Early and short-term acenocumarine or dalteparin for the prevention of central vein catheter-related thrombosis in cancer patients: a randomized controlled study based on serial venographies.

BACKGROUND: We evaluated efficacy and safety of early and short-term prophylaxis with acenocumarine or dalteparin in the prevention of non-occlusive or occlusive central vein catheter-related thrombosis (CVCrT). PATIENTS AND METHODS: Consecutive cancer patients scheduled for chemotherapy randomly received: acenocumarine 1 mg/day for 3 days before and 8 days after central vein catheter (CVC) insertion; dalteparin 5000 IU 2 h before and daily for 8 days after CVC insertion; no anticoagulant treatment (NT). All patients underwent venography on days 8 and 30, some of them on days 90, 150 and 210 after CVC. RESULTS: A total of 450 patients were randomized, 348 underwent at least two venography. Both acenocumarine and dalteparin reduced venography-detected CVCrT rate [21.9% acenocumarine versus 52.6% NT, odds ratio (OR) 0.3, P < 0.01; 40% dalteparin versus 52.6% NT, OR 0.6, P = 0.05]. Acenocumarine was more effective than dalteparin (OR 0.4, P = 0.01). The rate of occlusive CVCrT was not different in the three groups (0.9% acenocumarine, 3.3% dalteparin, 1.8% NT; P = 0.40). Most CVCrTs (95.6%) were observed on day 8 after CVC insertion and were non-occlusive. CONCLUSIONS: In this study of early and short-term prophylaxis, acenocumarine was more effective than dalteparin on non-occlusive and asymptomatic CVCrT events. The first days following CVC insertion represent the highest risk for CVCrT.

Plasma HHV-8 viral load in HHV-8-related lymphoproliferative disorders associated with HIV infection.

This is a mono-institutional analysis of the clinical features, immunological and virological findings, and prognostic factors of patients with HIV infection and HHV-8-lymphoproliferative disorders. Patients with Multicentric Castleman Disease and HHV-8-related lymphoma diagnosed and treated from April 1987 to June 2004 were included in the study. HHV-8 and HIV plasma viral load, CD4+ count, hematologic parameters, and general wellbeing (performance status) were assessed at the onset of the diseases and analyzed in order to identify possible prognostic factors. Nine patients with Multicentric Castleman disease, and 16 with HHV-8-related lymphomas (13 primary effusion lymphomas and 3 solid lymphomas), were diagnosed and treated out of 327 HIV-related non-Hodgkin's lymphomas. Four patients with Multicentric Castleman disease received only antiretroviral drugs; 5 HAART plus oral etoposide. Nine patients with primary effusion lymphoma were treated with a CHOP-like regimen (Cyclophosphamide, Prednisone anthracyclines, Vinca alkaloids, Bleomycin, Etoposide) and HAART; 1 with etoposide and HAART, 1 with HAART alone. The patients with solid lymphoma underwent CHOP-like chemotherapy. Patients with Multicentric Castleman disease showed lower median values of HHV-8 viral load and longer overall survival compared with HHV-8-related lymphomas. Patients with viral load of HHV-8, >40,000 cp/ml had a significant shorter overall survival. In the univariate analysis, HHV-8-related lymphoma, HHV-8 viral load >40,000 cp/ml and performance status >2 were associated with an increased risk of death. Multivariate analysis confirmed the diagnosis of lymphoma as an independent predictor of shorter survival.

Surgical second look in ovarian cancer: a randomized study in patients with laparoscopic complete remission--a Northeastern Oncology Cooperative Group-Ovarian Cancer Cooperative Group Study.

