Acute polyneuropathy after high dose cytosine arabinoside in patients with leukemia

BACKGROUND: Peripheral nerve toxicity has been reported but is not a commonly recognized complication of high dose cytosine arabinoside (HDAC) therapy. This study was undertaken to estimate the prevalence and describe the clinical spectrum of acute polyneuropathy associated with HDAC therapy for leukemia. METHODS: Records of 153 acute leukemia patients who received 194 courses of HDAC at the City of Hope were reviewed for evidence of severe peripheral neuropathy with onset 2-3 weeks after HDAC therapy. RESULTS: Two patients were identified who developed motor disability 2-3 weeks after HDAC therapy, and the disability progressed in a monophasic course to quadriparesis. There was neurophysiologic evidence of peripheral nerve demyelination with slowed nerve conduction velocities and conduction block. One patient who was autopsied had demyelination identified in luxol-fast blue sections of peripheral nerve (with Bielschowsky-stained sections showing intact peripheral nerve axons). There were foamy macrophages in the peripheral nerve but no chronic inflammatory cells. For comparison, data from these two patients were combined with those from four published case reports of polyneuropathy associated with HDAC therapy. Quadriparesis occurred in five of six cases with the need for ventilatory support in four. Cerebrospinal fluid protein was elevated in five of six cases. Etiologic evidence incriminating HDAC included simultaneous cerebellar signs in two of six cases and a narrow interval of clinical onset after HDAC therapy. CONCLUSIONS: Demyelinating polyneuropathy occurs in approximately 1% of HDAC courses and produces severe motor disability. HDAC immunosuppression could trigger an immune-mediated neuropathy; alternatively, a direct neurotoxic effect of HDAC on Schwann cells is also an etiologic possibility.     

Pulmonary insufficiency complicating therapy with high dose cytosine arabinoside in five pediatric patients with relapsed acute myelogenous leukemia

BACKGROUND: The occurrence of fatal or nearly fatal pulmonary insufficiency in 5 of 22 pediatric patients with relapsed acute myelogenous leukemia (AML) treated with high dose cytosine arabinoside (Ara-C) at St. Jude Children's Research Hospital, Memphis, Tennessee, and institutions affiliated with the Pediatric Oncology Group (POG) is reported. METHODS: Cytosine arabinoside (1.0-1.5 g/m2/day) was given as a 5-day continuous infusion to all patients. Four patients with persistent leukemia received a second 3- or 5-day course. The POG protocol included the administration of granulocyte colony stimulating factor for the priming of myeloblasts. Diagnostic criteria for pulmonary insufficiency included noncardiogenic pulmonary edema with exclusion of underlying cardiorespiratory, infectious, or metabolic conditions. Autopsy material also was reviewed. RESULTS: Of the 22 patients 5 died (23%), including 2 who received a second course of Ara-C as a result of pulmonary insufficiency that developed at a median of 8 days (range, 3-38 days) after the first course. Three patients died despite intubation and pressor support. Two patients were managed successfully with colloids, diuresis, and oxygen by face mask; remission was achieved in both. The postmortem examination of one patient disclosed airless lungs, profound pulmonary edema, and subpleural nodules, but no evidence of leukemia. CONCLUSION: Pulmonary insufficiency from high dose Ara-C varies in severity and may be fatal. It may occur during or after treatment. Awareness of this potential complication, careful attention to fluid status, and aggressive supportive care may optimize outcome.     

Induction therapy for acute myelogenous leukemia in patients over 60 years with intermediate-dose cytosine arabinoside, mitoxantrone and etoposide

Using a broth microtiter dilution method, the minimum inhibitory concentrations of antipseudomonal antibiotics were determined against 19 P. aeruginosa isolates. Two different concentration of inoculum, 10(5) and 10(8), were used to show the inoculum concentration effect of in vitro antibiotic susceptibility tests. On the basis of the MIC values and using Howard B.J. (1) breakpoints, the effect of inoculum density was most prominent for amikacin and aztreonam, intermediate for mezlocillin, ticarcillin, piperacillin, cefotaxime, cefoperazone, netilmicin, tobramycin, gentamicin, and least apparent for ciprofloxacin and carbenicillin respectively.     

