were scheduled to receive cisplatin-based chemotherapy, were randomly assigned to receive either a single intravenous dose of granisetron (3 mg) (n = 20) or multiple doses of metoclopramide (2 mg/kg) (n = 20) as trial. The efficacy of antiemetic therapy was assessed based on the patient's subjective assessment of nausea and vomiting, and the physician's global evaluation of nausea and vomiting in the first 24 hours and during the following 6 days.

RESULTS

During the first 24 hours, there was a statistically significant advantage for the granisetron group in terms of prevention of both nausea and vomiting. The number of complete responders in the first 24 hours for the granisetron and metoclopramide groups was 16 (80%) and 9 (45%), respectively (p < 0.05). The control rate of anti-nausea over 6 days was 45% and 5% in the granisetron and metoclopramide groups, respectively (p < 0.001). The frequency of adverse events in the granisetron and metoclopramide groups was 10% and 45%, respectively. Analysis of laboratory data showed no significant difference between these two groups prior to and after administration of chemotherapy.

CONCLUSIONS

A single 5-minute infusion of 3 mg granisetron was more effective and produced a less adverse effect than multiple doses of metoclopramide in controlling chemotherapy-induced emesis, both in the first 24 hours and over a 6-day period.

Liver disease after bone marrow transplantation--the Taiwan experience

To investigate the causes of impaired liver function (LF)* after BMT, 88 patients were included for analysis of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, transplant methods, preconditioning regimens, and graft-versus-host disease (GVHD). Fifty of them (56.8%) developed abnormal LF after BMT and among them, 29 (32.9%) developed chronic hepatitis (CH). By univariate analysis, HCV infection, pretransplant abnormal LF, allogeneic BMT, and preconditioning regimen with total body irradiation were all significantly related to higher incidence of post-BMT impaired LF. However, only HCV infection, pretransplant abnormal LF, and acute GVHD were associated with higher incidence of CH. By multivariate logistic regression analysis, HCV infection and pretransplant abnormal LF were the two most significant interpreters for abnormal LF, especially for CH (odds ratios: 7.86 and 4.735, respectively) after BMT. Although the incidence of abnormal LF was found high in this study, there was no significant disadvantage in terms of survival for patients who developed abnormal acute and chronic liver function after BMT. However, a long-term follow-up is needed to evaluate survival pathology of CH, such as liver cirrhosis and hepatoma.

1,25-Dihydroxyvitamin D3 suppresses cell growth, DNA synthesis, and phosphorylation of retinoblastoma protein in a breast cancer cell line

Cells of a breast adenocarcinoma cell line, CAMA-IEe, were found to contain a moderate concentration of 1,25-dihydroxyvitamin D3[1,25(OH)2D3] receptors. The receptors' dissociation constant calculated by Scatchard analysis was 4.1 x 10(-10) M. These receptors sedimented at around 4.0 S position on a linear 5-20% sucrose density gradient and exhibited an apparent molecular weight of about 46 kDa. Receptor concentration was found to be highest in the early stages of cell growth, decreased continuously when cells were actively growing, and reached the lowest level at confluence. Suppression of cell growth, of DNA synthesis, and of the phosphorylation of retinoblastoma protein by 1,25(OH)2D3 at concentrations about 10(-7) M were observed. Treatment with 10(-7) M 1,25(OH)2D3 for 12 hr or longer caused elevation of cytosolic free calcium in CAMA-IEe cells. These results show that CAMA-IEe cell growth is suppressed by 1,25(OH)2D3 and that the suppression is possibly mediated through calcium mobilization.

Bone marrow transplantation in Taiwan: low incidence of acute GVHD in patients with hematologic malignancies and severe aplastic anemia

A total of 116 consecutive patients, including 82 cases of hematologic malignancies and 34 cases of severe aplastic anemia (SAA), were treated by allogeneic bone marrow transplantation (BMT). The conditioning regimens and post-graft immunosuppressive agents were as described by Thomas in Seattle and Santos in Baltimore. The incidence of grades II-IV acute GVHD in patients with hematologic malignancies with a full HLA match, with one locus and with two loci mismatches was 6.3% (4 of 63), 0% (0 of 11) and 37.5% (3 of 8), respectively. None of SAA patients developed grade II-IV acute GVHD. The low incidence of acute GVHD after BMT among Chinese patients may be associated with the use of isolation in laminar airflow rooms and a relatively low level of genetic diversity in histocompatibility antigens. This is an interesting issue for further study.

The application of immunocytochemistry in diagnosis of meningeal carcinomatosis in a patient with unknown primary site

A 55-year-old female with meningeal signs was suspected to have carcinomatosis meningitis based on cytospin cytology study of cerebrospinal fluid (CSF) with Wright stain. There was no primary site of any malignancy which could be identified as the source of metastasis. Immunochemical staining for cytokeratin and carcinoembryonic antigen on suspicious large immature cells in the CSF gave positive results and confirmed the malignant nature of her disease. Intrathecal chemotherapy with methotrexate and whole brain irradiation then eradicated the symptoms rapidly. Immunocytochemistry was considered to be a very powerful diagnostic tool in management of this patient.

