Biomedical subjects
Publications and source records attributed to S Chaitchik.
Chronic lymphedema predisposes for local immune incompetence, manifested by development of Stuart-Treves syndrome, Kaposi's sarcoma and fibroma-like lesions. A 91-year-old female with multiple cancers developed classic Kaposi's sarcoma on a chronically lymphedematous arm 26 years after radical mastectomy and irradiation of the involved axilla. The Kaposi lesion partially responded to electron beam irradiation.
Small cell carcinoma of the gall bladder is a rare tumor. The neoplasm is highly lethal, metastasizes early, and may cause death shortly after diagnosis. An oat cell carcinoma of the gallbladder metastatic to the liver and adjacent lymph nodes is described in a 60-year-old male. Partial cholecystectomy was performed followed by aggressive chemotherapy with etoposide and cisplatinum. An 80% reduction in the size of the unexcised tumor was noted over a period of 6 months. The partial response and the relatively long survival of the patient suggest the use of the above protocol for these rare cases.
The authors describe two cases of tamoxifen-induced organic delusional syndrome that resulted from administration of 40 mg daily for the adjuvant treatment of breast carcinoma. After discontinuation of the tamoxifen therapy, the psychiatric episode resolved within 2 to 4 weeks. Because tamoxifen might cause delusional syndrome, the authors recommend full psychiatric evaluation in appropriate cases.
Three patients with metastatic malignant melanoma, 2 of whom were males with primary lesion on the shoulder, and a female with primary lesion on the ankle, with Clark's level III-IV, completely responded to interferon-DTIC, but failed in the brain. Radiologically, all the lesions were peripheral in location, and none showed any bleeding tendency. Clinically, these lesions seemed to be resistant to radiotherapy, chemotherapy or steroid treatment, and were the cause of death after a very short survival period. Interferon apparently is inactive against melanoma brain metastases, but does cause CNS symptoms. Because CNS metastases are sometimes the sole site of clinical relapse, and are frequently disabling, prophylactic cranial irradiation (PCI) needs to be studied in high risk patients.
The term cortical blindness indicates loss of sight due to bilateral lesions in the occipital lobes. It is a rare but severe side effect produced by chemotherapeutic agents. Cortical blindness was diagnosed in a 75-year-old man who had been treated with alpha-interferon for metastatic renal-cell carcinoma. The absence of focal neurological signs and of abnormal findings as determined by two repeated computed tomography (CT) scans of the brain, which excluded structural damage to the occipital lobes, suggest that metabolic or toxic reactions may have caused the cortical blindness diagnosed in our patient. The temporal relationship between the treatment with alpha-interferon and the development of cortical blindness indicates that this substance may have been the causative agent for this phenomenon.
This study explored doctor-patient interaction by focusing on a specific type of encounter in an oncology ward, designed to enable discussion of the case by the doctors and informing the patient. In line with the cognitive orientation theory of Kreitler and Kreitler, the encounter's effects were examined in regard to three aspects--disease, treatment, and general state--on four levels: the information the patients have, their feelings, the information they desire, and the information they consider desirable. The patients were 52 men and women with different cancer diagnoses. Comparable questionnaires were administered to the patients before and after the meeting, and to the doctors only after it. The patients responded before and after also to Spielberger's scales of state anxiety and state anger. The results showed that patients claimed they had gained hardly any new information concerning the disease and their overall state. There were no decreases in the desired and desirable information. Their feelings were affected negatively to a slight extent, especially concerning treatment. In a quarter of the subjects, anxiety decreased and was replaced by anger. In regard to all levels and aspects there was a large gap between the evaluations of doctors and patients. The major conclusions were that patients and doctors differ in the meaning they assign to information, and that patients are conflicted in regard to asking for the personally relevant information they want.
Seventeen patients with histologically proven melanoma and measurable metastatic disease received 7-week cycles of fotemustine 100 mg/m2/day on days 1 and 8, and decarbazine (DTIC) 500 mg/m2/day on days 15 and 16, in a prospective open study, to assess the efficacy of fotemustine-DTIC combination. Response rate was 11.7%: one partial response (PR) in brain for 4.5 months, and one PR in brain and lymph nodes for 4 months. There was also one (5.8%) minimal response (MR) in brain, stomach, and lymph nodes for 8 months, and three (17.6%) patients with stable disease. Survival of responders was significantly superior to nonresponders. There was no response in brain without response in extracerebral sites. Toxicity was generally mild and well tolerated by all the patients. Fotemustine-DTIC showed some activity against metastatic melanoma, and should be further evaluated.
