Failure of diltiazem to prevent 1:1 conduction of atrial flutter: a case report.

BACKGROUND: Atrial flutter with 1:1 conduction to the ventricles is a dangerous cardiac arrhythmia. Contemporary guidelines recommend atrioventricular nodal blocking agents should be co-administered with class 1C anti-arrhythmics, as prophylaxis against 1:1 flutter. No guidance is provided on the type or strength of atrioventricular nodal blockade required, and in practice, these agents are frequently prescribed at low dose, or even omitted, due to their side effect profile. CASE PRESENTATION: A 62 year old Caucasian man with a history of paroxysmal atrial fibrillation treated with flecainide, presented with atrial flutter with 1:1 conduction to the ventricles and was cardioverted. Diltiazem was added to prevent this complication and he again presented with atrial flutter with 1:1 conduction to the ventricles, despite prophylaxis with coadministration of diltiazem. CONCLUSIONS: This case report demonstrates failure of diltiazem to prevent 1:1 flutter in a patient chronically treated with flecainide for paroxysmal atrial fibrillation.

Vomiting, electrolyte disturbance, and medications; the perfect storm for acquired long QT syndrome and cardiac arrest: a case report.

BACKGROUND: Acquired long QT syndrome is an important and preventable cause of cardiac arrest. Certain medications and electrolyte disturbance are common contributors, and often coexist. In this case, we report five contributors to cardiac arrest. CASE PRESENTATION: This case is of a 51-year-old Caucasian female patient who presented with vomiting associated with hypokalemia and hypomagnesemia. She subsequently received ondansetron and metoclopramide, on the background of chronic treatment with fluoxetine. She then suffered an in-hospital monitored cardiac arrest, with features of long QT and torsades de pointes retrospectively noted on her prearrest electrocardiogram. She was diagnosed with acquired long QT syndrome, and her QT interval later normalized after removal of offending causes. CONCLUSIONS: This case highlights the importance of proper consideration prior to prescribing QT prolonging medications, especially in patients who have other risk factors for prolonged QT, such as electrolyte disturbances and pretreatment with QT prolonging medications.

Basal cell carcinoma of the nose: an Australian and New Zealand radiation oncology patterns-of-practice study.

Patients with a basal cell carcinoma (BCC) of the nose may be recommended radiotherapy (RT) with a wide variation in techniques and prescribed dose fractionation schedules between clinicians. The aim of this study was to ascertain variability in the patterns of practice among Australian and New Zealand radiation oncologists (ROs) when treating BCC arising on the nose. A postal survey was sent to 222 practising ANZ ROs detailing 12 different clinical scenarios of a BCC arising on the nose. The treatment selected for each scenario was analysed according to clinician's attitudes, training, experience and the availability of resources. The response rate was 74% (165/222) with 90 respondents treating non-melanoma skin cancer. Training was perceived to have a marked influence on treatment practice by most (79%). In total, 72% of ROs were 'very certain' in their choice of a dose fractionation schedule for obtaining local control and 61% for a satisfactory cosmetic outcome, respectively. Most (76%) favoured low-voltage photons over electrons as the optimal method of treatment, although for certain clinical scenarios most would use electrons. Dose fractionation schedules were highly variable with a lower total dose and hypofractionation favoured for older patients. Low-voltage photons were favoured for the T1 BCC and electrons for the T2 and T4 BCC. Nearly one-third of the ROs chose megavoltage photons for the T4 lesion. There is marked variation in treatment practices in terms of recommending RT over other treatment options, the choice of RT method, the dose fractionation schedule, the extent of field margins and the point of dose prescription.

Use of topical misoprostol to reduce radiation-induced mucositis: results of a randomized, double-blind, placebo-controlled trial.

Radiation-induced mucositis is an acute reaction of the mucosa of patients undergoing head and neck radiotherapy. It can have debilitating and dose-limiting consequences. There is no consensus on an accepted intervention that significantly reduces its severity. Misoprostol is a synthetic prostaglandin E1 analogue, with properties of a mucosal cytoprotectant. We designed a randomized, double-blind, placebo-controlled trial of misoprostol in patients with head and neck cancer. The aim of this study was to determine if topical misoprostol was effective in reducing the severity of radiation-induced mucositis in patients receiving radical dose radiotherapy. The effect of this intervention on a patient's general well-being was also investigated. The primary end-point of the study was the incidence of Radiation Therapy Oncology Group grade 3 mucositis. Between 1999 and 2002, 83 patients were recruited into the study at Westmead and Nepean Hospitals, Sydney. Forty-two patients were randomized to receive misoprostol and 41 to receive a placebo. Most patients received radiotherapy in the adjuvant setting (52 of the 83) and had either an oral cavity (42 of the 83) or an oropharyngeal (16 of the 83) cancer. We could not identify any significant difference in the incidence of severe mucositis based on whether patients were allocated to receive misoprostol or placebo. There was no significant difference in the mean area under the mucositis curve (13.2 vs 16.6; P = 0.1). Patients allocated to misoprostol did report slightly increased soreness (7.6 vs 6.9; P = 0.04) and a greater use of analgesics. However, this difference did not translate into a worse feeling of general well-being as measured by a simple visual analogue scale (5.8 vs 5.2; P = 0.3). In conclusion, we were unable to identify a reduction in radiation-induced mucositis in patients receiving misoprostol. There is a paucity of high-level evidence on potentially useful interventions and a continued need for new and innovative research, incorporating quality-of-life measurements, in patients experiencing radiation-induced mucositis.