Reverse seroconversion of hepatitis B virus infectious status after allogeneic bone marrow transplantation from a carrier donor

A 35-year-old man with acute promyelocytic leukemia received an allogeneic bone marrow transplant (BMT) in second complete remission. The donor was his 18-year-old brother, a chronic hepatitis B virus (HBV) carrier with detectable serum hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg) and hepatitis B virus DNA (HBV DNA). Before BMT, the recipient was immune to HBV, with serum antibody to HBsAg (anti-HBs), antibody to HBeAg (anti-HBe) and normal liver function. Examination of the recipient serum drawn 2 months after BMT revealed reverse seroconversion from anti-HBs/anti-HBe to HBsAg/HBeAg, which remained positive thereafter. Upon reducing cyclosporin 6 months after BMT, acute hepatitis occurred with HBV DNA in serum as evidence of active HBV replication; the patient then developed chronic hepatitis which progressed to cirrhosis and hepatic decompensation within 8 months. Transfusion of HBV DNA/HBeAg-positive bone marrow is thus harmful even when the recipient has anti-HBs prior to BMT.

Withdrawal of immunosuppressive therapy in allogeneic bone marrow transplantation reactivates chronic viral hepatitis C

A 28-year-old female patient with acute myelogenous leukemia and post-transfusion chronic viral hepatitis C received an allogeneic bone marrow transplantation (BMT) in first complete remission. The inflammatory activity of chronic hepatitis C decreased dramatically with the start of BMT and during the whole course of cyclosporin A treatment. After the immunosuppressive therapy was stopped, however, the chronic hepatitis C activity increased and the serum alanine amino-transferase levels thereafter remained as high as before BMT. Hepatitis C virus RNA was detected by polymerase chain reaction in serum drawn 60 days and 52 months after BMT. Since fulminant viral hepatitis B may take place after tapering of immunosuppressive therapy following BMT due to an excessive response of recovering immunity to the actively replicating virus during immune suppression, careful monitoring of liver function for patients with chronic viral hepatitis C in BMT is suggested.

[Diagnosis and treatment of small intracerebral abscess]

Diagnosis and treatment of 39 cases of small intracerebral abscess are reported. All of them were proved pathologically. The main symptom was epilepsy. It may be due to hemorrhagic infection, occurred more in teenagers, and located around the parietal lobe. Some diagnostic characters and essential points on surgery are also presented in the paper. Finally, the authors suggest two-stage management for the disease is the best choice. About 89.7% of patients obtained good results.

Gene rearrangement of cutaneous T-cell lymphoma

Gene Rearrangement is considered to be a helpful tool for diagnosis of cutaneous T-cell lymphoma. In this study five patients with clinical diagnosis of cutaneous T-cell lymphoma were reviewed for their clinical presentation, skin biopsies and surface marker phenotypes. Southern blot analysis of DNA extracted from their skins revealed that rearrangement of T-cell receptor beta chain (TCRB) genes happened in three patients but rearrangement of immunoglobulin heavy chain genes was absent. TCRB rearrangement could also detect lymphoma involvement of lymph nodes, peripheral blood and bone marrow in our patients. In these conditions, systemic therapy is suggested.

[Screening of antibodies to human T-cell leukemia virus type I (HTLV-I) in sera of blood donors and comparison of different methods]

Nine hundred and sixty five serum samples of blood donors from the blood bank of Veterans General Hospital Taipei were screened for antibodies to human T-cell leukemia virus type I (HTLV-I) by different methods. Adult T-cell Leukemia cell lines MT-1, MT-2, KH-2 and MT-2 stimulated by phorbol 12-myristate 13-acetate (PMA) were used as target cells in immunofluorescence microscopy (IF) examination with positive rates as 0.20% (2/965), 0.62% (6/965), 0.20% (2/965) and 0.51 (5/965) respectively. In addition to these, enzyme-linked immunosorbent assay (ELISA) gave a 2.59% (25/965) positive rate and particle agglutination (PA) test revealed a positive rate of 0.93% (9/965). The samples positive in IF were also positive in PA and those positive in PA were found positive in ELISA without exceptions. The 25 ELISA positive samples as well as 75 samples randomly chosen from the ELISA negative ones received Western blot (WB) analysis as a confirmation test. Only 3 of these 100 were considered positive in WB, giving a final positive rate of 0.31%, (3/965), and all of them were originally positive in both PA and ELISA. Particle agglutination test as the screening test and Western blot analysis as the confirming one were suggested to be a routine procedure for detecting anti-HTLV-I antibodies in blood banks through detailed comparison and discussion.