Reliability of implantable central venous access devices in patients with cancer.

We reviewed complications requiring removal of Hickman catheters (HCs) and implantable central venous access devices (ICVADs) in patients with cancer over a 30-month period. The study was unique in the sense that patients chose which system would be inserted, unless continuous infusion was anticipated. A total of 115 systems were inserted in 102 patients. Forty-four HCs were inserted in 34 patients (total system days, 8533 [mean, 194 days]); 71 ICVADs were inserted in 68 patients (total system days, 18,681 [mean, 263 days]). Complications required removal in 38.6% of HCs and 18.3% of ICVADs. Complication rates were one in 501 days in the HC group and one in 1450 days in the ICVAD group. Although 15 systems were removed for suspected infection, closer analysis revealed that bacteremia ultimately found to be unrelated to the catheter resulted in premature removal in many cases. The catheter tip was located high in the superior vena cava or in the subclavian vein in all systems removed due to thrombosis. Miscellaneous complications in HCs included dislodgment and catheter embolism. The increased longevity, lower complication rate, and decreased maintenance requirements in the use of ICVADs support their superiority over HCs in the treatment of patients with cancer.

Recognition and treatment of patients with hereditary nonpolyposis colon cancer (Lynch syndromes I and II).

Primary genetic factors are etiologic in at least 5-10% of patients with colon cancer. The polyposis syndromes (FPC) are easily identified examples because of the spectacular number of polyps. The hereditary nonpolyposis syndromes (HNPCC), although five times more common than FPC, are usually not recognized because they do not have such a distinctive clinical, premonitory genetic marker. Colorectal cancer expression was surveyed in 10 extended, thoroughly documented HNPCC kindreds. One hundred sixteen patients were found to have 183 colorectal cancers. Despite the striking family history, less than 5% were correctly treated by subtotal colectomy. This provided a unique opportunity to study the natural history. Five findings differed significantly (p less than 0.05) from patients with sporadic colon cancer: (1) mean age of initial colon cancer diagnosed was 45.6 years; (2) 69.1% of first colon cancers were located proximal to the splenic flexure of the colon; (3) 18.1% had synchronous colon cancer; (4) 24.2% had metachronous colon cancer develop with life table analysis showing the risk for a metachronous lesion at 10 years to be 40%; and (5) only 23.3% of cancers were located in the sigmoid colon or rectum. Based on this data, it is recommended that the family history of all patients with a newly diagnosed colon cancer be evaluated for evidence of this syndrome. If an autosomal dominant inheritance pattern emerges, an in-depth genetic investigation is indicated. When HNPCC is confirmed, the following recommendations apply: a subtotal abdominal colectomy is indicated at the time of the initial colon cancer because of the risk of synchronous and metachronous lesions. The rectum should be spared in favor of careful lifetime surveillance because of the proclivity for proximal colon cancer involvement. As yet unaffected members of a newly diagnosed HNPCC kindred who are in the "direct genetic line" should be cautioned that they are at 50% risk and must begin an intensive surveillance program beginning in the third decade with careful attention to the right colon. Patients from newly diagnosed HNPCC families who have had a previous conventional colectomy for colon cancer should, at the very least, enter an intensive surveillance program; a prophylactic completion subtotal colectomy should be considered for patients who are less than totally compliant.