Treatment of relapsed adult acute lymphoblastic leukemia with fludarabine and cytosine arabinoside followed by granulocyte colony-stimulating factor (FLAG-GCSF)

The aim of the present study was to evaluate the efficacy of the combination of fludarabine 30/mg/m2 + cytarabine 2g/m2 followed by the administration of G-CSF to achieve a complete remission (CR) in patients with relapsed acute lymphoblastic leukemia (ALL). We treated twelve patients in first relapse, overall 10 patients achieved a second CR, one patient showed resistant disease and one patient died during remission induction. The regimen was well tolerated and we observed a short period of neutropenia with a low incidence of myelosuppression-associated problems. Eight patients in second CR received the same chemotherapeutic regimen as consolidation used for the reinduction. In six patients the chemotherapeutic regimen was well tolerated, two patients died, (cerebral hemorrhage in one patient and sepsis in the other). In conclusion the combination of fludarabine, cytarabine and G-CSF has significant antileukemic activity and non hematological toxicities were acceptable. The addition of G-CSF reduced the period of neutropenia obtaining a low incidence of myelosuppression-associated problems.     

CD7, HLA-DR, CD38 positive acute undifferentiated leukemia with subcutaneous tumor and thymoma

A case of acute undifferentiated leukemia (AUL), accompanied by subcutaneous tumor and thymoma is reported. The analysis of immunophenotype showed that the leukemic blasts were positive for CD7, HLA-DR, CD38 and CD34 in 17.5% but negative results were obtained for other lymphoid and myeloid antigens. The leukemic blasts had a rearranged immunoglobulin heavy chain (IgH) gene and T cell receptor delta (TCR-delta) chain gene chromosomal abnormality, 47, XY, +8, t(13; 17) (q12; q21), -17, +M was observed. In general, the CR rate is low and prognosis is poor in patients with AUL. In our case, CR was not achieved by the therapy with JALSG-ALL87 protocol, but was achieved by subsequent treatment with high dose ara-C therapy and combination chemotherapy including intermediate-dose ara-C, mitoxantrone, etoposide and prednisolone.     

Acyclovir-resistant herpes zoster encephalitis successfully treated with vidarabine: a case report

A 78-year-old man developed herpes zoster virus (HZV) encephalitis. Initially, treatment with aciclovir (750 mg per day) improved CSF cell count and protein level. During the treatment, however, encephalitis in the patient deteriorated in spite of the treatment with aciclovir, suggesting that HZV in the patient had become resistant to aciclovir. Subsequent treatment with vidarabine (600 mg per day, for 15 days) resulted in dramatic improvement in CSF pleocytosis. About two months after the discontinuation of vidarabine, the CSF cell count was normal. The patient became alert gradually, but his amnestic syndrome remained unchanged. Vidarabine may be recommended in the treatment of HZV encephalitis when aciclovir is not effective.     

Response of children with high-risk acute lymphoblastic leukemia treated with and without cranial irradiation: a report from the Children's Cancer Group

PURPOSE: Intensified intrathecal (i.t.) chemotherapy without cranial radiation therapy (CRT) prevents CNS relapse in children with low-risk and intermediate-risk acute lymphoblastic leukemia (ALL). In the current study, high-risk ALL patients who achieved a rapid early response (RER) to induction chemotherapy were randomized to receive intensive systemic chemotherapy and presymptomatic CNS therapy that consisted of either i.t. methotrexate (MTX) and CRT or intensified i.t. MTX alone. PATIENTS AND METHODS: Children (n = 636) with high-risk ALL (aged 1 to 9 years and WBC count > or = 50,000/microL or age > or = 10 years, excluding those with lymphomatous features) who achieved an RER (< or = 25% marrow blasts on day 7) to induction therapy and lacked CNS disease at diagnosis were randomized to receive systemic therapy with either i.t. MTX and CRT (regimen A, n = 317) or intensified i.t. MTX alone (regimen B, n = 319). RESULTS: Interim analysis in July 1993 revealed 3-year event-free survival (EFS) estimates of 82.1% +/- 4.0% (SD)and 70.4% +/- 4.2% for patients treated on regimens A and B, respectively (P = .004). As of January 1996, outcome had changed: 5-year EFS estimates were 69.1% +/- 3.4% and 75.0% +/- 2.7% for regimens A and B, respectively (P = 0.50). Marrow relapses comprised 57 events on regimen A and 43 events on regimen B. Fewer late events occurred on regimen B. CONCLUSION: For high-risk pediatric ALL patients who show an RER to induction therapy and are treated with systemic Children's Cancer Group (CCG)-modified Berlin-Frankfurt-Munster (BFM) chemotherapy, presymptomatic CNS therapy that consists of either i.t. MTX plus CRT or intensified i.t. MTX alone results in a similar 5-year EFS outcome. Furthermore, intensified i.t. MTX may protect against late bone marrow relapse.     

