Symptoms and signs of port-related infections in oncology patients related to the offending pathogens.

AIM: There is limited information about symptoms and signs of port-related infections linking to their offending pathogens. METHODS: Oncology patients proven to have port-related infections were retrospectively analysed. We divided them into two subgroups according to their symptoms and signs. Onset of fever and chills with or without hypotension following the port flush was classified as 'port flush form infection'. Presence of local inflammatory signs, including erythema, warmth, tenderness and pus formation and systemic infection signs, including fever, chills with or without hypotension was classified as 'local inflammatory form infection'. RESULTS: There were 29 episodes of port-related infection among 28 patients, with port flush form 22 episodes and local inflammatory form seven episodes. Of 22 episodes of port flush form infections, 20 (91%) were nosocomial glucose non-fermenting gram-negative bacilli, with Acinetobacter baumannii (11 episodes, 50%) and Enterobacter cloacae (four episodes, 18%) the most common. Polymicrobial infections occurred in four episodes (18%). Candida infection occurred in two episodes (9%). Of seven episodes of local inflammatory form infections, six (86%) were gram-positive cocci, with Staphylococcus aureus (five episodes, 71%) the most common. The time from port implantation to its infection was 272 +/- 255 days (30-993 days) for the port flush form infections and 82 +/- 87 days (22-265 days) for the local inflammatory form infections. This difference was not significant difference (p = 0.068). CONCLUSIONS: The differences between infection of patients with port flush form and local inflammatory form in incidence and offending microorganism suggest that the aetiology of infection were different.

Gender discrepancy observed between chemotherapy-induced emesis and hiccups.

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

Mitomycin C with weekly 24-h infusion of high-dose 5-fluorouracil and leucovorin in patients with biliary tract and periampullar carcinomas.

We have reported a 33% partial response rate with acceptable toxicity using weekly 24-h infusion of high-dose 5-fluorouracil (5-FU) and leucovorin (LV) in patients with far advanced biliary tract cancers (BTC). In this study, we added mitomycin (MMC) to 5-FU and LV in an attempt to improve the response rate and survival. From July 1997 to September 1999, 25 chemotherapy-naive patients with pathology-proven far advanced BTC and periampullar cancers were enrolled. The regimen consisted of MMC 10 mg/m(2) every 8 weeks combined with 5-FU 2600 mg/m(2) and LV 150 mg at a schedule of 24-h infusion weekly for 6 weeks followed by a 2 week break. There were 10 males and 15 females with a median age of 57 years (range 40-76). The sites of primary tumor were 15 intrahepatic cholangiocarcinomas (CC), one perihilar CCs, three distal BTC, three gallbladder cancers (GB) and three periampullar cancers. A total of 148 sessions of chemotherapy were given with a mean of 8 (range 2-18). Nineteen patients were evaluable for response. The response rate was: 26% (five of 19) partial response, 42% (eight of 19) stable disease and 32% (six of 19) progressive disease. All of the patients were evaluable for toxicity. Toxicities more than grade III-IV were thrombocytopenia 16% (four of 25), leukopenia 12% (three of 25) and vomiting 4% (one of 25). There were four treatment-related deaths. The median time to disease progression was 3 months. The median survival was 6 months. A combination of MMC with weekly high-dose 5-FU and LV in patients with BTC did not improve the response rate, but produced more toxicity than weekly high-dose 5-FU and LV alone.

Mimicking lip features in free-flap reconstruction of lip defects.

This paper introduces a technique of lip reconstruction using free flaps in which recognisable landmarks are mimicked by strategic placement of flap junctions. The technique was applied in 15 patients undergoing reconstruction of combined cheek and lip defects using single (n= 9) or double (n= 6) free flaps. Attention to flap design and strategic placement of flap junctions successfully created the vermilion-cutaneous junction, oral commissure and labiomental groove. The presence of these distinguishing features improved the appearance of the reconstructed lip.

Pulmonary lymphangitic sarcomatosis from cutaneous angiosarcoma: an unusual presentation of diffuse interstitial lung disease.