PURPOSE: The usefulness of extensive and repetitive surgery for patients with ovarian cancer still remains unproven (at least for some conditions). We planned an accurate prospective test of the hypothesis that patients with advanced-stage disease, after they had reached a clinical complete remission (CR), may benefit from surgical second look (SSL). PATIENTS AND METHODS: One hundred two patients in CR (as assessed by clinical findings, markers, and visualization by computed tomographic [CT] scan and laparoscopy), after initial debulking and first-line chemotherapy, were randomized to two arms, which were well balanced for predictive criteria such as age, stage at presentation, histology, grading, date of randomization, and residua after first surgery. Forty-eight patients were randomly assigned to receive follow-up evaluation only, while 54 were assigned to receive second surgery (eight of them refused). Of 46 surgical patients, 35 had negative and 11 positive surgical findings (24% clinically false-negative). RESULTS: Despite the microscopic residua found at open surgery, and the fact that the patients were then treated with second-line chemotherapy, SSL did not increase the probability of survival in this setting. In an analysis of the results according to the intention-to-treat criteria, after a 60-month follow-up period, the overall survival rates in the two groups of patients (SSL v no SSL) were 65% and 78%, respectively (P = .14). Multivariate analysis according to predictive criteria confirmed there was no significant difference between the two groups (P = .39). CONCLUSION: Our study shows the following: (1) our second-line treatment is scarcely effective; (2) SSL accurately defines complete responders to first-line chemotherapy; (3) SSL per se does not prolong survival; and (4) if confirmed, a less invasive procedure could replace SSL as a valuable method in new first-line regimens in ovarian cancer patients with clinical CR confirmed by laparoscopy.

Central venous thrombosis: an early and frequent complication in cancer patients bearing long-term silastic catheter. A prospective study.

Studies on catheter-related central venous thrombosis (CRCVT) have been focused mainly on clinically evident CRCVT due to occlusive thrombi, underestimating therefore the actual thrombosis prevalence. This prospective study was aimed at evaluating prevalence, timing and evolution of thrombosis, and identifying involved veins and risk factors in cancer patients (pts) undergoing percutaneous subclavian central venous catheterization (CVC) for chemotherapy, parenteral nutrition or both. We enrolled 127 consecutive pts requiring partially or totally implanted central venous silastic catheters. The study protocol included peripheral phlebography (P) at day 8, 30 and every two months following CVC and/or when clinically indicated, along with peripheral and pullout P on catheter withdrawal. A quantitative scale was developed to evaluate thrombus grading in subclavian, innominate and cava veins. Age, sex, coagulation profile tumor histotype, metastases, therapy, catheter type, and catheter insertion side were also investigated. Only pts who underwent at least two P were evaluated, and chi 2 test was adopted for statistical analysis. Altogether, 95 pts were evaluable. CRCVT was observed in 63/95 (66%) pts. At day 8, 30 and 105 (representing the median days in which first, second and last P were performed) CRCVT was evidenced in 64%, 65% and 66% of the pts, respectively. Thrombus grading did not differ among first, second and last P. CRCVT was symptomatic in 4/63 (6%) pts. Thrombosis prevalence was higher in subclavian (97%) with respect to innominate (60%) or cava (13%) veins (p < 0.001). Thrombosis was higher in left subclavian catheters (14/16; 87.5%) than in right ones (49/79; 62%), p < 0.01. No associations were established between CRCVT and other investigated parameters. Our data show a very high actual frequency of CRCVT in cancer pts, and emphasize that first days following CVC are at the highest risk for CRCVT development. Based on our results, a study on short-term antithrombotic prophylaxis in cancer pts requiring CVC is warranted. Finally, our data indicate that left subclavian vein catheterization represents a risk factor for CRCVT.

Antithrombin III deficiency as a risk factor for catheter-related central vein thrombosis in cancer patients.

The fibrin sleeve of venous catheters (VC) and parietal thrombi represent frequent and dangerous side-effects of central venous catheterization (CVC), due to the risk of embolism. Reduced levels of coagulation clotting factors inhibitors (such as Antithrombin III) are known to be associated with increased thrombogenic risk. The aim of this study was to evaluate the role of Antithrombin III (AT III) deficiency as a risk factor for thrombosis in cancer patients undergoing CVC. The study groups included patients with a reduced AT III activity (< 70%, 20 consecutive patients) and with normal AT III values (> 70%, 20 randomly selected patients), requiring a VC for chemotherapy and/or total parenteral nutrition. The study protocol included evaluation of Hb, PLTs, PT (INR), aPTT, Fibrinogen and AT III at days 0, 1, 3 and 8 after CVC and upon VC removal. Peripheral and pullout phlebographies were performed in all patients on catheter withdrawal. A quantitative scale was developed to evaluate both VC and parietal thrombus degree in each catheter-containing venous segment (subclavian, innominate, superior vena cava); the sum of the mean values was defined as overall thrombus. The average VC dwelling time was similar in both groups. There were no significant differences in Hb, PLTs, PT (INR), aPTT, Fibrinogen and in the remaining parameters of the study between the two groups. The group with AT III deficiency presented a higher degree of both parietal (p < 0.05) and overall thrombus (p < 0.02). Data showed a higher severity of CVC-related thrombosis in patients with AT III deficiency than in the control group. Further studies are needed to evaluate whether the therapeutically-induced normalization of AT III levels can reduce the thrombosis degree.

