Risk evaluation of the use of complementary and alternative medicines in cancer

INTRODUCTION

Cancer patients use complementary and alternative medicines (CAM) to improve their well-being. Little is known about real risks.

OBJECTIVE

To highlight 3 different types of axes: 1/cancer patients' perceptions concerning CAM; 2/misinformation/miscommunication about CAM; 3/CAM toxicity (direct toxicity, CAM-anticancer drugs, CAM-cancer interactions).

METHOD

A questionnaire was proposed to cancer patients for 2 months. The CAM toxicity was analyzed if patients documented their drugs and CAM.

RESULTS

Eighty-five patients responded: 72/85 were taking≥1CAM. In total, 95% patients were satisfied. There was an increasing CAM intake after cancer diagnosis. One hundred and seventeen different CAM were identified (63 herbs, 24 essential oils, 28 food supplements, 2 homeopathic specialities). Only 30/85 were aware CAM could interact with anticancer drugs. No other type of risk was perceived.

INFORMATION SOURCES

43/85 Internet, 38/85 general practitioner, 38/85 community pharmacist, 32/85 entourage, 25/85 other patients, 22/85 oncologist. In total, 81.3% questioned healthcare professionals (HCP) about CAM. Twelve patients noticed HCP lacked knowledge regarding CAM. The toxicity analysis was carried out for 24 patients who consumed 1 to 24CAM. In total, 133CAM were reported, including 87 different CAM. For only 43CAM/87, studies were found. All patients presented≥1risk: 14 at risk of CAM-cancer interactions, 15 of CAM-anticancer drug interactions, 21 of CAM direct toxicities.

CONCLUSION

Many CAM are used by patients. The diagnosis of cancer favors their use. The risks are manifold: low perception of risk that can be induced by CAM, diverse and insecure sources of information and many potential toxicities that are not scientifically documented.

Diagnosis of pulmonary embolism in hospitalised patients: retrospective survey of an institutional standard

The aim of the present study was to assess the safety and implementation of a diagnostic strategy in hospitalised patients with suspected acute pulmonary embolism (PE). A diagnostic strategy was established and implemented in a general hospital. A retrospective cohort study, including 400 consecutive in-patients, was performed in order to assess the appropriateness of the diagnostic management and the incidence of symptomatic venous thromboembolic events (VTE) during follow-up. PE was confirmed in 116 (29%) patients. The incremental value of adding compression ultrasonography (CUS) to multidetector-row computed tomography (MDCT) for the diagnosis of PE was 8.6%. PE was appropriately excluded in 169 (42%) patients due to a normal lung scan (n = 34), a negative MDCT providing an alternative diagnosis (n = 94), and a negative MDCT and CUS (n = 41). During follow-up, VTE occurred in 3.5% patients. The almost unique cause of inappropriate management was the absence of further work-up after a MDCT-negative result for PE providing no alternative diagnosis (n = 115). Inappropriate management was associated with a nonsignificant increased risk of VTE (7.2%). A frontline diagnostic work-up based on pulmonary multidetector-row computed tomography associated with a compression ultrasonography of the leg veins is effective and more sensitive than pulmonary multidetector-row computed tomography alone in ruling out pulmonary embolism.

[Primary non-small-cell lung cancer: analysis of 419 T1 (<or=3 cm) tumors in the KBP-2000-CPHG study]

T1 tumors have the best prognosis among primary non-small-cell lung cancers, basically because surgery is generally possible. Among 5.667 patients with primary lung cancer included in the KBP-2000-CPHG study, we examined the characteristics of 419 T1 tumors, i.e. 9.2% of the non-small-cell cancers. Compared with the group of patients with non-T1 tumors, patients with T1 tumors were younger (p=0.0007). They had an equivalent percentage of squamous-cell tumors but more adenocarcinomas (40.3% versus 35.5%, p=0.05). TNM staging showed that 27.6% of the T1 tumors were metastatic at diagnosis (stage IV) with 12.4% T1N0M1 nad 15.2% T1N1-3M1. For the M0 tumors, 52.2% were T1N0 (stage IA) and 20.1% were T1N1-3. Squamous-cell tumors were significantly more frequent among the T1M1 tumors (p=0.07). More than one quarter (27.6%) of the T1 tumors were in stage IV, pointing out the importance of the initial work-up. This findings suggests we should revisit strategies in order to take into account new diagnostic possibilities. Likewise for the therapeutic strategy. Combinations using chemotherapy, surgery and radiotherapy should be better defined for this group of tumors.

Chimiothérapie en pratique de routine des cancers bronchiques non à petites cellules (CBNPC) localement avancés ou métastasés

BACKGROUND

Patients in ANCCLC chemotherapy-trials are not representative of the general lung cancer population. The purpose of this study was to describe the ANCCLC population routinely treated by chemotherapy in a general hospital, and to assess the results of chemotherapy in this population.

METHODS

All newly diagnosed IIIB/IV ANCCLC chemotherapy-treated patients over a three-year period were prospectively assessed for response rate, toxicity and survival.

