Vascular toxicity associated with antineoplastic agents.

Vascular complications associated with antineoplastic agents are being reported with increasing frequency. Such vascular toxicity is clinically heterogeneous, ranging from asymptomatic arterial lesions to a fatal thrombotic microangiopathic syndrome. Mitomycin is most commonly implicated in the thrombotic microangiopathic syndrome, while bleomycin, either alone or in combination with a vinca alkaloid or cisplatin, appears to be an important cause of Raynaud's phenomenon. Acute arterial ischemic events, ie, myocardial infarction and cerebrovascular accidents, occur most frequently after cisplatin-based combination chemotherapy. Putative mechanisms for such toxicity include drug-induced endovascular damage, perturbation of the clotting system, platelet activation, an abnormality of thromboxane-prostacyclin homeostasis, autonomic dysfunction, vasculitis, and stimulation of fibroblasts. More than one mechanism may be operative in an individual patient. Better documentation of the incidence and types of vascular toxicity and studies to help elucidate the pathogenesis and management of such toxicity are needed.

Acanthocytosis associated with myelodysplasia.

Dysplastic hematopoiesis associated with erythrocyte macrocytosis is a morphologic hallmark of myelodysplasia. We report the cases of six patients with myelodysplasia in which acanthocytosis was the predominant red blood cell (RBC) abnormality. In each case acanthocytes represented 5% to 10% of circulating RBC forms and was the primary reason for referral in two cases. None of the patients had comorbid conditions known to be associated with acanthocyte formation. Myelodysplasia should be considered in the differential diagnosis of acanthocytosis, particularly in the anemic, elderly individual. Acanthocytosis may be a harbinger of an unrecognized, hematologic stem-cell disorder.

Management of cancer during pregnancy.

Although cancer during pregnancy is infrequent, its management is difficult for patients, their families, and their physicians. When termination of the pregnancy is unacceptable, decisions regarding the use of irradiation and chemotherapy are complicated by the well-known high risks of abortion and fetal malformation. This risk is concentrated in the first trimester and varies with the choice of chemotherapeutic agents or combinations of agents. There is only minimal evidence of increased risk of malformation or abortion in the second or third trimester. Recent progress in cancer therapy has made cure a reasonable goal, and for some malignant neoplasms, cure is still possible even when initial therapy is modified or delayed. When cure is a reasonable goal, curative therapy should not be compromised by modification or delay. When treatment for cure or significant palliation is not possible, however, the goal should shift to protection of the fetus from damage by the injudicious use of teratogenic cancer therapy. This report will review the available data that may assist in these difficult decisions.

The value of the physical examination in the diagnosis of anemia. Correlation of the physical findings and the hemoglobin concentration.

Certain clinical findings, such as pallor of the conjunctivae, nail beds, lips, oral mucosa, and palmar creases have traditionally been used by physicians in the diagnosis of anemia. We prospectively examined 50 patients to determine whether there was any correlation between these clinical findings and hemoglobin concentration. We noted a statistically significant correlation between hemoglobin concentration and the following: color tint of the lower eyelid conjunctiva, nail-bed rubor, nail-bed blanching, and palmar crease rubor. Results from our study support the contention that the presence and degree of anemia can be estimated clinically by careful physical examination.

Tumors of unknown origin in the bone marrow.

Tumors of unknown origin represent a common presentation of malignancy. However, tumors of unknown origin presenting as bone marrow metastases are infrequently reported. The records of 11,820 bone marrow biopsy procedures over a 15-year period at a university hospital and a veteran's hospital were reviewed, disclosing 25 cases of tumor of unknown primary site. Most of the patients were elderly and presented with bone pain or abdominal pain. Anemia, thrombocytopenia, and a leukoerythroblastic blood picture were common hematologic findings. Examination for detection of the primary site was usually unrewarding. The median survival of patients was very short (18 days) and therapy seldom altered survival.

Treatment of hypercalcemia of malignancy with intravenous etidronate. A controlled, multicenter study. The Hypercalcemia Study Group.

In a prospective, randomized, double-blind, multicenter study, 202 patients with cancer from 19 medical centers were treated for hypercalcemia of malignancy with daily intravenous infusions of etidronate disodium (136 patients) or saline alone (66 patients) for 3 consecutive days. Patients also received up to 3.25 L of saline daily during the treatment period. Of 157 patients for whom data could be evaluated for efficacy, 63% (72/114) of etidronate-treated and 33% (14/43) of saline-treated patients had a normalization of total serum calcium levels. When serum calcium levels were adjusted for albumin (147 assessable patients), 24% of the etidronate- and 7% of the saline-treated patients responded to treatment. No serious side effects or treatment-related deaths occurred. When accompanied by adequate hydration and diuresis, intravenous etidronate was safe and more effective than hydration and diuresis alone in controlling hypercalcemia of malignancy.

The pathophysiology of thrombosis in cancer.

Multiple mechanisms are involved in the pathophysiology of thrombosis in cancer. It is highly likely that, in an individual patient, a multifactorial etiology is operative. The three basic mechanisms for hypercoagulability in cancer are interrelated to a degree and probably are also the mechanisms involved in metastasis in addition to thrombosis. Manipulation of coagulation in the cancer patient has the potential to prevent complications, abrogate metastasis, and potentially prolong survival.

Efficacy of oral administration of etidronate disodium in maintaining normal serum calcium levels in previously hypercalcemic cancer patients.

