High dose of prokinetics for refractory hiccups after chemotherapy or the return to a simple drug.

Hiccups in patients with cancer might be difficult to treat, impacting negatively on the quality of life. Many therapies are available, but they are usually started empirically, and often they are unsuccessful. We report a case of a man with metastatic colon cancer who after the first cycle of chemotherapy developed persistent hiccups refractory to neuroleptics and low dose of metoclopramide. After searching for the potential cause, a high dose of prokinetics was initiated in the hospital and his symptoms disappeared. This case shows how searching for potential causes helps start the right treatment immediately, and therefore it is relevant for the prompt relief from this bothersome symptom. So far, no cases reporting high doses of prokinetics to treat persistent hiccups after chemotherapy have been published. This option should be taken into account when developing hiccups and gastro-oesophageal reflux after chemotherapy, especially if low doses of prokinetics have already been tried.

Early appearance of osteonecrosis of the jaw after zoledronic acid in a patient with a long history of taking oral bisphosphonates.

Osteonecrosis of the jaw (ONJ) is a serious side effect in patients receiving intravenous nitrogen-containing bisphosphonates (B). It has also been reported to occur due to oral administration of B. Most cases will appear after receiving B for more than 1 year. The authors report a case of a 67-year-old woman with osteoporosis who had received oral alendronate sodium for 2 years and stopped the treatment due to dyspepsia. 18 months later she was diagnosed with breast cancer and bone metastases. She started a treatment based on aromatase inhibitors and zoledronic acid (Z). She developed ONJ soon after the third administration. She was treated with antibiotics, anti-inflammatories and a chlorexidine colutory. She recovered 3 months later. ONJ secondary to Z may occur also earlier than it was thought in patients with a history of taking oral B.

Intraventricular metastases from small cell carcinoma of the lung.

Small cell lung carcinoma (SCLC) represents 15-20% of all lung cancers. It is characterised by rapid growth and early metastatic dissemination. Generally, the prognosis of these patients is poor. When brain metastases develop, the prognosis is even poorer. Most of these cases present parenchymal metastases; however, intraventricular dissemination may also occur although it is very uncommon. To our knowledge the case reported here is the first showing multiple synchronic intraventricular dissemination from SCLC.

Pilot study of a clinical pathway implementation in rectal cancer.

BACKGROUND: Rectal cancer is a highly prevalent disease which needs a multidisciplinary approach to be treated. The absence of specific protocols implies a significant and unjustifiable variability among the different professionals involved in this disease. The purpose is to develop a clinical pathway based on the analysis process and aims to reduce this variability and to reduce unnecessary costs. METHODS: We created a multidisciplinary team with contributors from every clinical area involved in the diagnosis and treatment in this disease. We held periodic meetings to agree on a protocol based on the best available clinical practice guidelines. Once we had agreed on the protocol, we implemented its use as a standard in our institution. Every patient older than 18 years who was diagnosed with rectal cancer was considered a candidate to be treated via the pathway. RESULTS: We evaluated 48 patients during the course of this study. Every parameter measured was improved after the implementation of the pathway, except the proportion of patients with 12 nodes or more analysed. The perception that our patients had about this project was very good. CONCLUSIONS: Clinical pathways are needed to improve the quality of health care. This kind of project helps reduce hospital costs and optimizes the use of limited resources. On the other hand, unexplained variability is also reduced, with consequent benefits for the patients.

Parkinsonism secondary to metastatic lesions within the central nervous system: a case report.

INTRODUCTION: Colorectal cancer is one of the most common human diseases worldwide, and metastases are detected in approximately 20% of patients at diagnosis. Brain metastases occur in only 4% of cases, however, and usually present with hemiparesis or other motor or sensory symptoms. There have been only a few reports of parkinsonism secondary to a brain tumor-related mass effect. CASE PRESENTATION: We present an unusual case of parkinsonism secondary to multiple brain metastases. A 57-year-old Caucasian man had recently been diagnosed with primary carcinoma of the colon and had multiple metastases in the lungs and liver. He subsequently developed bilateral symmetrical parkinsonism, and multiple brain tumors were detected by computed tomography scanning. The condition of our patient deteriorated rapidly, and he became akinetic and dependent for all activities of daily living. He was followed up and treated at home by our palliative care unit team and died two weeks after the onset of his neurologic symptoms. CONCLUSION: Although primary and secondary brain tumors are uncommon causes of parkinsonism, their clinical presentation may resemble that of idiopathic Parkinson's disease. An awareness of this rare differential diagnosis is therefore important in ensuring early diagnosis and treatment, thus improving prognosis and quality of life. A rapid progression in neurologic symptoms was observed in our patient, and clinicians should be alert to this atypical presentation of secondary parkinsonism.

Atypical presentation of acute neurotoxicity secondary to oxaliplatin.

