Complications associated with the use of Port-a-Caths in patients with malignant or haematological disease: a single-centre prospective analysis.

Totally implantable central venous catheters are widely used in the management of patients with haematological or malignant disease. This paper investigates device-related complications and compares it with the literature. A total of 143 Port-a-Caths (PaCs) were implanted in 140 patients at a single centre during 2004 and followed until March 2005. Indication for implantation was mainly administration of chemotherapy. High standards of care were applied through intensive training of staff. Complications were registered prospectively and cross-checked with the medical records at the end of the observational period. The ports were in place for a total of 29 107 days (mean 204, range 3-443 days per port). A total of 25 complications were recorded. These included 13 infections [9.1% with 5 cutaneous (3.5%) and 8 systemic (5.6%) infections], one deep vein thrombosis (0.7%). In 6 patients (4.2%) the device had to be removed because of complications. No device-related death was observed. The use of totally implantable central venous catheters for treating haemoto-oncological patients is safe. The need for device removal due to complications was particularly low in this analysis as compared with the literature.

A randomized study comparing interferon (IFN alpha) plus low-dose cytarabine and interferon plus hydroxyurea (HU) in early chronic-phase chronic myeloid leukemia (CML).

This multicenter randomized phase III study was designed to compare the efficacy and toxicity of IFN alpha-2c (3.5 MU/d) in combination with either araC (10 mg/m(2) d1-10) or hydroxyurea (HU: 25 mg/kg per day) in newly diagnosed CML patients. A total of 114 patients were randomized. Following a median observation period of 36 (range 1-73) months the major cytogenetic response rates were 25 and 27% and the 4-year survival probabilities 62.5 and 63% for the araC and HU group, respectively. While the overall toxicity profile was comparable between both groups, patients in the HU arm exhibited a slightly higher degree of WHO grades 3 and 4 non-hematological toxicities.

[Fracture and embolization of a central venous port catheter without prior compression between the clavicle and the 1st rib]. / Bruch und Embolisation eines zentralvenösen Portkatheters ohne vorherige Kompression zwischen Klavikula und erster Rippe.

A central venous port catheter inserted infraclavicularily via the subclavian route may be compressed by the clavicle and the adjacent first rib. It's appearance on chest x-ray has been previously described as the 'pinch-off phenomenon' and requires the removal of the catheter due to a significant risk of fracture. We report the case of a catheter fracture without prior evidence of pinch-off. The free catheter fragment was embolized into the right atrium and caused pericardial effusion. Percutaneous removal of the fragment was attempted but failed and thus open heart surgery with a cardiopulmonary bypass was required. The myocardial lesion caused by the catheter was sutured.

Dose escalation of ara-c may improve response rates in a subgroup of chronic myeloid leukemia patients with poor response to interferon-alpha and low-dose ara-C.

The present analysis was performed to evaluate the impact of cytosine arabinoside (ara-C) dose escalation on hematological and cytogenetic responses in patients with chronic myelogenous leukemia (CML) who failed to respond to low-dose ara-C (LD ara-C) at a dose of 10 mg/m2/d over 10 days per month and interferon-alpha (IFNalpha, 3.5 MU/d). Following the same administration schedule, dose escalation of ara-C to 15 and 20 mg/m2/d 1-10 was performed in 36 of 119 patients (30%) due to inadequate hematological response and/or disease progression. As a result, improvement of hematological and cytogenetic responses was achieved in 22 (61%) and nine (25%) patients, respectively. Escalated ara-C dose levels were usually well tolerated, although some patients experienced deterioration of preexisting side effects. Our results support the critical role of ara-C dose towards a better disease control in CML.

Interferon-alpha for the treatment of elderly patients with chronic myeloid leukaemia.