As part of a multicenter trial of etidronate disodium for control of hypercalcemia in patients with malignancies, patients achieving normocalcemia within seven days after starting intravenous therapy with etidronate disodium plus saline were enrolled into a double-blind, placebo-controlled trial of oral etidronate disodium to maintain normocalcemia. By random assignment, patients received either oral etidronate disodium, 20 mg/kg/day, or placebo for up to three months. Efficacy was evaluated after 30 days of maintenance therapy: patients who were normocalcemic on day 30 were considered treatment successes. Of 81 patients who entered this phase of the study, 63 were evaluable for efficacy. Analysis of this group revealed that significantly (P less than 0.01) more patients in the etidronate disodium group (35%) than in the placebo group (6%) were normocalcemic at day 30. Life-table analysis of response indicated that patients treated with etidronate disodium maintained normocalcemia significantly (P less than 0.01) longer than did patients receiving placebo (median, 29 days versus 11 days). These results suggest that in patients whose calcium levels were normalized with IV etidronate disodium, oral etidronate disodium maintained normocalcemia significantly longer than no maintenance therapy in patients treated for hypercalcemia secondary to malignancy.

Why are some pamphlets hard for patients to read?

In this study with lung cancer patients, we describe not only text characteristics that hinder comprehension, including unfamiliar words and poor organization, but also reader characteristics that hinder comprehension, such as educational level, and what the patient wants to know. Based on our and other's research we recommend writing what the reader wants to know, relating new learning to what the learner already knows, and using organizational cues for clarity and emphasis.

Tumors of unknown origin.

Tumors of unknown origin (TUOs) account for 3% of cancers and represent the eighth-most common cancer diagnosis. Although TUOs are commonly classified by their histological presentation, examination of the location of the metastases is equally important. When the histological type and location of metastases are both known, a finite number of common clinical syndromes emerge and one can predict the most common occult primaries.

Acute nonlymphocytic leukemia: the first 48 hours.

The initial care of patients with acute nonlymphocytic leukemia can be lifesaving. Such patients are most often treated at tertiary care centers where resident physicians, working under the supervision of a subspecialist, are responsible for the diagnosis and initial treatment. During the first 48 hours, the house officer must recognize and understand the management of perilous complications such as hyperleukocytosis, hemorrhage, and infection. Specific lifesaving measures will grant the patient and his physicians sufficient time to reach a decision regarding the initiation of curative induction chemotherapy.

Danazol therapy in acquired idiopathic sideroblastic anemia.

Danazol, a synthetic androgen, was used in the treatment of 6 patients with acquired idiopathic sideroblastic anemia. No patient had a response to therapy as determined by an increase in either the hemoglobin or platelet count.

Malignant ascites of unknown origin.

To determine the clinical characteristics of patients presenting with malignant ascites, as well as means of evaluating the outcome of patients with the disease, a retrospective review was conducted of all cases of malignant peritoneal effusions diagnosed from 1978 to 1987 at a University Hospital and a Veterans Administration Hospital. Of 65 patients with malignant ascites (40 women; 25 men), the primary site was known in 51 cases (80%). Common sites in women were the ovaries, endometrium, and cervix; in men, common sites were the colon, rectum, and stomach. For five women and nine men the primary site was unknown. Median survival from diagnosis was 7.5 days (mean, 43 days; range 1-256 days). Chest radiograph and abdominal computed tomography (CT) scan did not disclose the occult primary. An occult primary was detected while the patient was alive in only two cases and at autopsy in two other patients. Due to the poor prognosis for this disease, we do not recommend an aggressive approach to malignant ascites of unknown origin, except perhaps in women, in whom ovarian cancer should be suspected.

Epidural spinal cord compression as the presenting manifestation of tumor of unknown origin.

Epidural spinal cord compression is a common complication of malignancy. In the majority of cases, the primary site is known at diagnosis or is evident following limited investigation. During the period January 1975 to December 1987 we encountered seven cases of tumor of unknown origin presenting as cord compression. Myelography detected the site of cord involvement in six cases, and computed tomography of the spine was utilized in one case. All seven patients underwent laminectomy. Histologic diagnosis was adenocarcinoma in four cases, squamous in one case, and large cell undifferentiated carcinoma in two cases. Evaluation for a primary site was unrewarding. Prognosis was poor, with a median survival of 10 weeks. Only one patient had a satisfactory response to treatment.

Postmastectomy educational needs and social support.

Due to shorter hospitalization periods and changes in surgical procedures, breast cancer patients have less inpatient contact with rehabilitation resources. A questionnaire related to educational needs and social support was mailed statewide to 2,000 postmastectomy women who had received a Reach to Recovery visit. The findings are based on quantitative data reported by 933 women and from 27 women in follow-up interviews. Respondents ranked their educational needs in six categories from greatest to least importance as follows: (1) information about breast cancer, (2/3) personal hygiene/exercise and nutrition/weight control (both ranked of equal importance), (4) prosthesis/clothing information, (5) social support, and (6) sexual issues. Performance on the knowledge assessment correlated directly with the amount of educational experience and inversely with age. Respondents who lived in communities of less than 2,500 were less informed than those from other locations. Participation in formalized support groups was infrequent (11%). The major source of information was the media, with 88% indicating they would watch television programs about breast cancer. Thirty-three percent of the respondents indicated they owned a video cassette recorder (VCR); about 93% said VCRs were available for rent in their community. Work associates were identified as a group that encouraged information seeking; health care professionals were the most successful in motivating women to participate in support groups.