Prognostic factors in soft tissue sarcomas: a study of 395 patients.

AIMS: The aim of this study was to report prognostic factors, end-points of local recurrence, distant recurrence, post-metastasis survival, and overall survival in a cohort of patients with soft tissue sarcomas. METHODS: We analysed a database of 395 patients affected by primary soft tissue sarcomas of various primary sites, treated and followed up at the Centro di Riferimento Oncologico, Aviano, Italy from January 1985 to January 1997. RESULTS: Grade, size, stage, surgical margins, distant metastasis, age, sex, performance status, and haemoglobin value were significant for overall survival. Histology, grade, stage, and surgical margins were significant for local recurrence. Grade, size, and stage, were significant for distant recurrence; and surgical margin was significant variable for post-metastasis survival. CONCLUSIONS: Grade, size, and TNM stage (UICC/AJCC) have stronger prognostic significance for overall survival and distant recurrence than for local relapse. Positive surgical margins are the main predictors for local relapse. Age was the most consistent adverse independent prognostic factor for survival.

Raysum reconstruction algorithm in MR cholangiopancreatography.

Magnetic resonance cholangiopancreatography (MRCP) is a new, non-invasive imaging technique for the visualization of the biliary ducts. The presence of stones within the choledocus is easily detectable in source images. However, three-dimensional reconstructions using the maximum intensity pixel (or projection) algorithm (MIP) fail to reproduce accurately the eventual presence of filling defects or parietal irregularities due to biliary stones. We used the Raysum algorithm in addition to the MIP in evaluating MRCPs of twelve patients with known choledocolithiasis. A visualization of the stones was obtained in nine (75%) patients by using the Raysum while visualization was obtained in one patient by using MIP. No additional sequences are required, and the post-processing time takes only a few seconds. The Raysum reconstruction can be successfully associated to the MIP in the three-dimensional evaluation of biliary stones in MRCP.

Central venous catheter-related thrombosis in clinically asymptomatic oncologic patients: a phlebographic study.

Fifty-seven oncologic patients with short- or long-term central venous catheters (CVCs) and without clinical signs of axillary-subclavian thrombosis were evaluated phlebographically. Different degrees of incomplete thrombosis were found in 26 patients (45.5%) and complete thrombosis, clinically silent, was found in six patients (10.5%). A fibrin sleeve around the CVC was radiologically demonstrated in 45 (78%) patients, 21 of them (46%) with negative standard venogram. Only in four patients there was no evidence of fibrin sleeve or parietal thrombosis. There were no significant differences between patients with long-term and short-term CVCs. We conclude that parietal thrombosis of the axillary-subclavian veins is a frequent event, even if there is no clinical evidence of flow obstruction and we confirm in vivo that a fibrin coating of the CVCs is present in the majority of the cases.

The Italian multi-centre project on evaluation of MRI and other imaging modalities in early detection of breast cancer in subjects at high genetic risk.

This report presents the preliminary results of the first phase (21 months) of a multi-centre, non-randomised, prospective study, aimed at evaluating the effectiveness of contrast-enhanced magnetic resonance imaging (MRI), X-ray mammography (XM) and ultrasound (US) in early diagnosis of breast cancer (BC) in subjects at high genetic risk. This Italian national trial (coordinated by the Istituto Superiore di Sanità, Rome) so far recruited 105 women (mean age 46.0 years; median age 51.0; age range 25-77 years), who were either proven BRCA1 or BRCA2 mutation carriers or had a 1 in 2 probability of being carriers (40/105 with a previous personal history of BC). Eight cases of breast carcinomas were detected in the trial (mean age 55.3 years, median age 52.5; age range 35-70 years; five with previous personal history of BC). All trial-detected BC cases (8/8) were identified by MRI, while XM and US correctly classified only one. MRI had one false positive case, XM and US none. Seven "MRI-only" detected cancers (4 invasive, 3 in situ) occurred in both pre- (n = 2) and post-menopausal (n = 5) women. With respect to the current XM screening programmes addressed to women in the age range 50-69 years, the global incidence of BC in the trial (7.6%) was over ten-fold higher. The cost per "MRI-only" detected cancer in this particular category of subjects at high genetic risk was substantially lower than that of an XM-detected cancer in the general women population. These preliminary results confirmed that MRI is a very useful tool to screen subjects at high genetic risk for breast carcinoma, not only in pre-, but also in post-menopausal age, with a low probability of false positive cases.

