Gastric pneumatosis after endoscopic argon plasma coagulation.

INTRODUCTION: Endoscopic argon plasma coagulation (APC) is gaining widespread usage but its risk is underreported. CLINICAL PICTURE: A 74-year-old man who received radical radiotherapy for gastric carcinoma 6 months ago was admitted for anaemia and maelena. Gastroscopy revealed haemorrhagic radiation gastritis. Endoscopic APC was performed but terminated when he complained of severe epigastric pain. Computed tomography scan showed gastric pneumatosis. TREATMENT: His pain subsided with a period of overnight rest and observation. OUTCOME: He continued to have 3 sessions of endoscopic APC at monthly intervals and at 10 months posttreatment, his haemoglobin remained stable at 11.1 g/dL. CONCLUSIONS: This case report highlights a complication of gastric pneumatosis and discusses the safe usage of this modality of endoscopic haemostasis. This is to increase cognisance of this potentially fatal complication among endoscopists.

A phase II trial of etoposide, leucovorin and 5-fluorouracil (ELF) in patients with advanced gastric cancer.

Etoposide, leucovorin and 5-fluorouracil (ELF) chemotherapy has been reported to be less toxic yet effective (response rates of 50%) in patients with advanced gastric cancer. A phase II study of ELF in 25 patients (11 males, 14 females, median age 53 years) with advanced adenocarcinoma of the stomach is reported. Patients received outpatient intravenous etoposide 120mg/m2 over 2 hours, folinic acid 300 mg/m2 over 2 hours, 5-fluorouracil 500 mg/m2 boluses daily for 3 days every 21 days. Of 17 measurable patients, there was one complete response (CR), 4 partial responses (PR) for a total response rate of 29.4%. Non-hematologic toxicity was modest (grade 0 vomiting 11/21, stomatitis 16/21, diarrhea 17/21). Grade 3/4 neutropenia was seen in 14/23, thrombocytopenia in 2/23, anemia in 5/23 patients. Median progression-free and overall survival was 4.1 and 7.1 months, respectively. In conclusion, ELF chemotherapy shows only modest activity in patients with advanced gastric cancer and is associated with severe hematologic toxicity.

CPT-11 and cisplatin in the treatment of advanced gastric cancer in Asians.

There is no standard chemotherapy for advanced gastric cancer. A combination of CPT-11 and cisplatin was evaluated for response and toxicity in Asians. 38 patients with histologically proven stage IV gastric/gastroesophageal junction adenocarcinoma were treated with CPT-11 50 mg/m2 and cisplatin 30 mg/m2 weekly for 3 weeks. Each cycle was repeated every 28 days. The median number of cycles was 1.66 (range 0.33-4.33). Dose delay was needed in 11 (29%) patients and dose reductions in 19 (50%) patients. The overall response rate was 42%. There was no complete response. Grade 3 and 4 hematological toxicity was 26%. Grade 3 or 4 diarrhea was not common. Median time to progression for all patients was 15 weeks. Median duration of survival of all patients was 42 weeks. Patients with better performance status and no prior chemotherapy did better. CPT-11 and cisplatin is a useful regimen with significant but manageable toxicity that can be administered without a central venous catheter.

Polypharmacy in palliative care: can it be reduced?

INTRODUCTION: Minimising polypharmacy is important A study was done to see if this was achievable in patients under palliative care and compares the types of drugs used before and after referral. METHOD: Medication charts of 345 patients seen in June to August 2000 in hospital-based palliative consultation service, home care and hospice, were reviewed. The drugs used were recorded on two occasions--before referral and two weeks after or just before discharge from hospital or hospice, provided that death was not imminent. RESULT: The median number of drugs used was five, before and after referral. Analgesics and laxatives were frequently used in palliative care (60.3% and 60% respectively). The commonest analgesic was opiates (41.2% before and 47.8% after referral). Only the difference in laxative usage (50.4% prior to referral and 60% after) was statistically significant at p<0.01. 40.3% of the patients had an increase in the number of drugs after referral and 45.3% of them had addition of laxatives, compared to less than 30% for other drugs. A significantly higher proportion of patients (24.6% versus 18%) were on two or more drugs for constipation after referral. CONCLUSIONS: Reducing polypharmacy in palliative care is often difficult. There was higher awareness of bowel habits and treatment of constipation amongst those involved in palliative care. In addition to reviewing the use of some drugs, other measures such as patient education may be useful in minimising polypharmacy.

A study of the P blood group system in the Singaporean population.

