Reperfusion Injury-Postendovascular Recanalization in Chronic Mesenteric Ischemia: A Rare Clinical Case Scenario.

Regardless of the number of vessels involved endovascular recanalization of mesenteric vessels is the treatment of choice for chronic mesenteric ischemia. Reperfusion injury post-endovascular recanalization in chronic mesenteric ischemia is a rare clinical scenario as it is mostly encountered in cases of acute mesenteric ischemia. Here in, we describe a case with characteristic clinical and imaging findings of reperfusion syndrome, post-endovascular recanalization of chronically occluded superior mesenteric artery and severely stenosed celiac trunk in a patient with chronic mesenteric ischemia.

Ovarian Artery Embolization in a Case of Refractory Obstetric Hemorrhage.

Transcatheteric pelvic artery embolization (PAE) has now become accepted treatment for obstetric hemorrhage providing us the opportunity to control bleeding and avoiding surgical morbidity, preserving uterus, and subsequent fertility. There is little we can offer to the patient if bleeding persists after obstetric hysterectomy and embolization of bilateral uterine and hypogastric arteries. Here in, we present a case of refractory post obstetric hysterectomy hemorrhage where uterine and internal iliac artery embolization failed to control the bleeding. Aortic angiogram showed active contrast extravasation from the ovarian artery, which was successfully embolized with good clinical outcome.

Endovascular treatment of a mycotic intracavernous carotid artery aneurysm using a stent graft.

Intracavernous carotid artery mycotic aneurysms are rare and management is determined by clinical presentation. We describe the first documented proximal intracranial mycotic aneurysm treated by a balloon expandable Aneugraft PCS covered stent. An 11-year-old female child presented with acute onset fever, headache, chemosis followed by diplopia, right-sided ptosis with ophthalmoplegia. Magnetic resonance imaging revealed bilateral cavernous sinus thrombosis. Subsequent work-up included serial computed tomographic arteriography and digital subtraction angiography which revealed a progressively enlarging intracavernous carotid aneurysm. An Aneugraft PCS covered stent was successfully deployed endovascularly, and complete exclusion of the aneurysm was achieved while maintaining the patency of the parent artery. The use of covered stents in intracranial vasculature can be an effective and safe treatment modality for exclusion of the mycotic aneurysm in selected cases.

Pulmonary nocardiosis--a rare case of pulmonary nocardiosis in an immunocompetent patient.

Nocardiosis is localised or disseminated infection caused by soil dwelling aerobic actinomycetes, which habitually enter through the respiratory tract. There has been an increase in the incidence of nocardia species infections probably due to higher degree of clinical suspicion, aggressive diagnostic examinations, increased use of immunosuppressive treatments (chemotherapy agents and immunosuppressive agents) and the appearance of AIDS. Here we are presenting an atypical case of Nocardia asteroides in a 45-years-old immunocompetent female patient presenting with history of cough with scanty expectoration, haemoptysis and fever for 4 months. Clinical and radiological diagnostic consideration were tuberculosis and malignancy. Diagnosis of nocardiosis was confirmed microbiologically and the patient responded to cotrimoxazole.

The "dot in circle" sign on MRI in maduramycosis: a characteristic finding.

Mycetoma or Maduramycosis is a localized chronic suppurative infection characterized by exuberant granulation tissue, discharging sinuses, and bone involvement later in the course of the disease. Early clinical diagnosis before the appearance of sinuses and grains (aggregates of organism surrounded by granulation tissue, which are discharged from the draining sinuses) is difficult. Delay in diagnosis may lead to amputation of the affected part. Definitive diagnosis is through biopsy and microbiological examination. However, at times diagnosis may still be difficult. The recently described "dot in circle" sign on magnetic resonance imaging (MRI) is easy to recognize and highly specific. We present a case of mycetoma foot with characteristic MRI features.

Racial disparity in outcomes of a clinical trial population with metastatic renal cell carcinoma.

OBJECTIVES: Population studies have revealed that black Americans with renal cell carcinoma (RCC) have a shorter survival than do white Americans. Differences in socioeconomic status and treatment are frequently cited as the reasons for this disparity. The effect of these social obstacles may be reduced by studying a patient population with advanced RCC enrolled in clinical trials, because patients in these trials are likely to be similar in terms of their access to care, compliance, and performance status. METHODS: A retrospective review of all patients with metastatic RCC enrolled in clinical trials at Wayne State University from 1992 to 2002 was conducted. Log-rank survival analysis by age, sex, race, smoking history, nephrectomy history, prior therapy, type of protocol therapy (immunotherapy versus other), performance status (0 versus 1 to 2), and number of metastatic sites was conducted. Univariate and multivariate comparisons by race were performed for overall survival and time to progression. RESULTS: A total of 122 patients (median age 57 years) were enrolled; 21 (17%) were black and 101 (83%) were white. Overall survival was significantly shorter for the black Americans (P = 0.0027). The median survival for black Americans and white Americans was 6.9 and 11.5 months, respectively. On multivariate analysis, black race and performance status of 0 versus 1 and 2 were significant predictors of shorter survival. The presence of liver metastases and/or the absence of prior nephrectomy also influenced the length of overall survival through an interaction effect. CONCLUSIONS: Within a clinical trial patient population with RCC, race was a significant predictor of overall survival.

A phase II study of carboplatin and paclitaxel in adenocarcinoma of unknown primary.