Occult breast carcinoma presenting as axillary metastases.

PURPOSE: Breast carcinoma presenting with axillary lymphadenopathy and no clinical or radiological evidence of a primary tumor is a rare presentation. We aimed to examine the management of the breast by observation, radiation therapy, or mastectomy. METHODS AND MATERIALS: Departmental records from 1979 to 1996 of unknown primary presentations and cases of T0N1-2M0 breast carcinoma were reviewed to find cases of occult breast carcinoma presenting as axillary lymphadenopathy with no clinical or imaging evidence of a primary tumor. RESULTS: There were 6047 presentations of breast carcinoma with 20 cases of occult breast carcinoma meeting the criteria. The breast was treated by observation in 6 cases, mastectomy in 2 cases, and radiotherapy to the intact breast in 12 cases. Eighty-three percent of patients (5 of 6 patients) who had observation of the breast had a local recurrence, compared to 25% who had radiotherapy to the intact breast (3 of 12 patients) and 0% who had a mastectomy (0 of 2 patients). The median recurrence-free survival was 7 months in patients who had observation of the breast, compared to 182 months in patients who had local treatment. Three of the 6 patients who underwent breast observation have died whereas 1 of the 14 who had local treatment have died, with a mean follow-up of 73 months. It was found that patients having observation of the breast had a poorer recurrence-free survival (p = 0.003) and overall survival (p = 0.05) compared to those having local treatment of the breast. CONCLUSIONS: Patients with such a presentation should have a complete physical examination, mammography, ultrasound, and MRI of the breasts. If there remains no evidence of a primary tumor, an axillary dissection should be carried out and the breast treated by radiotherapy or mastectomy. Observation of the breast is not a recommended option.

Does waiting time affect the outcome of larynx cancer treated by radiotherapy?

AIM: To determine the impact of waiting for radiotherapy on local control in early larynx cancer treated by radiotherapy alone. METHODS: Records of patients with T1 and T2, N0-2 larynx cancer were examined at three radiotherapy centres. Waiting time was defined in three ways, (1) time from biopsy to radiotherapy, (2) time from presentation to radiation department to start of radiotherapy and (3) the minimum of (1) and (2). Time to relapse was the major end point. RESULTS: There were 581 patients with a median follow-up of 6.8 years. Stage distribution was as follows: T1, 370; T2a, 106; T2b, 94; T2 unspecified, 11; N0, 563; N+, 18. Median times from biopsy, presentation and minimum time to treatment were 24, 16 and 15 days, respectively. Ninety percent of minimum waiting times were < or = 31 days. The median dose was 61 Gy in a median of 30 fractions over a median 46 days. Local recurrence occurred in 126 patients. The actuarial recurrence free rate at 5 years was 77% (SE 2%). In a multivariate analysis the significant predictors of relapse were higher T stage, longer treatment duration and increasing field area. Waiting time was not significantly associated with local relapse. CONCLUSION: This study did not show longer waiting time to be a significant predictor of relapse in early larynx cancer. Other end-points which are relevant, such as quality of life, have not been examined. Longer treatment times were significantly associated with relapse.

Radiotherapy for melanotic freckles.

Five patients who received radiotherapy (RT) for 7 melanotic freckles (MF, also known as Hutchinson's freckles, lentigo maligna) were reviewed 8 to 37 months after their treatment by RT. Local control and a favourable cosmetic result occurred in all patients. Treatment toxicity was minimal. Few reports about the use of RT for MF exist. Many other treatments including observation alone have been associated with high rates of recurrence, and in some cases conversion to invasive melanoma has occurred. RT appears to be a safe and effective treatment for this condition, providing that doses equivalent to 44 Gy in 11 fractions or more are given.