The P blood-group system was discovered by Landsteiner and Levine in 1927. This study delineates: a) The ethnic group specific distribution patterns of the P1 blood group antigen in the population of Singapore. b) The occurrence rate of the anti-P1 antibody in the same population. In the blood donor population, the estimated incidence of the P1-negative phenotype was calculated to be 75%. Though the percentage of P1-negative individuals among the Chinese did not differ significantly from that for the Malays, it was significantly higher than that for the Indians (P less than 0.01). The weighted average incidence of anti-P1 in the blood-donor population over the period 1982-1987 was calculated to be 9.14 per 100,000. For the patients, the average incidence of the anti-P1 antibody was calculated to be about 13.9 per 100,000 patients. The Malays were noted to have the highest incidence of anti-P1 antibody despite the occurrence of a higher proportion of P1-negatives among the Chinese.

An audit of morphine prescribing in a hospice.

AIM OF STUDY: This audit was designed to investigate the morphine prescribing pattern in a hospice. METHOD: A review of 358 medical charts of all existing patients was conducted with a set of questionnaire. The prevailing practice was compared with an established standard guideline. RESULT: One-third (35%) of patients were receiving morphine. Several deficiencies in morphine prescribing were identified. These include omission of breakthrough morphine dosing, use of morphine as p.r.n. (when necessary) alone for chronic pain, absence of review after prescribing treatment, and lack of double dosing at night. Prophylactic laxative and anti-emetics were often not co-prescribed. CONCLUSION: Despite much of what is known about the pharmacology and therapeutic use of morphine, there is much variation and even inappropriate prescription in a palliative care institution. Implementation of recommended European guidelines and education may improve morphine prescribing habits. However, such guidelines may have to be validated in future studies to see if they need to be revised to suit our local population.

Hypodermoclysis or subcutaneous infusion revisited.

AIM OF STUDY: To review the use of hypodermoclysis in a local Hospice. METHOD: A review of all hypodermoclysis carried out over a six-month period was conducted. Special attention was paid to the reason for starting and stopping the drip, duration of the drip, complications, the type and amount of solution infused. RESULTS: Fifty-one (19%) out of 266 patients received hypodermoclysis during their stay. This constituted 5.9% of total patient-days in the study period. Vomiting and drowsiness were the main reasons for the use of drip. The commonest reason for stopping the drip was patient demise. Complications seen were drip site redness (16%), extravasation (15%) and bleeding (2.5%) There was no overt clinical sepsis in any of the patients. CONCLUSION: Hypodermoclysis is an easy and convenient means of providing hydration. The availability of a standard protocol with clearer guidelines on its use will help to reduce procedure-related complications and promote wider adoption of the practice.

Transpelvic rectus abdominis flap for perineal reconstruction following abdominal perineal resection with en bloc partial cystectomy and prostatectomy for locally advanced rectal cancer.

We report a case of locally advanced carcinoma of the rectum invading the bladder and prostate in a young man treated initially with neoadjuvant chemoradiotherapy. This was followed by an en bloc resection of the tumour, partial cystectomy and prostatectomy and an abdominal perineal resection. The urinary bladder was reconstructed and a new bladder neck reimplanted into the proximal urethra where the sphincter had been preserved. There was extensive radiation changes to the perineal skin where a wide excision had been performed. The pelvic defect was reconstructed with a pedicled transpelvic rectus abdominis myocutaneous flap. The patient recovered uneventfully and remains well with no clinical evidence of recurrence 18 months post-operatively. In very selected cases there is a definite role for neoadjuvant therapy and enbloc resection of the tumour followed by reconstruction of the perineum.

A report of infusional 5-fluorouracil and subcutaneous alpha-2A-interferon in the treatment of advanced colorectal carcinoma.

Systemic chemotherapy with 5-fluorouracil (5-FU) has been the mainstay of treatment for patients with metastatic colorectal carcinoma. Administering the drug in a continuous low-dose schedule has produced better result than bolus therapy. Resistance to short-pulse treatment can also be overcome by prolonged exposure. Recent studies suggest the feasibility of biomodulation of 5-FU with recombinant interferon (rIFN alpha-2a) with improved response. Sixteen patients were treated with continuous 5-FU 250 mg/m2 and rIFN alpha-2a 10 x 10(6) u thrice weekly for a maximum of 24 weeks. Five of them had received bolus 5-FU previously. Nine (82%) of the chemonaive group and 1 (20%) previously treated patient had partial response. The median duration of response was 7 months. Grade II to III mucositis were seen in 44% of the patients and 2 patients developed neurological complications. Although the overall response appeared encouraging, the incidence of toxicity was high. In the absence of further phase III studies, rIFN alpha-2a biomodulation of 5-FU cannot be regarded as standard treatment for patients with metastatic colorectal carcinoma.