Partial response to lonidamine of advanced bladder carcinoma: a case report.

A 76 year old woman presented with locally advanced papillary transitional cell carcinoma. The patient had elsewhere had trans-urethral resection and radiotherapy and declined salvage cystectomy. She was treated with Lonidamine (150 mg X 3/day p.o. Repeat CT scan after 8 months showed partial remission. This response was unchanged after 28 months Lonidamine therapy.

Cisplatin and mitomycin C in advanced chemotherapy-refractory breast cancer.

A combination of platinum (100 mg/m2 in a 24-h continuous i.v. infusion) and mitomycin C (10 mg/m2 i.v. push at the end of the cisplatin infusion) was administered in 20 patients with advanced breast cancer refractory to conventional treatments (CMF and anthracycline-containing regimens, hormonal therapies). The response rate was 20% (4/20), including one complete response of lung metastases which lasted 12 months. Median duration of partial responses was 4 months. Major toxicity was gastrointestinal and it was superimposable to that observed with other cisplatin-containing regimens. A marked and prolonged asthenia was reported in 6/20 patients (30%), and the regimen's compliance was poor. We conclude that at these doses and schedule, the cisplatin and mitomycin C combination has a limited efficacy in advanced breast cancer patients, and its use is not recommended in pretreated patients.

Epirubicin in the treatment of malignant mesothelioma: a phase II cooperative study. The North-Eastern Italian Oncology Group (GOCCNE)--Mesothelioma Committee.

From September 1986 to April 1988, all consecutive patients with histologically proven (pathologic review mandatory) malignant mesothelioma, measurable disease, age less than 75 years, Karnofsky performance status equal to or greater than 40, and no previous chemotherapy were treated with epirubicin at the dosage of 75 mg/m2 i.v. every 3 weeks. Of the 23 patients who entered the study, 2 were retrospectively found not to have malignant mesothelioma. In the 21 eligible patients (all evaluable), no complete remission, 1 partial remission, 11 stable diseases and 9 progressions were noted. Toxicity was very mild. Median survival was 7.5 months. At the dosage used, epirubicin proved to be of little value in the management of these patients. Whether higher doses are more effective, as has been noted in other tumors, remains to be ascertained.

Efficacy of total androgen blockade in metastatic prostatic carcinoma with transient hypogonadotropic hypogonadism: a case report.

A patient affected by metastatic prostatic carcinoma and hypogonadotropic hypogonadism (HH) was treated with flutamide 750 mg/day plus an LH-RH analog. After confirmation of basal castration during treatment, he continued with antiandrogens alone. Following the normalization of gonadic function and subjective mild bone flare-up, the patient resumed the initial treatment and obtained a partial response. When flutamide was interrupted because of liver toxicity, the patient showed progressive disease in the bone, which was unresponsive to both flutamide resumption and salvage hormone therapy (bicalutamide). The patient is currently receiving chemotherapy with VP16 and estramustine phosphate and is showing both serologic (PSA) and symptomatic response. The interest of this case lies in the incidental detection of HH during therapy and in the responsiveness to treatment.

Metastatic angiosarcoma of the spleen. A case report and treatment approach.

We report a case of a 28-year-old man with angiosarcoma of the spleen and liver metastases. The aim of this paper is to underline the importance of planned splenectomy in these patients even if they have metastatic disease, and to propose an intensive chemotherapy regimen consisting of anthracyclines, ifosfamide and mesna with G-CSF support.

Calcified gastric cancer--CT findings before and after chemotherapy. Case report and discussion of the pathogenesis of this type of calcification.

Diffuse calcifications in primary gastric cancer are very rare, most of them being found in mucinous adenocarcinoma. We present the CT aspects of a locally advanced gastric cancer, which showed partial response to neo-adjuvant chemotherapy. The pathological features of the surgical specimen after total gastrectomy are also reported and the pathogenesis of the calcifications is discussed.

[Urinary calculi in an intestinal loop used for ureteral substitution. A case report]. / Calcolosi urinaria in ansa intestinale utilizzata per sostituzione ureterale. Osservazione di un caso.