Bilateral knee gunshot wounds successfully treated with arthroscopic bullet retrieval: a case report

One unusual case of bilateral knee joint gunshot wounds caused by a low-velocity low-energy missile is presented. Arthroscopic retrieval of the bullets was performed resulting in recovery within 5 days.     

Benign fibrous mesothelioma successfully treated by thoracoscope-assisted surgery: report of a case

We report herein the case of an 84-year-old man in whom a benign fibrous mesothelioma (BFM) was successfully treated by thoracoscope-assisted surgery. In September 1996, the patient underwent a sigmoidectomy for colon cancer, soon after which a followup examination disclosed a coin lesion on his chest X-ray film. The patient was readmitted to our hospital in November 1996 for further investigation of this tumor. A chest computed tomography scan revealed a 3.5 x 3.0 cm homogeneous tumor arising from the pleura. A needle biopsy was performed under ultrasonographic guidance, and the specimen was histopathologically diagnosed as a BFM. In view of his poor respiratory function, the tumor was excised by thoracoscope-assisted surgery. This case report serves to demonstrate the benefits of thoracoscope-assisted surgery for such patients.     

Mitoxantrone and cytosine arabinoside as treatment for acute myelogenous leukemia (AML) at first recurrence

A total of 107 patients with newly diagnosed acute myeloblastic leukemia (AML) were referred to the ICRF Department of Medical Oncology at St Bartholomew's Hospital between August 1986 and July 1989. Of those referred, 92 (87%) were treated with remission induction chemotherapy comprising: Adriamycin, cytosine arabinoside (ara-C) and 6-thioguanine if aged < 60 years (57 patients) or mitoxantrone (MTN) and ara-C if aged > 60 years (35 patients). Of those treated, 54 (58%) entered complete remission (CR). Recurrent AML developed in 38 out of these 54 patients (70%) of whom 25 aged 19-73 years (median 50 years) subsequently received MTN and ara-C as reinduction therapy. The 19 younger patients (under 60 years old) received MTN at 12 mg/m2, intravenously, daily for 5 days and ara-C at 100 mg/m2, intravenously, twice daily for 7 days. The six older patients received the same ara-C schedule but the dose of MTN was reduced to 10 mg/m2 for 5 days. Second CR was achieved in 16 out of 25 patients (64%) [12/19 (63%) and 4/6 (67%) for patients aged under or over 60 years, respectively]. Eight of the patients in whom second CR was achieved were aged under 50 years and were thus eligible for additional consolidation comprising myeloablative therapy with autologous bone marrow transplantation (ABMT). Four patients actually received the latter treatment: two remain in second CR at 21 and 46 months. Three of the remaining eight patients aged > 50 years in whom second CR was achieved remain in second CR 8 to 43 months later. Censored for myeloablative therapy + ABMT, the overall median duration of second CR was 5 months. Although remissions tended to be short, in younger patients the possibility of proceeding to myeloablative therapy with autologous bone marrow support makes the regimen worthwhile and, even in older patients, it was sometimes possible to achieve prolonged second remissions.     

Poor outcome of intensive chemotherapy for adult acute lymphoblastic leukemia: a possible dose effect