Pulmonary lymphangitic sarcomatosis (PLS) is not much recognized clinically although it shows similar pathological patterns and diagnostic features to pulmonary lymphangitic carcinomatosis (PLC). We report a case with hand angiosarcoma whose chest X-ray findings revealed a diffuse interstitial pattern consistent with lymphangitic spreading. The final diagnosis was made by open lung biopsy. The clinical, diagnostic and pathological features of this disease process are reviewed.

Weekly 24-h infusion of high-dose 5-flurouracil and leucovorin in patients with advanced gastric cancer.

The effect of biochemical modulation of weekly high-dose 5-fluorouracil (5-FU) 24 h infusion by leucovorin (LV) in the treatment of 39 consecutive patients with advanced gastric cancer without prior chemotherapy from October 1996 to August 1997 was examined. There were 21 male and 18 female patients with a median age of 56 years. The regimen consisted of 5-FU 2600 mg/m2 and LV 150 mg administered by 24 h infusion weekly for 6 weeks followed by a 2 week break. The treatment was repeated every 8 weeks until disease progression, patient refusal or unacceptable toxicity. Placement of a central vascular device and a portable external infusion pump was required in all patients and was used for outpatient treatment. The response to treatment was evaluated every 8 weeks. A total of 395 chemotherapy treatments were given with a mean of 10 (2-24). This response rate was: 33% (12 of 36) partial response (PR) rate, 33% (12 of 36) stable disease (SD) and 33% (12 of 36) progressive disease (PD). In general, the toxicity was mild but two toxic deaths occurred, one due to neutropenic sepsis and the other due to hyperammonemia. The median time to progression was 4 months. The overall median survival was 7 months. The survivals of the PR, SD and PD were 12, 8 and 5 months, respectively. This regimen showed a modest activity against gastric cancer with acceptable toxicity. Weekly 24 h infusion of high-dose 5-FU with LV in an outpatient setting for patients with gastric cancer is feasible and deserves further study as a basis for combination therapy.

Microsurgical reconstruction in recurrent oral cancer: use of a second free flap in the same patient.

Primary microsurgical reconstruction is the treatment of choice for ablative defects of oral carcinoma. As a result of this trend, more and more patients with recurrent oral carcinoma who have been initially treated with surgical excision and reconstructed with free flaps are being seen. However, a second microsurgical reconstruction attempt in these cases raises questions about the flap choices, availability of recipient vessels, and effects of previous treatment modalities. Herein, 35 patients with perioral carcinoma who had two successive tumor resections and reconstruction with free flaps on each occasion are presented. A total of 75 free tissue transfers were carried out for the first and second reconstructions. After the first tumor resection, 28 radial forearm fasciocutaneous flaps, 7 fibula osteoseptocutaneous flaps, 1 iliac osteomyocutaneous flap, and 2 rectus abdominis myocutaneous flaps were used. For reconstruction after the recurrence, 17 radial forearm fasciocutaneous flaps, 13 fibula osteoseptocutaneous flaps, 3 rectus abdominis myocutaneous flaps, 2 anterolateral thigh flaps, 1 jejunum flap, and 1 tensor fasciae latae flap were used. More vascularized bone transfers were performed during the second reconstruction since the excision for the recurrence frequently required segmental mandibulectomy. The complete flap survival rate was 97.3 percent and 94.6 percent with a reexploration rate of 7.9 percent and 13.5 percent for the first and second free tissue transfers, respectively. The mean follow-up time throughout the procedures was 37.5 months. Disease-free interval between reconstructions was 20.8 months. At the time of evaluation, 54.3 percent of the patients were surviving an average of 19 months since the second reconstruction. The results suggest that free flaps represent an important option in reconstruction of recurrent perioral carcinoma cases undergoing reexcision. When used in this indication they are as safe and effective as the initial procedure.

Clinical benefit and response in patients with gastric cancer to weekly 24-hour infusion of high-dose 5-fluorouracil (5-FU) and leucovorin (LV).