RESULTS

Seventy seven patients (70% stage IV, 69% PS 1/0, 30% with cerebral metastases, 60% ineligible for major lung trials) received first-line chemotherapy (cisplatine or paraplatine with vinorelbine) with tumor control in 31 (40%) and symptom improvement in 20 (26%) patients. 17 (22%) patients experienced febrile neutropenia. 33 (43%) patients received second line chemotherapy (gemcitabine) with tumor control in 12 (36%) and symptom improvement in 9 (27%) patients. Overall median survival was 7 months and 30% patients were alive at 1 year.

CONCLUSIONS

Routinely ANCCLC chemotherapy-treated patients in our center have poor prognostic factors and many comorbidities. Chemotherapy results in tumor control in 43% patients, - of whom two thirds have symptom improvement -, with a high rate of febrile neutropenia.

Alveolar lymphocytosis in patients with chronic uveitis: relationship to sarcoidosis

Bronchoalveolar lavage (BAL) is frequently performed in patients with suspected ocular sarcoidosis. This study describes the immunogenetical, immunological, radiological, and functional features of a subclinical alveolar lymphocytosis unrelated to sarcoidosis in patients with chronic uveitis. Two hundred and ten patients with chronic uveitis of unknown origin, who underwent fiber-optic bronchoscopy with BAL as part of a prospective protocol over a three-year period, were evaluable for retrospective analysis. Sixty-five patients had alveolar lymphocytosis: Sarcoidosis was diagnosed in 13 (6%) patients, whereas alveolar lymphocytosis was considered unrelated to sarcoidosis in 52 (25%). Alveolar lymphocytosis unrelated to sarcoidosis was not associated with radiologically detectable interstitial lung disease or pulmonary function impairment. CD4/CD8 lymphocyte ratio was 3.7 +/- 3.0. Total cell count, total lymphocyte, and CD4 lymphocyte percentage were significantly lower when compared with sarcoidosis-related alveolitis (129,000 +/- 80,000 vs. 218,000 +/- 117,000, p <0.05; 33.1% +/- 13.2 vs. 39.7% +/- 13.2, p <0.05; and 54.3% +/- 18.2 vs. 65.4% +/- 10.1, p <0.05, respectively). Patients with alveolar lymphocytosis unrelated to sarcoidosis were older (47.8 +/- 17.7 years vs. 42.7 +/- 14.2 years, p <0.05) and more likely to carry the HLA-B51 allele (19.7% vs. 7.1%, p <0.01) than patients with chronic uveitis without alveolar lymphocytosis. They did not appear to be at risk of developing clinically apparent interstitial lung disease on followup. We conclude that alveolar lymphocytosis is frequently observed in patients with chronic uveitis. It is generally unrelated to sarcoidosis and may then be associated with a distinctive immunogenetic phenotype.

[Value of stereotaxic biopsy in diagnosis of subclinical breast lesions]

ALTERNATIVE TO SURGERY: New stereotactic guided breast biopsy procedures may constitute a major issue for the diagnosis of non-palpable breast lesions detected at mammography by eliminating the need for surgery in many women with benign breast disease.

INDICATIONS

Vacuum-assisted core biopsies provide more complete sampling than the conventional 14-gauge stereo-tactic core biopsies, reducing the number of unsatisfactory biopsies. The more invasive advanced breast biopsy device obtains an intact lesion in its entirety for histological assessment. Currently, there is no definite strategy delineating the precise indications for the diagnosis of screening detected abnormalities.

PERSPECTIVES

Because of the increase of the diagnostic armamentarium, care of women with non-palpable breast lesions should be multidisciplinary, involving radiologist, surgeons and histologists and rigorous medical and economic evaluation of diagnostic strategies involving these new health technologies should be pursued.

Traumatic coronary-pulmonary artery fistula, 23 years after a stab wound

We describe a 50-year-old man with onset of severe hemoptysis and anemia. Twenty-three years earlier, he had undergone a surgical procedure for a left thoracic wound as a result of a knife injury. Current diagnosis of aneurysm of the left ventricle and coronary-pulmonary artery fistula was made after coronary arteriography. The patient underwent resection of the aneurysm and repair of the fistula.

Transfer of human CD4(+) T lymphocytes producing beta interferon in Hu-PBL-SCID mice controls human immunodeficiency virus infection

Beta interferon (IFN-beta) exerts pleiotropic antiretroviral activities and affects many different stages of the human immunodeficiency virus (HIV) infectious cycle in IFN-treated cells. To explore whether transfer of genetically engineered human CD4(+) T cells producing constitutively low amounts of IFN-beta can eradicate HIV in vivo, we developed a new Hu-PBL-SCID mouse model supporting a persistent, replicative HIV infection maintained by periodic reinoculations of activated human CD4(+) T cells. Transferring human CD4(+) T cells containing the IFN-beta retroviral vector drastically reduced the preexisting HIV infection and enhanced CD4(+) T-cell survival and Th1 cytokine expression. Furthermore, in 40% of the Hu-PBL-SCID mice engrafted with IFN-beta-transduced CD4(+) T cells, HIV-1 was undetectable in vivo as well as after cocultivation of mouse tissues with human phytohemagglutinin-stimulated lymphoblasts. These results indicate that a therapeutic strategy based upon IFN-beta transduction of CD4(+) T cells may be an approach to controlling a preexisting HIV infection and allowing immune restoration.