BACKGROUND: Cisplatin-based combination chemotherapy is commonly used in the treatment of carcinoma of unknown primary site. Paclitaxel has shown promising activity as a single agent in a number of malignancies. This study was conducted to evaluate the efficacy and toxicity of combination carboplatin and paclitaxel in patients with adenocarcinoma of unknown primary site (ACUP). METHODS: Twenty-two patients with ACUP were enrolled in the study. Patients were treated with 200 mg/m2 paclitaxel intravenously (IV) over 3 hours followed by carboplatin IV with a targeted plasma area under the curve (AUC) of 5 mg/h/mL. RESULTS: A total of 73 treatment courses were administered with a median of 5 courses per patient. Five of the 22 registered patients had a major response for an objective response rate of 23% (90% confidence interval [CI], 0.11-0.40) by intention-to-treat analysis. The median response duration was 4.1 months (90% CI, 3.6-7.1). The median survival time was 6.5 months (90% CI, 5.5-10.1) and the 1-year survival rate was 27% (90% CI, 0.11-0.42). The major toxicity observed was neutropenia, with grade 3-4 neutropenia occurring in 3 patients (14%). There were no treatment-related deaths. CONCLUSIONS: The combination of carboplatin and paclitaxel is a tolerable and moderately active regimen in ACUP.

Phase II trial of fenretinide in advanced renal carcinoma.

PURPOSE: Fenretinide, a synthetic form of retinoid, induced apoptosis even in chemotherapy resistant cell lines. A phase II study was hence conducted to evaluate toxicity and efficacy of fenretinide in metastatic renal cancer. METHODS: Eligibility included unresectable or metastatic renal cell carcinoma (RCC), adequate organ function and Zubrod performance status < or =2. Prior immunotherapy and a maximum of one prior chemotherapy regimen were allowed. Fenretinide was administered at a dose of 900 mg/m(2) twice daily orally for 7 days in a 21-day cycle. Toxicity was assessed at the start of each cycle, and response every 2 cycles. RESULTS: Nineteen eligible patients enrolled of which fifteen had visceral/bone metastases. Seventeen patients had prior nephrectomy and 11 had prior immunotherapy. 76 cycles of therapy were delivered. Therapy was very well tolerated with few severe toxicities consisting of thrombosis in 1 individual and grade 3 fatigue, nausea and diarrhea in 1 patient. 5 patients had grade 2 nyctalopia and 3 patients had transient grade 2 visual toxicity. No objective responses were noted. Stable disease was seen in seven of nineteen cases (37%, 90% C.I. 0.21-0.59). Median time to progression was 1.5 months and median duration of stable disease was 5.8 months (90% C.I. 3.0-8.4). Median survival was 10 months. Tumor fenretinide levels were obtained in three patients and were in the lower end of the therapeutic range. CONCLUSION: Fenretinide was well tolerated but demonstrated minimal activity that was consistent with results of intratumoral drug measurements. Strategies are needed that will increase systemic and tumor levels of fenretinide.

Efficacy and safety of reteplase for central venous catheter occlusion in patients with cancer.

PURPOSE: To evaluate the efficacy and safety of reteplase for central venous catheter (CVC) occlusion in patients with cancer. MATERIALS AND METHODS: An open-label, single-arm, prospective study was conducted. Reteplase (0.4 U) was instilled into each catheter lumen with a dwell time of 30 minutes in patients with cancer with a dysfunctional CVC. If the function of the catheter was not restored in 30 minutes, an additional dwell time of 30 minutes was allowed (a total of 60 minutes possible dwell time for the first dose). A second dose was repeated at 60 minutes after the first dose if catheter function was not restored (a total of 120 minutes for up to two doses). The primary efficacy outcome was the restoration of CVC function. RESULTS: Of 139 patients who received reteplase, the first-attempt success rate after a 30-minute dwell time was 66.9%. The cumulative success rates at 60, 90, and 120 minutes were 88.5%, 94.7%, and 94.7%, respectively. The variation of patient age, catheter age, CVC occlusion age, CVC type, number of lumen, or occlusion type was not associated with the efficacy of reteplase. There were no treatment-associated adverse events reported during the study period. CONCLUSION: Reteplase at 0.4-U dosing per catheter lumen is an effective and safe alternative that rapidly restores the patency of occluded CVCs in patients with cancer.

A phase II study of rebeccamycin analog (NSC-655649) in metastatic renal cell cancer.

OBJECTIVE: Rebeccamycin analog (NSC-655649) is an antibiotic with antitumor properties demonstrated in preclinical and phase I studies. We conducted a phase II trial to evaluate the efficacy and toxicity of this agent in patients with advanced renal cell cancer (RCC). METHODS: Eligible patients had histologically or cytologically confirmed diagnosis of RCC that was either locally advanced unresectable, locally recurrent, or metastatic. Patients had to have measurable disease, no prior chemotherapy, life expectancy of greater than 12 weeks, an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2, adequate-organ function, and be >/=18 years old. Patients were treated with NSC-655649 at a dose of 165 mg/m(2) daily i.v. over 30-60 min for 5 days. Treatment was repeated every 21 days. Response was assessed every two courses. RESULTS: Twenty-four patients were enrolled. There were sixteen males and eight females with a median age of 60.5 years (range 42-76). Nineteen were Caucasians, seventeen had prior nephrectomy, and thirteen had prior immunotherapy. The major toxicity was myelosuppression with grade 3 and 4 neutropenia in 38% of patients and anemia in 33% of patients. There were two partial responses (2/24, 8%) and 11 patients (46%) achieved stable disease (SD). The 6-month progression-free rate for patients with SD was 30%. Of the seventeen patients with progressive disease at registration, one had a PR and eight had SD. The overall median survival time for all 24 patients was 10.0 months (90% CI=5.2, 17.4 months). The 12-month survival rate was 39%, with 90% CI=(0.21, 0.58). Nine patients are still alive with survival times ranging from 3.8 to 24.2 months, at a median follow-up time of 11.9 months. CONCLUSION: Rebeccamycin analog (NSC-655649) is well tolerated and has modest antitumor activity in patients with advanced RCC.