BACKGROUND: A prospective study evaluated the efficacy and correlation of different outcome measurements, including the WHO response criteria and clinical benefit (CB), to weekly high-dose 5-FU and LV for patients with advanced gastric cancer. PATIENTS AND METHODS: Thirty-nine chemotherapy-naive patients were enrolled from Sep. 1996 to Oct. 1997. The treatment consisted of a 24-hour continuous infusion of 5-FU 2600 mg/m2 & LV 150 mg weekly for 6 weeks with a subsequent 2-week break. The responses were evaluated by CB and WHO criteria at the end of the 8th week, then at 8-week intervals. RESULTS: There were 21 male and 18 female patients with a median age of 56 years. The median Karnofsky performance score was 70%. Thirty-six patients were evaluable for WHO criteria, and 12 (33.3%) had partial response, 12 (33.3%) had stable disease and 12 (33.3%) had progressive disease. Twenty-one of the 35 (60%) evaluable patients for CB were found to have a positive response. There was a significant correlation between WHO response and CB. The median survival was 10.5 months for CB responders, while the median survival among the CB non-responders was 5 months only. CONCLUSIONS: This study found that this regimen yielded a 60% CB, despite a 33% WHO response rate. Improvement in CB resulted in an improvement in survival as well as the correlation between CB and WHO response, and suggested the value of CB as an alternative indicator for clinical response.

Weekly 24 h infusion of high-dose 5-fluorouracil and leucovorin in patients with biliary tract carcinomas.

From October 1995 to June 1997, 19 chemotherapy-naive patients with pathology-proven locally advanced or metastatic biliary tract carcinomas (BTC) were enrolled. The regimen consisted of 5-fluorouracil (5-FU) 2600 mg/m2 and leucovorin (LV) 150 mg by weekly 24 h infusion for 6 weeks and followed by a 2 week break. The treatment was terminated if disease progressed, the patient refused or unacceptable toxicity occurred. All patients required a Port-A catheter insertion and were treated at outpatient clinics by portable infusion pumps. There were 12 males and seven females with a median age of 62 years (range 45-77). The primary tumor sites were nine intrahepatic cholangiocarcinomas (CC), three perihilar CC, one distal BTC and six gallbladder cancers. A total of 179 chemotherapy sessions were given with a mean of 9.5 (range 2-18). Eighteen patients were evaluable for response. The response rates were: 33% (six of 18) partial response (PR), 39% (seven of 18) stable disease (SD) and 28% (five of 18) progressive disease (PD). All of the patients were evaluable for toxicity. The most common toxicities were mild fatigue (nine of 19, 47%), loss of appetite (nine of 19, 47%), skin hyperpigmentation (five of 19, 26%) and diarrhea (two of 19, 11%). Only one patient had grade IV myelotoxicity with sepsis but without treatment-related death. The median time to progression was 4 months. The overall median survival time was 7.0 months. The median survival time of the PR was not reached, SD was 8.0 months and PD 3.5 months. In conclusion, weekly high-dose 5-FU with LV by 24 h infusion in an outpatient setting for patients with BTC is effective, only mildly toxic and deserves further study.

Intra-abdominal desmoplastic small cell tumors: report of two cases.

Two young adults that presented with intra-abdominal desmoplastic small cell tumors (DSCT) without any evidence of a primary site are described. Both cases share the clinical characteristic features of this rare tumor which include predominant intra-abdominal location as initial presentation, nesting pattern of growth, intense desmoplastic reaction, immunohistochemical reactivity for epithelial, neural and muscle markers, and highly aggressive behavior. Aggressive chemotherapy with a cisplatin-containing regimen was the main therapy to our patients. Up to the present, both cases are alive with disease. The survival is 18 and 15 months from the initial diagnosis, respectively. Interestingly, one of the cases encountered an episode of cerebral infarction at the territory of the left middle cerebral artery 12 days after the first cycle of chemotherapy. This is a previously unrecognized manifestation for this tumor type. This causal relationship between chemotherapy and an acute vascular event is the most likely explanation for our patient's stroke.