Thyroid dysfunction following radiotherapy for head and neck cancer.

PURPOSE: To determine the frequency of hypothyroidism (both subclinical and clinical) following external beam radiotherapy to the whole of the thyroid gland in the treatment of squamous cell cancers of the head and neck. METHODS AND MATERIALS: One hundred and four patients who had completed radiotherapy 30 days to 5 years earlier (84 patients) or who were scheduled for radiotherapy (20 patients) had a single measurement of serum-free thyroxine and thyroid stimulating hormone levels between August 1991 and May 1992. RESULTS: None of the 20 patients assessed prior to treatment showed thyroid dysfunction. Twenty of 84 (23.8%) previously treated patients had subclinical (9.5%) or clinical (14.3%) hypothyroidism. By 5 years, up to 40% of patients may become hypothyroid. Thyroid underactivity was significantly more common in patients having both laryngectomy (including hemi-thyroidectomy) and radiotherapy compared to radiotherapy alone (p < 0.001). Hypothyroidism had not been suspected clinically in any patient tested. CONCLUSION: In view of the frequency and potential morbidity of this complication, thyroid function testing should become a routine part of posttreatment follow-up for these patients.

Synchronous radiotherapy and chemotherapy in the treatment of nasopharyngeal carcinoma.

PURPOSE: Because of the high rates of local tumor control obtained by combining moderate doses of external beam radiotherapy and synchronous 5-fluorouracil/mitomycin C chemotherapy in the treatment of squamous and basiloid cancers of the anal canal, we chose to investigate this regimen for nasopharyngeal cancer which shows significant local and distant failure rates after treatment with radiotherapy alone. METHODS AND MATERIALS: Between 1983 and 1990, 43 patients with previously untreated squamous cell and undifferentiated nasopharyngeal cancer, without evidence of distant metastases at diagnosis were treated with radical radiotherapy and concurrent chemotherapy using mitomycin C (10 mg/m2 i.v. day 1 of radiotherapy) and 5-fluorouracil (1000 mg/m2 continuous i.v. infusion days 1-4 of radiotherapy and repeated at least 28 days later). Ninety-one percent of cases had Stage IV tumors and 93% had clinically involved regional lymph nodes. RESULTS: Actuarial rates of survival, local control, regional nodal control and distant metastases at 5 years were 37%, 71%, 94%, and 53%. Grade 3 or 4 skin and mucosal reactions occurred in 30% and 34% of patients, respectively. Only one patient developed greater than Grade 2 myelosuppression and he died of overwhelming sepsis. A second patient died of malnutrition 4 months after treatment giving a 5% incidence of treatment-related mortality. Nine percent of patients developed significant late complications of treatment. CONCLUSION: Despite the morbidity observed, the treatment outcome is not obviously superior to that reported for radiotherapy as a single modality of treatment.

Single institutional experience with non-seminomatous germ cell tumours of the testis: local perspectives on a curable cancer.

We have reviewed 77 patients with Non-seminomatous germ cell tumour of the testis (NSGCTT) treated at a single institution. A residual mass following definitive treatment occurred in 16 patients (35%), 13 of whom had a resection of the mass, yielding active tumour in only one patient. Nine patients (12%) relapsed including four of the 14 with Stage I disease who were treated by orchidectomy alone. Four relapses occurred at more than two and a half years after primary treatment. Relapse prior to the development of clinical symptoms or signs was evident in three of nine patients; in two patients by routine imaging and one with elevated routine serum markers. Three of the nine patients who relapsed had elevated serum markers. Two patients died from disease but there were four treatment-related deaths (7%). Overall, 64 patients (83%) remain disease free at the time of follow-up. A further seven (9%) have been lost to follow-up but were disease-free at a minimum of 26 months after diagnosis. This study confirms features of this disease including the excellent prognosis when adequately treated. However, it also reveals the problems of late or marker negative relapses, the implementation of an observation policy in Stage I disease and treatment related mortality in young men.

Locally advanced (stage III and IV) head and neck cancer: Westmead Hospital experience.