The authors report the case of large urinary calculi formed inside the ileal conduit diversion in a patient who underwent radical surgery for an ovarian carcinoma involving the right ureter. Two ureter stents were left to ensure drainage and were endoscopically removed after six months. Renal function and ureteral canalization were normal. However, because of a knot in the proximal end of stents, a piece 5 cm-long-was left inside the diversion. After six months the patient developed recurrent renal colics: plain abdomen X-ray and urography showed a large urinary stone around the stents fragment and several smaller stones nearby. They all were removed surgically. The pathogenesis of such complications was considered: even though the slow flux of urine in the diversion, the abnormal mucus production from the ileal mucosa and the excessive and chronic bicarbonate loss played an important role in the developing of urinary calculi, the authors believe that in this case the main responsible for the stone formation was the foreign body in the urinary diversion.

[Diagnostic imaging in immunosuppressed subjects: malignant tumors]. / Diagnostica per immagini nei soggetti con immunodepressione: tumori maligni.

Each state of immunodeficiency is complicated by an increased incidence of certain types of cancer. The risk factors in the development of malignancies increase in a time-dependent relationship with the age of the defect in cell-mediated immunity and some tumors will develop at fairly distinct time intervals during immunodeficiency. Thus, Kaposi's sarcoma appears mostly when the degree of immunodeficiency is slight (average time: 23 months), non-Hodgkin's lymphoma is prevalent in an intermediate phase (average time: 37 months) and some carcinomas will appear only if immunodeficiency lasts many years. Many hypotheses have been suggested as to the biological mechanisms by which an immunity defect contributes to the development of malignancies: the most credible of them is the one suggesting the action of some oncogenic viruses which are not sufficiently controlled by the immune system. Kaposi's sarcomas and non-Hodgkin's lymphomas are the most common types of tumor in AIDS patients. Other tumors--except for Hodgkin's lymphoma--are seldom reported in HIV patients. However, the incidence of carcinomas is thought to be likely to increase in the next few years, because the longer survival of HIV patients, without strengthening their immune system, will unfortunately allow the tumors with longer onset time to develop. As for Kaposi's sarcomas and non-Hodgkin's lymphomas, the major epidemiological data are reported, together with some etiopathogenetic hypotheses and the main clinical and radiologic patterns. Other solid tumors in HIV patients and their clinical and radiologic features are reported too. Our series of cases was collected by the GICAT (Italian Cooperative Group on AIDS-related Tumors) which coordinates epidemiological studies, supports medical research and standardizes the treatment of patients suffering from HIV-related tumors.

[Computerized tomography in the staging of carcinoma of the oropharynx, the tongue and the mouth floor]. / La tomografia computerizzata nella stadiazione dei carcinomi dell'orofaringe, della lingua e del pavimento orale.

Eighty-seven patients with carcinoma of oropharynx, tongue and floor of the mouth were examined by means of CT; (TNM criteria); tumor staging was reviewed and compared with that obtained by clinical examination, by endoscopy, at surgery and histology. CT proved to be a reliable technique to detect both the presence of neoplasms, with the exception of very superficial ones, and their deep spread to parapharyngeal space, to muscles of floor of the mouth and prevertebral pterygoid muscles. Lymph node metastases, especially to retropharyngeal nodes, were also clearly demonstrated on CT scans, which indicates this technique as the examination of choice in oropharyngeal and oral cavity tumor staging, for it yields valuable information which can integrate clinical findings.

Lymphangiography and abdominal computerized tomography in persistent generalized lymphadenopathy.

Lymphangiography (LAG) and abdominal computed tomography (CT) were performed on 13 intravenous drug (heroin) abusers with persistent generalized lymphadenopathy (PGL). All 12 LAG performed were abnormal with a repetitive pattern of diffuse abnormalities of internal structures with small filling defects of both pelvic and abdominal lymph nodes. In 12/13 (92%) of the patients, lymphadenopathy was evidenced by CT scan as well. Retroperitoneal lymph nodes were always abnormal, mesenteric and pelvic nodes in 7 patients each. In 9/13 (69%) of the patients, the spleen was found to be moderately enlarged. The LAG films of our first 2 patients referred to us with an erroneous histologic diagnosis of malignant lymphoma were read to be consistent with involvement by lymphoma. Considering that patients with PGL are at risk for transformation to malignant lymphoma, the LAG and CT findings of PGL should be kept in mind when transformation to malignant lymphoma occurs and staging is performed.