[Stent implantation as a palliative therapeutic measure in tumor-induced stenoses of the large veins of the body]. / Stentimplantation als palliative Therapiemassnahme bei tumorinduzierten Stenosen der grossen Körpervenen.

PURPOSE: Self-expandable metallic stents were used to treat patients with malignant venous obstructions to determine their effectiveness in producing symptomatic palliation. METHODS: 20 patients with a total of 28 tumour-induced obstructions of the superior vena cava (n = 13), the inferior vena cava (n = 4), the subclavian (n = 4), the innominate (n = 5) and the iliac veins (n = 2) were treated with self-expandable metallic stents. 38 Gianturco stents and 21 Wallstents were applied. Patients were heparinised during the procedure and up to three days afterwards. RESULTS: In all patients correct positioning of the stents was achieved. In 16 patients stent placement resulted in relief of their symptoms. In 8 patients the symptoms completely disappeared without recurrence until death as a result of tumour progression. The follow-up ranged from 10 days to 14 months. In 8 still living patients no re-obstruction occurred (follow-up average three months). In one patient thrombotic stent occlusion occurred 6 days after the procedure; the v. cava superior was reopened again by local urokinase therapy. Three patients finally developed re-occlusion due to tumour progression. In one patient stent placement was complicated by migration of the Gianturco stent one day after stent implantation and reocclusion of the subclavian vein. CONCLUSION: The application of self-expandable metallic stents in patients with malignant venous obstruction is a useful palliative therapy.

Surgical palliation of head and neck cancer.

Palliative care in head and neck cancer has not been studied systematically. Patients with incurable head and neck tumors may live months and even years. Ideal palliation should enable them to engage in a normal life before death ensues. It is likely that our improving ability to treat these tumors without achieving cures will cause people to live longer with their cancer. Hence, the need for palliation will probably increase. Also, treatments that cure patients produce conditions that require palliation. Achievement of the best possible function is the major consideration in dealing with head and neck tumors. Difficulty with speech, swallowing, oral hygiene, and laodorous tumors are all common. Depression too should be addressed in a comprehensive fashion by the "head and neck team". The surgeon, radiotherapist, and medical oncologist will need help from dentists, prosthodontists, dental hygienists, psychiatrists, physiatrists, occupational and physical therapists, visiting nurses, nutritionists, and social workers. Palliative care in the hospital is the least desirable, although often unavoidable. Proper hospice support will benefit patients and their families.

Time-dependent efficacy of bacterial filters and infection risk in long-term epidural catheterization.

BACKGROUND: Epidural infection represents a serious albeit infrequent complication of long-term epidural catheterization. The catheter hub is regarded as the main point of entry for microorganisms among the three possible routes (hematogenous, insertion site, hub) of microbial colonization of the inserted catheter. The current study was aimed at evaluating whether frequent changing of antimicrobial filters carries an increased risk of catheter hub contamination and the time-dependent efficacy of commonly used antimicrobial filters after prolonged use. METHODS: In the first part of the study, a microbiologic survey (skin, filter, hub, and catheter tip) was performed weekly in a group of 47 patients with cancer bearing subcutaneously tunneled catheters managed at home. Subsequently, the time-dependent efficacy of 96 micropore filters (32 Portex, 32 Sterifix-Braun, 32 Encapsulon TFX-Medical) differing in surface areas and/or composition of the filtering membrane was evaluated in a laboratory study. Filters were perfused, under the usual conditions of clinical use (flow resistance, injection pressure, temperature), every 8 h up to 60 days, with 5 ml of two different analgesic solutions, either sterile or containing 1.5 x 10(5)/ml of Streptococcus milleri I. Eight filters of each type subsequently were flushed with a S. milleri suspension (0.5 McFarland) after 7, 14, 28, and 60 days of continuous perfusion, and the resulting filtrates were cultured. RESULTS: In 16 of 19 positive hub cultures, the same microorganisms (species, biotype, antibiotype) were cultured from skin and filters. A statistically significant positive trend was found between the number of filter changes and the rate of positive hub cultures (chi 1(2) trend 5.11; P = 0.02). A high correlation coefficient was found between number of positive skin cultures and number of positive filtrates (r = 0.88; P = 0.01) and between number of positive filtrates and number of positive hub cultures (r = 0.93; P = 0.003). Cultures obtained from Portex and Sterifix-Braun filters yielded no bacterial growth (64/64) throughout the study period. Cultures from Encapsulon TFX-Medical filters showed bacterial growth 2/8 at seventh day, 7/8 at the 14th day, and 16/16 from the 28th day onward. CONCLUSIONS: Our data indicate significant correlation between the incidence of catheter hub colonization and the filter-change frequency, when the skin close to the filter-hub connection is contaminated. Our results also show that Portex and Sterifix-Braun bacterial filters, when perfused with reduced volumes at low injection pressures, maintain an unmodified antimicrobial function for at least 60 days. Based on these data, it appears clinically feasible to reduce the frequency of filter changes during long-term epidural catheterization, with a consequent possible decrease of epidural catheter colonization.