Fanconi's anaemia and recurrent squamous cell carcinoma of the oral cavity: a case report.

Fanconi's anaemia is a rare genetic disorder and majority of the patients die of haematologic complications in their second or third decades of life. Others who have mild or no cytopenias survive long enough to develop malignancies. This is a report of a 44-year-old woman who presented with recurrent oral squamous cell carcinoma during her adulthood, without clinical haematological problem. Despite treatment with cis-retinoic acid, she developed a third squamous cell carcinoma 6 months later. In a review of the literature, only in 1 reported case was the patient treated with low-dose retinoids but he developed recurrent anal cancer after 14 months.

Effect of polysaccharide-peptide (PSP), an extract from yun-zhi, on chemotherapy-induced cytopenias.

Polysaccharide-peptide (PSP) is a protein-bound complex carbohydrate derived from mycelia extract of Chinese fungus coriolus versicolor, or better known as Yun-Zhi. It has been shown to inhibit growth of cultured tumour cells, and it prevents cytotoxic-induced bone marrow suppression. An animal study was conducted with 24 Wistar rats to verify the myeloprotective effect of PSP. The rats were divided into two equal groups: group A (given cyclophosphamide [CTX]) and group B (given PSP and CTX). The body weights were similar in both groups of rats. In phase 1, all rats were given intravenous CTX 75 mg/kg. In addition, B rats received PSP 20 mg/day orally from 7 days before CTX to 14 days after CTX. Phase 2 was carried out two weeks after full recovery from CTX-induced cytopenia. The CTX was decreased to 60 mg/kg, and the group B rats received an increased dose of PSP 1.2 g/day for the same 21 days. In both phases, the CTX was well tolerated. Nadir white blood cell count was reached on day 4 and all counts recovered by day 10. There was no difference in absolute neutrophil, lymphocyte and platelet counts between groups A and B. We concluded that oral PSP did not prevent CTX-induced cytopenia in rats.

Continuous infusion 5-fluorouracil as salvage chemotherapy in patients with advanced colorectal cancer.

For almost 40 years, 5-fluorouracil (5-FU) has been the only useful drug with clinically meaningful activity in metastatic colorectal carcinoma. When the disease progresses or recurs despite bolus 5-FU treatment, the options are limited. Our study shows that 5-FU given by continuous infusion is a viable alternative. Fifty-three patients received continuous infusion 5-FU. The overall response was 9%. Median survival of the entire cohort was 5 months. Patients with partial response and stable disease had median survival duration of 8 and 9 months, respectively. A dose-response relationship was observed. The commonest toxicities were mucositis (34%) and palmar-plantar syndrome (24%). There was no central line-related complication. Continuous infusion 5-FU is an effective "second-line" treatment. Further work is needed to ascertain its role, in comparison with newer agents like irinotecan (CPT-11), and oxaliplatin.

A study of the Lewis blood group system in the Singapore population.

The purpose of this retrospective study is to delineate: a) The ethnic group specific distribution patterns of the various Lewis phenotypes in our population in Singapore. b) The occurrence rates of the various anti-Lewis antibodies in our population. The approximate frequencies of the Lewis A-B-, Lewis A-B+ and Lewis A + B- phenotypes in the blood-donor population were estimated to be about 10%, 48% and 42% respectively. It was evident that frequency of the Lewis A-B- phenotype was highest among the Malays, being almost 3 times more frequent than it was among the Chinese (P less than 0.01). The anti-Lewis antibodies were noted to be the commonest irregular antibodies seen in our blood donor population, with an occurrence rate of about 127 per 100,000. Likewise, from 1982 to 1987, the anti-Lewis antibodies were also noted to be the most frequently encountered antibodies in our patient population, accounting for nearly 60% of all cases. Although the Malays comprised only about 15% of the Singaporean population, they accounted for as much as 42.9% of all patients with anti-Lewis antibodies. Similarly, out of all 76 blood donors in 1987 with anti-Lewis antibodies, 50% were found to be Malays although they comprised only 14.28% of the donor population. It was also interesting to note that a sizeable proportion of all patients with anti-Lewis antibodies were pregnant women with or without obstetric complications.