The term 'cortical blindness' indicates loss of sight due to bilateral lesions of the occipital lobes. It is a rare, but severe, side effect of chemotherapeutic agents. Cortical blindness was diagnosed in a 67 year old woman with leiomyosarcoma of the large bowel, treated by vincristine-containing chemotherapy. Cortical blindness without focal neurological signs and with two repeated normal brain computed tomography scans, in which there was no structural damage to the occipital lobes, suggests a metabolic or toxic reaction as a cause in our patients. The temporal relationship between vincristine treatment and cortical blindness implicates vincristine as the possible causative agent for this catastrophic phenomenon.
The sensation of a sudden electrical impulse travelling along the spine to the legs and feet on flexion of the neck has been known as Lhermitte's sign. Lhermitte's sign, as part of cisplatin-related neurotoxicity, was observed in four patients, with ovarian or lung cancer, simultaneously with peripheral neuropathy, after a dose of 375-700 mg/m2. The dose intensity (DI) of cisplatin in our patients ranged from 12.5 to 26.9 mg/m2/week. No direct relationship was found between DI and the timing of Lhermitte's sign. Other relevant causes for this sign were ruled out. The mechanism responsible for the development of Lhermitte's sign is unclear. Interruption of treatment with cisplatin may not prevent the appearance of Lhermitte's sign. In most of the reported cases in the literature this sign developed after the end of cisplatin courses.
Is it justified to treat a small, localized and relatively indolent malignancy by systemic combined chemotherapy? Five patients with locally advanced skin tumors were treated by salvage cisplatin and adriamycin for three to five courses. Three achieved complete response, one achieved partial response and one succumbed to an unrelated cause. The rapid induction of response, high response rate, unmaintained complete remissions of long duration and relatively low rate of toxicity may justify the use of this combination for the treatment of small skin tumors when other treatment options are of no avail.
Interferon (IFN) related neurotoxicity includes somnolence and confusion, fatigue, lethargy, psychiatric symptoms, conceptual disorganization, neurological deficits, cortical blindness, coma and, rarely, death. The neurologic syndromes seem to be more common in elderly patients, following intramuscular or intravenous administration, at higher doses of frequent injections of IFN-alpha and in primary renal cell carcinoma. The duration of the treatment was not strongly related to neurotoxicity. Computed tomography findings were non-specific and included atrophy or periventricular lucencies. Electroencephalograph studies demonstrated a generalized increase in slow wave activity which returned to normal after cessation of treatment. Behavioral and mental changes in patients treated with IFN are warning signs, and indicate the need to withdraw treatment.
Although chemotherapy has been generally of limited clinical benefit in the treatment of metastatic malignant melanoma (MMM), fotemustine (FM) is a newly developed drug which is active against this disease. Twenty-four patients with histologically proven MMM were treated with fotemustine, with or without dacarbazine (DITC) according to different phase II trials. In the first schedule, three patients received FM alone on days 1, 8, 15 followed by a 5-week rest period. The second schedule consisted of FM administered on days 1 and 8 alternating with DTIC on days 15 and 16, followed by a 5-week rest period (19 patients). The third schedule, given to two patients, consisted of DTIC followed 4 h later by FM. The overall response rate was 8.3%. Response in those who were treated with alternating drugs, included one partial response (PR) in the brain which lasted 4 months, and one PR in brain metastases with complete response (CR) in lymph nodes for 4 months. Clinical and radiological evidence of regression was observed mainly in brain metastases (22.2%), reflecting the intracerebral activity of the drug. It seems that fotemustine is superior to any other drug currently available in the treatment of these metastases.
Acute encephalopathy following treatment with ifosfamide and mesna was observed in 5 (4 women and 1 men) of 28 patients (17.8%), with advanced sarcoma, lymphoma or ovarian carcinoma. This appeared within 2 to 7 days following the first dose of ifosfamide treatment, and included mental status changes, urinary incontinence, weakness, seizure activity, altered consciousness and psychiatric manifestations. Three cases were fatal, while two patients recovered completely. Brain CT and morphometric studies were normal in all the patients. Associated findings were myelosuppression, renal failure and electrolyte alterations.