Two hundred and fifty-one patients with Stage III and IV (UICC staging system) squamous cell cancers of the oral cavity, oropharynx, hypopharynx and larynx were assessed between January 1980 and December 1988 at Westmead Hospital. Of these, 50 patients received palliative treatment or were not treated and the remaining 201 patients received treatment with curative intent by various combinations of radiotherapy, surgery and chemotherapy. Thirty-nine operable cases were entered into a multimodality protocol initiated in April 1985, which consisted of induction chemotherapy (cisplatin 100 mg/m2 i.v. day 1, 5-fluorouracil 1000 mg/m2 per 24 h i.v. days 1-5, q3w x 2) followed by surgery and postoperative radiotherapy. The median follow-up for all 251 patients was 57 months. Actuarial 3-year survival rate for all 201 patients receiving radical treatment was 48% (Stage III 66%, Stage IV 36%; P less than 0.001). Overall actuarial local and nodal control rates at 3 years were 67% and 69%. Thirty-two of 201 patients (16%) developed distant metastases at a median time of 11 months. Twenty-one patients (10%) had a previous or subsequent second primary cancer. In the group of 39 protocol patients, overall actuarial survival, local and nodal control rates are 68%, 77% and 73% at 3 years. A group of 22 'protocol' patients was compared with a group of 22 patients treated prior to commencement of the protocol, matched as closely as possible on the basis of site, stage, age, sex and ECOG status.(ABSTRACT TRUNCATED AT 250 WORDS)

Radical radiotherapy for carcinoma of the larynx--Westmead Hospital experience.

Between January 1980 and December 1988, 141 patients were treated with radical radiotherapy for carcinoma of the larynx. One hundred and ten (78%) tumours arose on the vocal cords, twenty nine (21%) from the supraglottis and two (1%) from the subglottis. All 63 stage T1 cases, and all except three of 62 T2 cases seen in the time period, were treated by radiotherapy. In addition 14 selected T3 and 5 T4 cases were irradiated. Only 7% had clinical evidence of regional lymph node metastases at presentation. Median follow up is 47.5 months and 2+ year actuarial local control rates are T1-87%, T2-63%, T3-79% and T4-53%. The rates for vocal cord primaries are T1-86%, T2-58%, and T3-75%. Median time to local failure was 8 months with none occurring beyond 21 months. Two of 130 N0 cases (1.5%) relapsed in cervical lymph nodes with a policy of selective prophylactic irradiation of the regional lymphatic areas. Thirty three/thirty seven patients with locoregional failure underwent salvage surgery with 27/32 (84%) evaluable patients achieving ultimate locoregional control with median follow up of 18.5 months from salvage. Four patients (3%) developed distant metastases and 21 (15%) developed a second primary malignancy (including 13 lung cancers) with an actuarial rate of second primary tumours of 23% at five years. Three year actuarial survival for the whole group is 77% but 66% of deaths were due to causes other than larynx cancer. Tumour specific mortality by stage is T1-1.6%, T2-12%, T3,4-21%.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of testicular seminoma at Westmead Hospital from 1980 to 87.

Testicular seminoma comprises fewer than 1% of male cancers but is a relatively common malignancy in young men. The management and outcome of 73 consecutive patients with testicular seminoma were reviewed. Median follow-up was 51 months (range: 15-109 months). Their median age was 37 years (range: 21-67 years). There was a history of testicular maldescent in 5.5% of patients. Beta-human chorionic gonadotropin was elevated in 22% of patients prior to orchidectomy and in 5% post-surgery. The majority of patients had stage I (78%) or stage II (19%) seminoma after clinical staging. One patient (2%) with stage I seminoma relapsed, while two patients (14%) with stage II seminoma relapsed. The latter two were salvaged with further therapy. One of two patients treated for stage III seminoma died. A residual mass after radiotherapy was commonly observed in patients with stage II seminoma, but did not represent viable tumour. These results reflect the high cure rates that are achievable in seminoma with radiotherapy for early stage and non-bulky abdominal disease and, more recently, with cisplatin-based chemotherapy for bulky abdominal or disseminated disease.

The role of bipedal lymphangiography in testicular seminoma.

Determining the extent of intra-abdominal spread of testicular seminoma by radiographic studies is an essential step in planning rational treatment following orchidectomy. CT scanning is generally accepted as being superior to lymphangiography in assessing the retroperitoneal space. We reviewed the relative contribution of these two procedures in a retrospective analysis of 73 consecutive patients with testicular seminoma managed at Westmead Hospital between January 1980 and September 1987. Abdominal CT scans and bipedal lymphangiography (LAG) were carried out in 72 and 51 patients respectively, 50 patients undergoing both procedures. We found concordance between the two techniques to be 88%. Upstaging occurred in 5 patients using CT (10%), 7 patients using LAG (14%), and in 8 patients (16%) when both tests were utilised. Four patients were upstaged by both techniques while the remaining 4 patients were upstaged using one technique alone. Serum beta-HCG was not a reliable screen for residual disease. Residual disease in the few patients with an elevated serum beta-HCG was easily detected by CT scanning. We conclude that there is a continuing role for LAG in assessing patients with clinical Stage I seminoma when the abdominal CT scan is equivocal or normal.