Neurotoxicity is the main and dose-limiting toxicity of oxaliplatin. It may produce two different syndromes, acute and chronic. We describe here a case of a patient with an acute syndrome with the particularity of affecting only contralateral hemibody to arm of infusion. A 62-year-old female diagnosed with stage IV colon cancer, underwent palliative treatment with combination of oxaliplatin (130 mg/m( 2) on day 1), capecitabine (1.250 mg/m(2) bid on days 1 to 14 every 3 weeks), and bevacizumab. Thirty minutes after cycle 1 oxaliplatin infusion, which was into the left arm, she experienced right hemibody paresthesia with muscle cramping of her right calf. She associated dysphonia and painful jamming sensation in her right upper limb with difficulty to release grip. She noted also undulating movements under the skin of her right lower extremity. She was unable to stand or walk. She was given intravenous magnesium sulfate and calcium gluconate and after 3 h all her symptoms were solved. Subsequent doses were reduced by 25% and the infusions were prolonged to 3 h and the patient tolerated well except minimal paresthesia in her right hand lasting few minutes.

Unexplained liver laceration after metastasis radiofrequency ablation.

Many studies have established the role of radiofrequency (RF) ablation as a minimally invasive treatment for liver metastases. Although relatively safe, several complications have been reported with the increased use of RF ablation. We describe here a case of unexplained liver laceration after a RF procedure. A woman who presented a solitary metachronous liver metastasis underwent RF ablation treatment for this lesion. Six hours later the patient displayed fatigue and pallor. Emergency blood tests showed a haemoglobin level of < 7 g/dL and markedly elevated transaminase levels. A computed tomography examination revealed two areas of liver laceration with haematoma, one of them following the path of the needle and the other leading away from the first. Following a blood transfusion, the patient was haemodynamically stable and completely recovered 24 h later. The patient remained in bed for 1 wk. No surgical intervention was required, and she was discharged 1 wk later.

Gastric cancer: predictors of recurrence when lymph-node dissection is inadequate.

BACKGROUND: The TNM classification (sixth edition) requires at least 15 lymph nodes to be examined to allow an accurate staging. However, in our environment, only 20% of patients have the recommended minimum of 15 nodes removed. PURPOSE: To evaluate clinicopathological predictors of recurrence in patients with gastric cancer undergoing radical resection with an inadequate number of lymph nodes examined. METHODS: 101 patients were included in this retrospective cohort. We evaluated age, gender, tumoral location, Borrmann type, Lauren histotype, type of gastrectomy, grade, invasion depth of tumor, lymph node involvement, ratio between metastatic and total number of excised lymph nodes keeping 20% as the cutoff value (LNR) and adjuvant treatment. The association between these variables and recurrence was investigated by using univariate methods and multivariate logistic regression analysis. RESULTS: Median (range) age was 63 years (44-85). 63% males, 37% females. Median follow-up time for the whole patients population was 36 months (10-104). Median number of lymph nodes retrieved was 6 (0-14). Recurrence: 50 of 101 cases (49,6%); 41 hematogeneus dissemination, 9 locoregional recurrences. The following factors were found to be correlated with the recurrence risk: tumoral location, invasion depth of tumor, lymph node involvement and LNR. A multivariate analysis revealed that depth of invasion [odds ratio (OR) 2.80, 95% confidence interval (CI) 1.03-7.58, P = 0.04] and LNR (OR 2.34, 95% CI 1.05-5.21, P = 0.03) were independent risk factors for recurrences of gastric cancer. Median time to recurrence: 16 months (2-50). 82% of recurrences occurred within the first two years after surgical treatment. The estimated cumulative risk of recurrence at five years: 61% in the whole patients population, with serosal invasion and LNR > and < 20% was 82% and 44%, without serosal invasion 73% and 39% respectively. CONCLUSION: Invasion depth of tumor and LNR were independent predictors of recurrence in gastric cancer after potentially curative resection with an inadequate number of lymph nodes examined.

Tongue paralysis after orotracheal intubation in a patient with primary mediastinal tumor: a case report.

INTRODUCTION: Several lesions have been described as post-intubation complications. Most frequent are injuries of the pharynx/larynx or trachea. Cranial nerve injury following routine endo-tracheal intubation appears to be rare, and most reports describe Tapia's syndrome with hypoglossus/recurrent laryngeal nerve paralysis; cases that describe only bilateral hypoglossus palsy are infrequent. The cause is attributed to neuropathy of the nerve, provoked by compression following inflation of the cuff within the larynx or damage after neck hyperextension during a difficult intubation. However, similar cases after non-traumatic intubation have not been reported. CASE PRESENTATION: We report here a case of bilateral hypoglossus palsy in a young man undergoing a diagnostic anterior mediastinotomy that was attributed to prolonged non-complicated oro-tracheal intubation. Progressive recovery of function by the patient supports neuropraxic damage as the cause. CONCLUSION: To avoid such problems, special attention should be paid to the correct positioning of the head during surgery or during rapidly performed tracheostomy if prolonged intubation is anticipated.

Drug extravasation: a dreaded complication.