Efficacy and tolerability of irinotecan in patients with advanced colorectal cancer in Singapore.

INTRODUCTION: Colorectal cancer is the commonest malignancy encountered in Singapore. The long-term outcome of patients with advanced diseases is poor. For many decades, 5-fluorouracil was the only effective cytotoxic drug against colorectal cancers. Randomised trials have documented the efficacy of irinotecan in patients with metastatic colorectal cancer. We investigated the efficacy and safety profile of irinotecan (CPT-11), as a second-line treatment for an Asian population who had failed 5-fluorouracil-based chemotherapy. MATERIALS AND METHODS: A total of 33 patients were enrolled in the study between October 1996 and May 1999. This was an open label phase II study. All patients who had received at least one dose of CPT-11 were evaluated for toxicity. Thirty patients were evaluated for response. RESULTS: Six patients (20%) had partial responses and 1 (3%) experienced minor response. Fourteen patients (47%) progressed. Nine patients (30%) had stable disease. The range of time to progression was 5.8 months to 21 months. The median survival was 9.5 months. There was no treatment-related death. Seven patients (23%) who received treatment had diarrhoea. Only 2 of the 7 patients had grade 3-4 diarrhoea. Eleven patients (37%) suffered from haematological toxicity, of whom 2 patients had grade 3-4 neutropenia. CONCLUSION: We demonstrated efficacy and tolerability of CPT-11 in Singaporean patients with advanced colorectal cancer.

Immunotherapy of human cancers.

Advances in molecular biology technologies have significantly facilitated the identification of functional genes which cause, promote or control a variety of human diseases. Through recombinant DNA and polymerase chain reaction technologies, individual genes responsible for specific diseases have been identified, and consequently, the prospect that these diseases might be "cured" through replacement of the defective genes by their normal counterparts become distinct possibilities. Therefore, the goal of gene therapy is to apply this technology to the treatment of human diseases. In addition to its logical role for the correction of inherited diseases caused by a missing or defective gene product, gene therapy also holds promise for treatment of acquired disorders such as human cancer through the introduction of genes whose products have been implicated in controlling the growth of cancer. In this report, we present our results on the introduction of allogeneic major histocompatibility complex genes into cancer cells as an approach to increase the host's immune response against cancer. Various gene delivery strategies have been optimized for the introduction of DNA into various human tumour cells and these data are presented.

Measuring quality of life in Chinese cancer patients: a new version of the Functional Living Index for Cancer (Chinese).

INTRODUCTION: Since its translation into Chinese, the Functional Living Index for Cancer (FLIC) has not been widely received due to some of its difficulties. We modified its visual analogue scale (VAS) to an ordered categorical scale and changed some of the wording in the instrument. This study examined the measurement properties of the modified FLIC. MATERIALS AND METHODS: The modified version of FLIC and the Functional Assessment of Cancer Therapy (FACT-G Chinese version 4) were filled in by 140 patients recruited from the National Cancer Centre Singapore. The patients' FLIC scores were compared with their clinical characteristics to establish known-group validity. Convergent and divergent validity of FLIC were examined by correlation analysis with FACT-G and its sub-scales. Cronbach's alpha and relative efficiency were also examined. RESULTS: FLIC and most of its sub-scales could indicate a clear and statistically significant difference of quality of life (QOL) according to patients' performance status and treatment status. FLIC strongly correlated with FACT-G. The Physical, Psychological, and Symptoms sub-scales of FLIC converged to and diverged from FACT-G sub-scales as conceptually expected. Cronbach's alpha indicated a satisfactory level of reliability. FLIC appeared to be more efficient than FACT-G, meaning that a smaller sample size will be required for FLIC than for FACT-G to achieve the same research purpose. CONCLUSIONS: The modified version of FLIC was found to have achieved satisfactory measurement properties. This is a user-friendly alternative to the original FLIC.

After-hour home care service provided by a hospice in Singapore.

A home care Hospice programme was set up to provide care to the patients with advanced diseases and their families in Singapore. After office-hour, the service is managed by a doctor on weekdays, with the assistance of a nurse during daytime on Saturdays, Sundays and public holidays. The doctor on-call made an average of 3.1 phone calls and 1.3 visits each weekday evening. Over the weekends and public holidays, there were a mean of 16.7 phone calls and 6 visits each day. More than half of the visits (50.3%) were made for certification of death. The commonest symptoms that prompted visits were dyspnoea (20%) and pain (12.2%). The busiest period during weekdays was between 6.00 pm and 11.00 pm, when our doctors did most of their visits. The workload of the hospice home care service is likely to increase and resources such as family health physicians can be explored to help to meet this increasing demand. This can be achieved through the provision of comprehensive training and easy accessibility to medical records which are kept with patients.