A case is presented of endometrioid carcinoma of the ovary, metastasizing to the breast in a 63-year old woman. Differentiation of metastatic cancer to the breast for primary breast carcinoma and discovering the primary tumor site are rather important for treatment and prognosis. Lumpectomy, followed by panhysterectomy, was performed and six courses of cisplatinum and cyclophosphamide were given. No signs of recurrence or metastasis are apparent 16 months after the discovery of the breast lesion.
Thirty patients with malignant melanoma and cerebral metastases confirmed by CT were studied. Metastases were classified according to their size: < or = 1 cm (group A), 1.1-4 cm (group B), and > 4 cm (group C), in order to assess the clinical course of the disease and predict the response to treatment with fotemustine. Group B lesions were the most common, independent of the site of the primary tumour, except for patients with rectal melanoma. Group C metastases were least common and were usually solitary. Asymptomatic patients usually had group A metastases, whereas those with non-specific complaints, hemisyndrome or neurobehavioural changes usually had group B metastases. The time from diagnosis of the primary tumour to discovery of disease in the CNS was significantly longer for those who had group A lesions, compared with those who had groups B or C lesions (P < 0.0001). Solitary lesions usually belonged to groups B or C, whereas multiple lesions belonged mainly to groups A or B. All the responders to fotemustine has mainly cortical, group A or group B lesions. Patients with group C lesions or leptomeningeal spread did not respond to fotemustine. Our findings suggest an association between the size of the cerebral metastatic lesion from malignant melanoma and clinical parameters characteristic of tumour behaviour.
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A large body of research shows that social support in general and of family members in particular plays an important role in determining cancer patients' quality of life. We assumed that the spouse's information about how the patient experiences the situation determines the spouse's ability to help. The present study was designed to examine how much the spouse knows about the attitudes and experiences of their husband or wife who is a cancer patient, and whether this knowledge depends on the questions' structure, disease duration, its severity, or level of patient's information about the disease and prognosis. A questionnaire with multiple-choice and open-ended questions assessing 13 domains (e.g., fears and worries concerning health, functioning in the family, and anxiety) was administered to patients and their partners. Subjects were 55 head-and-neck cancer patients, 40 men and 15 women, with disease stages I to IV, grade of tumors G1 to G3-4, and disease duration of 0.5 to 21 years. The results showed that correspondence between the patients' and their spouses' responses was very low, and was not affected by the structure of the questions or the disease's duration and severity. Correspondence was high only in patients informed about their disease. In the discussion, it was pointed out that when the patient is informed, communication channels in the family are opened and this brings about an increase in the spouses's information about the patient and hence in the spouse's ability to provide the patient the needed social support as a psychotherapeutic agent and a friend. The cancer nurse may play a crucial role in instituting the patient-spouse dialogue.
Our 3-year clinical experience using recombinant interferon (rIFN) alpha-C in patients with metastatic renal cell carcinoma (RCC) is summarized. This type of IFN is a new subspecies of the IFN-alpha protein family. Its specific activity is 1-2 x 10(9) U/mg protein, the highest among IFN-alpha species presently available. Pharmacokinetic study indicated good bioavailability of the preparation from the intramuscular injection. A phase II study was performed to assess the response rate related to rIFN-alpha C at a low dosage. A dose of 3 x 10(6) U daily was administered, followed by 3 x 10(6) U/m2 every other day to avoid severe toxicity. Among 33 treated patients, a partial remission rate of 9.7% and stable disease rate of 25.8% were achieved. Side effects were usually mild and the treatment was well tolerated by the patients. However, mental deterioration and behavioral changes were observed in five patients with RCC treated by rIFN-alpha C and were related to neurotoxicity of IFN. The role of vinblastine in addition to IFN in the treatment of RCC was assessed in nine patients who had failed on IFN alone. No response was observed. It appeared that vinblastine had little if any effect in being added to IFN as second-line therapy. We conclude that rIFN-alpha C has moderate activity in the treatment of RCC. Familiarity with the possible toxicity of this agent will lead to more careful management of patients.