Endoscopic palliation of oesophageal carcinoma with Atkinson prosthesis.

To assess the degree of palliation, the associated morbidity and mortality and to compare our results with other published series, we reviewed our use of the Atkinson prosthesis in 100 consecutive patients for the palliation of unresectable oesophageal carcinoma. The group had a mean age of 71.2 +/- 2.3 years. All prostheses were placed by the pulsion method. Intubation was successful in 91%. Improvement in swallowing was seen in 82.1%. Major early procedure-related morbidity was high at 23% with 11 perforations (11%). Procedure-related mortality was 12%. Those aged 70 years or more had a 34.5% risk of morbidity and 15.5% risk of dying from the procedure. Late procedure-related complications requiring further endoscopic procedures occurred in 27%. Our 7 day mortality was 14.7% (14 patients) and 31 patients (32.6%) had died within 30 days, usually from the disease itself. Those surviving the procedure (> 7 days) had a mean survival of 105 (range 9-735) days. We obtained acceptable palliation but with a significant morbidity and mortality. Endoscopic intubation remains a useful palliative treatment for patients with unresectable carcinoma of the oesophagus and cardia.

[Occlusive jaundiced caused by liver metastases. Results of endoscopic surgical treatment]. / Verschlussikterus durch Lebermetastasen: Ergebnisse der endoskopisch-chirurgischen Behandlung.

The results of endoscopic drainage treatment in 69 patients with metastases of the liver have been analyzed for the period from 1982 to 1992. Fifty-five patients had follow-up. Criteria for inclusion were: positive diagnosis of liver metastases, jaundice, and primary origin of tumors distant from the pancreaticobiliary system ("distant" primary). Localisations of metastic obstructions were: hilum of the liver (n = 24), commonbile duct (n = 16), and prepapillary region (n = 15). Treatment was performed by transpapillary applications of one or more (n = 3) pig-tail or Tannenbaum stents. Concentrations of mean serum bilirubin could be reduced from 14.5% to 8.8 mg%, 16 patients reached a normal level (less than 1.0 mg%). The median survival time was 76 days ranging vom 4 to 299 days. The most frequent complication was cholangitis in 29% of the cases with mortality in 6 patients. Patients less than 60 years of age and with obstructions in the mid commonbile duct gained most by this kind of treatment. Results were poor in elderly patients with hilar stenosis. Selected patients with known liver metastases may benefit from endoscopic treatment of jaundice.

Palliative, intraarterial chemotherapy for advanced head and neck cancer using an implantable port system.

PURPOSE: Intraarterial drug therapy for head and neck cancer has been used for more than 30 years. However, because of catheter-related complications occurring quite frequently, this method was abandoned in many institutions. The development of subcutaneously implantable injection ports has renewed interest in regional drug delivery. PATIENTS AND METHODS: This study reports the authors' experience with 11 injection ports implanted in 10 patients suffering from advanced or recurrent head and neck cancer. RESULTS: The regional chemotherapy was well tolerated; the predominant side effects were hemialopecia and mild unilateral mucositis. CONCLUSIONS: These results suggest that regional, intra-arterial chemotherapy using implantable injection ports should be considered for palliative treatment of advanced head and neck cancer.

[Radiotherapy of malignant obstructive jaundice]. / Strahlentherapie beim malignen Verschlussikterus.