Clinical utility of an amplification test based on ligase chain reaction in pulmonary tuberculosis

We evaluated the sensitivity and specificity of a new semiautomated direct amplification test (DAT), the LCx-MTB, for the diagnosis of pulmonary tuberculosis (TB) and assessed its positive predictive value by focusing on patients with high clinical and radiologic suspicion of pulmonary TB. Respiratory tract specimens from 32 consecutive patients with high suspicion of active pulmonary TB (case patients) and from 204 control patients were cultured for Mycobacterium tuberculosis and tested by LCx-MTB. Sensitivity and specificity of LCx-MTB when compared with culture was, respectively, 80 and 98%. Pulmonary TB was confirmed in the 32 case patients without knowledge of the LCx results: 18 patients were smear- and culture-positive for M. tuberculosis, and all gave at least one specimen that was LCx-positive. Eight patients were smear-negative culture-positive, and seven gave at least one LCx-positive specimen. LCx-MTB was negative in all the specimens obtained from six patients with smear- and culture-negative TB. A positive LCx-MTB result in a smear negative specimen was 100% predictive that at least one of the case patients' specimens would yield M. tuberculosis. As a consequence, knowledge of the LCx-MTB results at the time of specimen collection could have hastened the start of the antituberculosis therapy in three (21%) smear-negative case patients and could have avoided unnecessary invasive diagnostic procedures in four (29%). We conclude that the sensitivity of LCx-MTB in detecting M. tuberculosis DNA in respiratory tract specimens is similar to other DATs, that LCx-MTB is a reliable test for confirmation of TB in smear-positive patients and that LCx-MTB could be beneficial as a diagnostic step in smear-negative patients with a high suspicion of pulmonary TB.

Preliminary results of collapse therapy with plombage for pulmonary disease caused by multidrug-resistant mycobacteria

Seven patients underwent collapse therapy with polystyrene sphere plombage for pulmonary disease caused by multidrug-resistant mycobacteria. Four patients were infected with multidrug-resistant strains of Mycobacterium tuberculosis, two with Mycobacterium xenopi, one with Mycobacterium avium. All patients were heavily pretreated before surgery, had extensive, bilateral cavitary disease and were considered unsuitable for resection because of extensive disease or functional respiratory impairment. Six patients had active disease at time of surgery. Collapse therapy with insertion of six to 18 spheres resulted in long-standing bacteriological conversion in six patients. Collapse therapy was unilateral in six and bilateral in one. No immediate postoperative complication or death was observed. Hospital stay was short (mean 12 d). Collapse therapy is a conservative alternative therapy in patients with pulmonary disease caused by multidrug-resistant mycobacteria at high risk of treatment failure considered unsuitable for pulmonary resection.

[Thoracic infections in immunocompetent patients. The contribution of computed tomography]

Chest X-Ray is the most accurate method of imaging for infectious diseases in an immunocompetent patient. Computed tomography (CT) may be useful in certain circumstances, particularly in case of atypical findings at the time of diagnosis or in case of complications. CT helps to detect and perform a complete study of the lesions, some aspects being very suggestive of a diagnosis, as in post-primary active tuberculosis. CT may also detect an unknown underlying etiology. Multiplanar reformations with helical CT can be useful for example in case of empyema. In case of non tuberculous bacterial infections, CT is mainly recommended when abscess and empyema are difficult to differentiate or in case of pleural complications with possible percutaneous treatment. In case of tuberculosis, CT may be indicated when clinical and chest X-Ray findings are discordant, in case of mediastinal adenopathies, when reactivation is suspected or in case of complications as hemoptysis. A baseline CT examination could be proposed at the end of a specific treatment to facilitate the diagnosis of reactivation tuberculosis. A nontuberculous mycobacterial infection should finally be suspected in front of peculiar CT findings.

[Antitubercular chemotherapy]

Treatment of tuberculosis has three major goals: healing the patient, preventing selection of resistant strains and control transmission of tuberculosis. A 6 month regimen consisting of isoniazid, rifampin with addition of pyrazinamide for 2 months is the preferred treatment for pulmonary and extra-pulmonary tuberculosis. If resistance to isoniazid is suspected, ethambutol should be added until drug susceptibility studies become available. This treatment is effective in both HIV infected and uniinfected persons. Treatment failure is mostly related to lack of patient adherence to the drug regimen and to multidrug-resistant tuberculosis. The treatment of multidrug-resistant tuberculosis requires second line drugs which are less effective and poorly tolerated. Prevention of resistant tuberculosis needs adequate treatment of each case of tuberculosis and improving of the patient compliance.

Lymphocytic alveolitis after primary HIV infection with CMV coinfection

Herein is a report of an adult case of primary HIV infection with cytomegalovirus coinfection causing cough, fever, and lymphocytic alveolitis. Primary HIV infection has not been previously reported as a cause of lymphocytic alveolitis.