Lessons learned from initial experience with peritonectomy and intra-peritoneal chemotherapy infusion.

INTRODUCTION: Patients diagnosed with peritoneal carcinomatous usually survive for less than 6 months. Cytoreductive surgery allows relief of the obstruction and improvement in functional status, while intraperitoneal chemotherapy infusion provides high local concentrations of chemotherapeutic agents. Our institutional experience is reviewed to assess the selection criteria, peri-operative complications, and outcomes. MATERIALS AND METHODS: We carried out a retrospective review of nine patients who had undergone aggressive cytoreductive surgery and hyperthermic intra- and early post-operative chemotherapy by a single surgeon between April 2000 and October 2004. The inclusion criteria were: (1) a demonstrated absence of extra-peritoneal and hepatic spread, (2) fitness of the patient and ability to tolerate cytoreductive surgery and intra-operative chemotherapy, and (3) the presence of a primary tumor originating form the gastro-intestinal tract (colonic, appendiceal, and gastric primaries). RESULTS: Seven women and two men, with a median age of 55 years, were treated. The median duration of the operation was 12 hours and 55 minutes. Seven of the nine patients required the insertion of at least one chest tube. All patients were monitored in the surgical intensive care unit (SICU) for a median of 1 day, started on feeds after a median of 6 days, and were hospitalized for a median of 16 days (range:11-18 days). There was no peri-operative mortality and only one major peri-operative complication (11.1%). At the time of analysis, the median follow-up was 16 months (range: 2-40 months), and the median disease-free survival was 8 months, with four of the nine patients showing no evidence of recurrence. To date, all of the patients are still alive. A 1-year survival rate of 100% is also documented. CONCLUSIONS: This article describes our initial experience with peritonectomy and intra-operative, intra-peritoneal chemotherapy infusion. Our initial problems included difficulty with leakage of the chemotherapeutic agents into the thoracic cavity that had to be overcome by the early insertion of chest-tubes. With appropriate patient selection, cytoreductive surgery with the infusion of intra-operative chemotherapy can be considered to be a therapeutic option for some patients with diffuse peritoneal metastases, and good disease-free and overall survival can be achieved with minimal morbidity.

Role of maintenance oral dexamethasone in prophylaxis of delayed emesis caused by moderately emetogenic chemotherapy.

BACKGROUND: Although usually a problem of cisplatin-based chemotherapy, delayed emesis can cause severe distress in patients treated with cyclophosphamide. Dexamethasone has been shown to be effective in the control of cisplatin-induced delayed emesis, but its role against the delayed problem in patients treated with cyclophosphamide has not been demonstrated. Our study was conducted to evaluate the effect of dexamethasone in delayed emesis induced by cyclophosphamide. PATIENTS AND METHODS: Ninety-eight patients were given i.v. granisetron and i.v. dexamethasone before chemotherapy, and randomised to receive either oral dexamethasone 4 mg twice daily as maintenance or no maintenance. RESULTS: Ninety-four patients were evaluable. Of those given maintenance oral dexamethasone, 57% had complete and 30% had major control of delayed emesis, versus 33% and 15%, respectively, of patients who did not receive maintenance. Side effects are mainly constipation and headache. CONCLUSION: The results shows that oral dexamethasone is an effective agent against cyclophosphamide-induced delayed emesis.

Adjuvant postoperative 5-fluorouracil chemotherapy combined with pelvic radiation for rectal cancer: results from an Asian population.

Prospective randomized clinical trials have shown the effectiveness of combined adjuvant 5-fluorouracil-based chemotherapy and radiotherapy after surgical resection of rectal cancer. To assess toxicity of this therapy, prospective data were collected from 236 Asian rectal cancer patients treated with combined 5-fluorouracil-based chemotherapy and radiotherapy after surgery. Almost 82% of patients completed planned therapy. Grade 3 and 4 diarrhea, stomatitis, and granulocytopenia occurred in approximately 18-21% of patients. There were two treatment-related deaths from granulocytopenia and sepsis. With median follow-up of 3.5 years, median disease-free and overall survival was 75 and 88 months, respectively. In conclusion, combined adjuvant 5-fluorouracil-based chemotherapy and radiotherapy after surgical resection of rectal cancer is tolerable in Asian patients with moderate toxicity.