A 62-year-old man diagnosed with a stage I lung adenocarcinoma was treated by an upper right lobectomy. Eighteen months later an elevation of carcinoembryoinc antigen (CEA) was detected, and CT tomography revealed a stage IV disease. Chemotherapy including cisplatin (Platinol) and docetaxel (Taxotere) was administered. He presented 12 days after receiving an intravenous infusion because he noticed a burning sensation, erythema and blisters at the site of the last infusion and proximal to that area. On physical examination he had a 9×4.5 cm swollen area of erythema and multiple blisters. The diagnosis of delayed and distant docetaxel extravasation was made. The treatment consisted of normal saline washes, topical hydrocortisone and antibiotic-based ointment which produced relief of the symptoms. This reaction resolved over the next 6 weeks, leaving two areas of brownish pigmentation of the skin as the only sequelae.

Gemcitabine and vinorelbine (GV) versus cisplatin, gemcitabine and vinorelbine (CGV) as first-line treatment in advanced non small cell lung cancer: results of a prospective randomized phase II study.

The objective of this study was to assess whether adding cisplatin to gemcitabine/vinorelbine combination improves the clinical outcome in patients with non-small-cell lung cancer (NSCLC). Chemotherapy-naïve patients with advanced NSCLC; age < or = 75 years: Karnofsky performance status > or = 60%, and with adequate hematological, renal and hepatic function, were randomized into 2 treatment groups to receive Gemcitabine 1250 mg/m2 + vinorelbine 30 mg/m2 (GV group), or cisplatin 50 mg/m2 + gemcitabine 1000 mg/m2 + vinorelbine 25 mg/m2 (CGV group). All drugs were administered on days 1 and 8 every three weeks: From September 1999 to March 2003, 114 patients were enrolled. No statistically significant difference was observed in GV vs CGV group in objective response (37 versus 47%, respectively; P = 0.5), median time to progression (5 versus 5.8 months; P = 0.6), overall survival (9 versus 10 months; P = 0.9) and 1-year survival (26 versus 28%; P = 0.9). Conversely, toxicities were significantly higher for CGV, including grade 3-4 neutropenia (24 versus 45%); neutropenic fever (4 versus 14%, including one toxic death); grade 3-4 thrombocytopenia (2 versus 14%); and grade 3-4 emesis (2 versus 14%). Our results suggest that the combination of gemcitabine and vinorelbine is less toxic than three-drug combination with cisplatin while showing similar efficacy.

Activity of carboplatin in patients with advanced non-small cell lung cancer pre-treated with a non-platinum combination.

To assess the efficacy of carboplatin when used as a single agent in patients with advanced non small cell lung cancer (NSCLC) and who are refractory to chemotherapy with a non-platinum combination, we recruited patients (n=40) NSCLC patients, 36 of whom were males, with an overall median age of 59 years (range 39-79) and Karnofsky Performance Status of 70% (range 60-90%). At baseline, the patients had a median of one disease site (range 1-3) and had received a median of one prior regimen (range 1-2). Carboplatin was administered (i.v.; AUC=6) every 3 weeks until disease progression or non-acceptable toxicity was reached. In total 169 cycles were administered (median 4 cycles/patient; range 1-8). Main toxicities were grade 2-3 anemia and grade 4 thrombocytopenia (22.5% of patients). Overall clinical response rate was 10% (4 partial responses); 26 patients (65%) had stable disease and 8 (20%) had disease progression. Median time to progression and median survival time were 90 and 187 days, respectively. One year survival rate was 13%. We conclude that carboplatin shows minimal toxicity with a discrete anti-tumor activity in patients with NSCLC and who are refractory to non-platinum combinations.

Activity of weekly irinotecan (CPT-11) in patients with advanced non-small cell lung cancer pretreated with platinum and taxanes.

Irinotecan (CPT-11), a semisynthetic derivative of camptothecin, is active in the treatment of non-small cell lung cancer (NSCLC). In this report we describe our experience with this drug when used as a single agent in patients with advanced NSCLC refractory to chemotherapy with platinum and taxanes. Nineteen NSCLC patients (thirteen males and six females; 53% adenocarcinoma and 26% squamous cell carcinoma) with a median age of 52 years (range 34-71) and a Karnofsky performance status of 60% (60-80%) were included in the study. At baseline, the patients had a median of two disease sites and had been treated with a median of two prior regimens. Irinotecan was given at a dose of 100 mg/m(2) i.v.) weekly for 4 weeks followed by 1 week of rest. A total of 123 weekly infusions were administered, and each patient received a median of 4 weeks of treatment (range 1-32). All patients were evaluated by intention-to-treat analysis for efficacy and safety. Main toxicities reported were grade 3 neutropenia (10% of patients), diarrhea (10% of patients), and grade 4 thrombocytopenia (5% of patients). The overall clinical response rate was 16% (95% CI: 8-24) with three partial responses and 9 (47%) patients with stable disease. The median time to progression and the median survival time were 7 and 15 weeks, respectively. In conclusion, weekly irinotecan showed antitumoral activity and minimum toxicity in NSCLC patients refractory to platinum and taxanes.