The present retrospective analysis is based on data of 213 patients with chronic myeloid leukaemia (CML). They were treated with interferon (IFN)alpha-2C (Berofor) at daily doses of 3.5 MU subcutaneously (s.c.), alone or in combination with low-dose ara-C or hydroxyurea, according to four consecutive studies of the Austrian CML Study Group. Comparisons were made between 41 patients aged > or = 60 years and 172 younger patients. The elderly patients (median: 64 years; range: 60-73) showed similar pretreatment characteristics compared with the younger group, but included a higher percentage of Sokal Stage three (51 vs 20%). Median observation periods were similar (38 vs 39 months), whereas the duration of IFNalpha treatment was shorter in the elderly group (median 57 vs 42 weeks). The rate of overall haematological responses (73 vs 78%) and complete haematological response (44 vs 54%), was similar in both cohorts. Differences seen in partial (5 vs 12%) and complete cytogenetic response (10 vs 13%), were not statistically significant, but a tendency in favour of the younger cohort had to be noted. Summing up, in elderly patients acceptable rates of haematological and cytogentic response can be expected after treatment with IFNalpha alone or in combination with LD ara-C or HU.

[AL amyloidosis--a hematologic disease with initial cardiac manifestation. 2 case reports]. / AL-Amyloidose - Eine hämatologische Erkrankung mit kardialer Erstmanifestation. 2 Fallberichte.

Cardiac involvement in AL-amyloidosis due to a multiple myeloma is present in up to 90% of cases. We present two patients with cardiac symptoms in whom a hematologic disease could be diagnosed because of suspicious cardiac finding. The leading symptom was dyspnea. The routinely performed laboratory tests, especially the erythrocyte sedimentation rate and the electrophoresis, were normal. After exclusion of coronary artery disease an infiltrative cardiomyopathy was suspected because of the echocardiographic examination with marked left ventricular hypertrophy, the restrictive flow pattern at the mitral valve and the electrocardiogram with a low voltage in limb leads and absent R waves in left precordial leads. Further, hematologic workup confirmed the production of light chains due to a myeloma. If the echocardiographic examination and the electrocardiogram raises the suspicion of an infiltrative cardiomyopathy as the cause of dyspnea, an immunofixation should be done in spite of normal laboratory tests to confirm or rule out the presence of a light chain disease due to a myeloma.

Portal hypertension due to traumatic hepatic arterioportal fistula: report of successful embolization.

We report a case of severe portal hypertension due to a post-traumatic hepatic arterioportal fistula. A 77-year-old male patient was admitted for abdominal pain, inappetence and weight loss. Further clinical signs were ascites and splenomegaly. Sonography showed a marked enlargement of an arterioportal fistula, which was diagnosed some years before as a consequence of abdominal trauma during the Second World War. Angiography demonstrated an imposing dilatation of the right hepatic artery filling an intrahepatic pseudoaneurysmatic cavity with fistula formation to the portal vein. By means of selective hepatic artery embolization, complete occlusion of the right hepatic artery and the arterioportal fistula was achieved. Within 4 weeks the patient recovered and sonography showed disappearance of ascites and splenomegaly.

First-line treatment of Waldenström's disease with cladribine. Arbeitsgemeinschaft Medikamentöse Tumortherapie.

PURPOSE: To assess the activity and side effects of cladribine (2-CdA) treatment in patients with advanced Waldenström's disease. PATIENTS AND METHODS: Ten symptomatic patients without prior therapy were included in a prospective multicenter trial. 2-CdA was administered daily at 0.12 mg/kg body weight in a 2-h i.v. infusion over 5 consecutive days: this was repeated every 28 days for four cycles. Patients achieving a remission received interferon alfa-2c (1F) 15 micrograms s.c. three times a week for 1 year. RESULTS: All 10 patients responded to 2-CdA (100%; 95% confidence interval, 68-100%), with one complete (CR) and eight partial responders (PR): one patient had only one 2-CdA cycle and showed a minor improvement (MR). Patients tolerated the treatment well. Despite considerable immunosuppression, an infection occurred in only two patients. After a median observation period of 57 weeks, three patients had shown progression, including one who died of lymphoma. CONCLUSION: 2-CdA induction and IF maintenance is a well-tolerated therapy for symptomatic untreated patients with advanced Waldenström's disease and offers excellent palliation.

Parameters of prognostic relevance to the patency of vascular access in hemodialysis patients.