Brachytherapy using the afterloading technique with iridium 192 and percutaneous irradiation using 16 MV photons are used for the irradiation of malignant obstructive jaundice. Mostly, however, a combination of both methods can be used to advantage. In bile duct tumors and Klatskin tumors, the endoluminal part can be treated using brachytherapy. The extralumenal growth and, if necessary, all affected regional lymph node areas can be treated by a 3D planned, percutaneous, moving field technique. Intraoperative radiotherapy can be used in a few cases as booster irradiation of tumor conglomerates at the porta hepatis. The decision to use irradiation must be made very carefully since solid tumors are usually involved that require a high target dose, the application of which can lead to unacceptable side effects. The radio-oncological spectrum is therefore confined predominantly to palliative therapy.

[Self-expandable metal prostheses. A new alternative palliative therapy of malignant stenotic lesions of the esophagus]. / Prótesis metálicas autoexpandibles. Una nueva alternativa terapéutica paliativa de las lesiones estenóticas malignas de esófago.

The treatment of malignant esophageal stenoses is a serious problem which may have a surgical solution at diagnosis in only a selected number of cases. Chemotherapy and radiotherapy are the main palliative treatments; surgery has a high morbidity and mortality rate. The insertion of esophageal prostheses could be an alternative palliative treatment. From January 1991 to November 1993, 41 autoexpandable metallic prostheses (12 Wallstent type, 19 Strecker type and 1 Rosch-Uchida type) have been implanted in 30 patients with esophageal cancer one with lung cancer and two with radiation induced esophagitis. Technical success resulted in 28 patients; an initial failure requiring a new prosthesis insertion occurred in 5 patients. Technical aspects and results are analyzed.

[The palliative treatment of venous stenoses in tumor patients with self-expanding vascular prostheses]. / Palliative Therapie venöser Stenosen bei Tumorpatienten mit selbstexpandierenden Gefässendoprothesen.

During 53 months 14 patients with tumour-induced obstructions of the superior vena cava (n = 8), the inferior vena cava (n = 2) and iliac veins (n = 4) were treated with self-expandable metallic stents. 21 Wall stents and 5 Gianturco double stents were applied. The follow-up lasted from 2 weeks to 16 months (range = 5.7 months). All patients showed a marked relief of inflow obstruction after stent placement. 6 of 7 patients, who died of their disease during follow-up, were asymptomatic regarding vein obstruction until their death (3 weeks to 16 months). In 6 of 7 still living patients no re-obstruction occurred during follow-up (2 to 16 months). Patency rate was 82%. These results suggest that self-expanding stents are a successful palliative therapy of malignant vein obstructions.

Minimally invasive palliative tumor therapy guided by imaging techniques: the UCLA experience.

Imaging-guided palliative therapy of recurrent and/or inaccessible head and neck tumors may soon become clinically practical since sensitive and noninvasive monitoring techniques of energy deposition in tissues are now available. Interstitial tumor therapy (ITT) is a technique whereby a source of energy (laser, radiofrequency, ultrasonic, cryoenergy, etc.) is directly applied into tumors at various depths. Recent studies have demonstrated the efficiency of ultrasound (UTZ) and magnetic resonance imaging (MRI) for real and/or "near" real time tumor and vessel identification as well as monitoring and quantifying energy-induced tissue damage. We now report our initial clinical experience with patients in which UTZ and/or MRI-guided ITT techniques were successfully applied for the treatment of recurrent, nonresectable, local, and/or metastatic head and neck carcinomas. Patients were treated on an outpatient basis either in the operating room or in an upgraded specially equipped SIGNA 1.5T MR suite. Most patients tolerated these procedures well and were successfully palliated for periods ranging from 3 months to 5 years posttreatment. The upgrades introduced in a standard MRI suite, the clinical experience, and future perspectives will be reviewed.

Intraluminal brachytherapy in the treatment of oesophageal cancers--some preliminary results.

Cancer of the oesophagus is the sixth commonest cancer in males in Singapore. The majority occur in the elderly and patients are often debilitated at presentation. Treatment is often aimed at palliation only. In this article, the preliminary results of 15 patients treated solely on a high dose rate remote afterloading Gammamed brachytherapy machine with an Iridium 192 (Ir192) source are reported. The patients were given 15 Gray (Gy) in a single or two 7.5 Gray fractions. All the patients treated had some improvement of their dysphagia, and seven out of 11 (63%) evaluable patients had symptom improvement lasting at least 11 weeks.