Fifty consecutive adult patients with acute lymphoblastic leukemia (ALL) were treated with an intensive cyclical chemotherapy and the mean received dose of individual cytotoxic drug was retrospectively studied. The median age was 28 years. Twenty-one (43%) had white blood cell (WBC) count over 30 x 10(9)/l. Of the 26 patients with successful cytogenetic studies, ten (28%) had unfavorable clonal chromosomal abnormalities (four Philadelphia chromosome, six others). A high complete remission (CR) rate (86%) was achieved. This was associated with delivery of 100% of the planned dosage of vincristine, prednisone, and daunorubicin at induction. Dose reduction of asparaginase, the fourth drug in the induction protocol, was recorded in 20 (40%) patients. The CR rate of these patients was not adversely affected. Dose reduction was recorded during consolidation (38 of 43 remitters) and maintenance (18 of 20 remitters) as a result of treatment toxicity. The mean received dose of teniposide, Ara-C, asparaginase, mercaptopurine, and methotrexate was 73% (SD 7%), 73% (SD 7%), 62% (SD 41%), 65% (SD 15%) and 73% (SD 17%) of the planned dosage, respectively. The 5-year overall survival and leukemia-free survival (LFS) were 11% (95% CI: 0-27%) and 13% (95% CI: 0-26%), respectively. Even standard-risk patients had 4-year LFS of only 26% (95% CI: 0-57%). Among 36 remitters not withdrawn from consolidation, there were 29 treatment failures after a median follow-up of 42 months; 25 (86%) of these were leukemia relapse, three (10%) were toxic death during consolidation, and one patient (4%) died from therapy-related myelodysplastic syndrome. We postulate inadequate drug delivery during postremission therapy contributed to the high relapse rate in the whole group as well as the standard-risk patients.     

Compulsive exhibitionism successfully treated with fluvoxamine: a controlled case study

BACKGROUND: Paraphilias are psychosexual disorders that are usually conceptualized as deviant in nature. Yet in some cases, paraphilia can be conceptualized as an obsessive compulsive disorder. METHOD: We describe an exhibitionist treated under partial single-blind conditions (patient was blind to placebo but was aware he was receiving desipramine and fluvoxamine) with the serotonin selective reuptake inhibitor fluvoxamine, followed by desipramine and a placebo that looked like fluvoxamine, in an ABACA design. He was serially assessed with the Yale-Brown Obsessive Compulsive Scale. RESULTS: Fluvoxamine eliminated the undesired impulse and behavior without affecting sexual desire. Desipramine and single-blind fluvoxamine-placebo treatment were both associated with relapses. CONCLUSION: A subset of paraphiliacs may be suffering from obsessive-compulsive-related disorders and may benefit from serotonergic agents.     

Long term follow-up of patients with acute myelogenous leukemia who received the daunorubicin, vincristine, and cytosine arabinoside regimen

Some previous studies have suggested that the fast phenotype of the N-acetyltransferase NAT2 may confer susceptibility to colorectal cancer because of greater activation of dietary heterocyclic amines, particularly in individuals who also consume well-done red meat, but other studies have not supported this. We describe a large case-control study examining the interaction between dietary, smoking and drinking habits, and acetylation genotype in relation to susceptibility to colorectal cancer. One-hundred-and-seventy-four incident cases and 174 matched controls were recruited. Genotyping for polymorphisms in NAT2 was performed using a method that detects >95% of slow alleles and data on personal habits were collected using a standardized questionnaire. We found no difference in the frequency of the fast acetylator genotype between cases and controls [odds ratio = 0.95 (95% CI 0.61-1.49)], and analysis by sex, age and site also revealed no difference in acetylator genotype. There was, however, considerable heterogeneity in dietary risk factors between fast and slow acetylators. Analysis by acetylator type shows that recent smoking was more frequent in slow acetylator cases than matched controls [OR = 2.31 (1.16-4.6)] and that heavy alcohol consumption was also more frequent in the slow acetylator cases than controls [OR = 2.5 (1.02-7.29)]. In contrast, frequent fried meat intake was seen more frequently in fast acetylator cases than matched controls [OR = 6.0 (1.34-55)]. The odds ratio for the combination of fast acetylator status and frequent fried meat consumption in cases was 6.04 (1.6-26). Our study suggests that there may be different risk factors for colorectal cancer in slow and fast acetylators, and reveals a new observation that slow acetylators may be at risk of colon cancer from smoking. In our community, the overall effect of acetylator status on colorectal cancer risk is neutral.     

Traumatic biliary stricture successfully treated by percutaneous transhepatic bile duct dilatation: a case report

A 24 year-old woman complained of obstructive jaundice 24 days after blunt abdominal trauma due to a traffic accident. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a stricture, 15 mm in length, at the common bile duct associated with upper bile duct dilatation. Jaundice was reduced by percutaneous transhepatic cholangio-drainage (PTCD). A 7 Fr-sized PTCD tube was exchanged for a larger-sized catheter for percutaneous transhepatic cholangioscopy expecting gradual dilatation of the stricture. Following the confirmation of satisfactory dilatation of the stricture, the catheter was removed. There was no recurrence of jaundice 16 months later in a follow-up study.