The objectives of this study were to evaluate whether age, sex, underlying renal disease, or the performing surgeon is of prognostic relevance to the patency of the vascular access. In a routine clinical setting, 139 first and 144 further fistula operations were done in 139 patients during 5 yr and were analyzed in retrospect. Within a group of 108 patients with first Cimino-Brescia fistulae, Cox multivariate regression analysis revealed the surgeon to be the only determinant with a continuous, significant effect on fistula patency throughout the observation period (P(out) < 0.1). The patency rates of the seven surgeons at 1, 2, and 3 yr differed from 34 to 69, 13 to 62, and 13 to 62%, respectively. Hazard ratios among the surgeons varied from 0.65 to 2.21. Additionally, age (P < 0.004) and diabetes mellitus (P < 0.02) were disclosed to be significant risk factors for impaired patency, but later in the course of disease (time dependent). Sex had no influence. After the failure of the first fistula, revisions of or new Cimino-Brescia fistulae (N = 56) were superior to polytetrafluoroethylene grafts (N = 61). The mean patency of the former amounted to 320 +/- 377 versus 156 +/- 281 days in polytetrafluoroethylene grafts (P < 0.05). It was concluded that increasing age and diabetes mellitus are time-dependent risk factors for the shortened patency of arteriovenous fistulae. The operating surgeon, however, seems to be the major determinant for the continuous patency of Cimino-Brescia fistulae.

[Spontaneous regression of a small cell bronchial carcinoma]. / Spontanregression eines kleinzelligen Bronchuskarzinoms.

A circular focus of 1 cm diameter was discovered by chance on a thoracic x-ray of a female patient of 66 years of age suffering from chronic interstitial nephritis due to analgesics. Bronchoscopic suction revealed histologically a small-cell carcinoma of the lung but there was no indication of formation of metastases. The patient refused any tumor-specific treatment. In the further course of the disease the focus showed up radiologically for seven months and was then no longer visible throughout the following 14 months. The patient finally died subsequent to an extensive posterior myocardial infarction. Postmortem examination excluded the presence of a primary tumor of the lung or metastases. Our case suggests the rare occurrence of a spontaneous regression of a small-cell bronchial carcinoma. Although spontaneous regression of malignant diseases is ascribed to immunological factors, such regression can also occur if the immunological system is impaired, as had been the case in this particular patient with chronic renal insufficiency.

Treatment of 11 patients with chronic myelogenous leukemia with interferon-alpha-2C and low-dose cytosine arabinoside.

Patients with Philadelphia (Ph) chromosome-positive chronic myelogenous leukemia (CML) and on interferon (IFN)-alpha-2c treatment for at least two months were entered in the present pilot study. IFN-alpha treatment was maintained identically and cytosine arabinoside (Ara-C) was added at monthly cycles of 10 mg/m2/day for ten days subcutaneously. In the case of a leukocyte nadir above 10 G/l, the Ara-C dose was increased to 20 mg/m2/day for 10 days per month. Ten of the eleven patients entered in this study were evaluable for toxicity and response. They received a total of 87 IFN-alpha/Ara-C cycles (3-14/patient). Five patients received 1-5 cycles with Ara-C dose intensification to 20 mg/m2/day. The following gastrointestinal and hematological toxicities were attributable to Ara-C, as they had not been observed in these patients during the preceding IFN-alpha monotherapy period. Gastrointestinal side effects consisted of nausea grade 1 (n = 5) and diarrhea grade 2 (n = 1). Hematotoxicity was observed in eight patients, grade 1 in five patients and grades 2, 3 and 4 in one of the patients each. Both episodes of grades 3 and 4 toxicity were seen during dose escalation to 20 mg/m2. Small cytogenetic responses (4-14%) were observed in 3 patients and a larger one (50%) in one patient, hematological improvement or stable disease in an additional three patients. These preliminary data suggest that the combination of IFN-alpha and low-dose Ara-C is active in inducing cytogenetic responses in CML patients at an acceptable rate of toxicity and therefore warrant further investigation.