E-SHAP: An effective treatment in selected patients with relapsed non-Hodgkin's lymphoma

BACKGROUND:: The optimal treatment of relapsed or refractory non-Hodgkin'slymphoma is unknown. The reported encouraging results of a salvageregimen, E-SHAP (etoposide 40 mg/m²/day x 4, methyl prednisolone500 mg daily x 4, cytosine arabinoside 2 gm/m² one dose andcisplatinum 25 mg/m²/day x 4), at the MD. Anderson Hospitalin Texas, which resulted in a 65% response rate, could not bereproduced in the United Kingdom (0% response). PATIENTS AND METHODS:: Twenty-six patients with relapsed (n = 16) or refractory (n= 10) non-Hodgkin's lymphoma were treated at our Centre by amodified E-SHAP regimen (cytosine arabinoside 1 gm/m² one dose).The treatment was intended as remission induction before BMT(n = 16), as salvage by itself (n = 5) and for palliation ofsymptoms (n = 5). RESULTS:: The overall response rate was 72% (CR = 7 and PR = 11). A comparisonof Kaplan-Meier curves showed a statistically significant improvementin median relapse-free survival in patients who had previouslyachieved CR (p = 0.0012), no bulky disease (P = 0.0006) andno B-symptoms (P = 0.0004). The toxicity was acceptable: 8 instancesof febrile neutropenia, 2 of reversible renal impairment and2 symptomatic electrolyte abnormalities. No fatal toxicitieswere encountered. The median time to treatment failure was 191days and median overall survival was 190 days. CONCLUSIONS:: E-SHAP is an active combination chemotherapy when used as asalvage regimen or for remission induction before bone marrowtransplantation in selected patients with relapsed non-Hodgkin'slymphoma. Patients who previously achieved CR, with low tumourburden and no B-symptoms are the best candidates for this treatment.It has a limited palliative effect. non-Hodgkin's lymphoma, salvage chemotherapy, etoposide, cisplatinum     

Low-flow priapism: risk factors for erectile dysfunction

OBJECTIVE: To evaluate our policy of managing priapism for the success rate of the treatments, potency afterward, complications, and the risk factors responsible for erectile dysfunction in these patients. PATIENTS AND METHODS: The study included 50 patients (mean age 37.1 years, range 22-66) with a diagnosis of priapism (1981-1999). Their records were reviewed; 35 patients were available for a long-term evaluation. Factors assessed were the duration of priapism, history of previous recurrent attacks, possible underlying causes (e.g. haematological disorders, medications or trauma), relation to sexual stimulation, pain, and any attempt at previous management. A complete blood screen and blood gases were assessed in corporal aspirates. Duplex ultrasonography was used in all impotent patients at their follow-up. Early and late complications were reviewed, and patients asked about their erectile function before priapism, and any recurrence. RESULTS: The median (range) duration of priapism was 48 (6-240) h; almost half the patients presented > 48 h after the onset of priapism. Sixteen patients (32%) reported a history of previous recurrent attacks, of whom seven had a history of previous treatments. The main cause of priapism was idiopathic or intracavernosal injection with papaverine. All patients were initially treated by corporal blood aspiration and injection with ephedrine; if this failed or if the priapism was prolonged (> 48 h) various shunts were used. The hospital stay was significantly shorter among patients with papaverine-induced or brief priapism. In the long-term follow-up of 35 patients (mean 66.4 months, range 3-220) only 15 (43%) reported preserved erectile function, and this was more likely in patients with brief priapism (< 48 h). Eight patients (23%) reported subsequent recurrent attacks of priapism; all were managed successfully as they presented shortly after their onset. Penile fibrosis was detected in 20 patients (57%), and was significantly more common in those with prolonged priapism (> 48 h) or from causes other than papaverine. The 20 impotent men evaluated by Doppler ultrasonography had severe echo-dense penile fibrosis and high end-diastolic velocities suggesting veno-occlusive incompetence in all except two. In five men with shunts cavernosography showed extensive venous leakage irrespective of site of the shunt. MRI in five patients with penile fibrosis showed heterogeneous areas of low signal intensity, corresponding with haemosiderin deposition and fibrosis. On univariate analysis the final result of management (complete detumescence or not), the duration of priapism and the presence of penile fibrosis significantly influenced erectile function. On multivariate logistic regression only the first remained significant. CONCLUSIONS: Low-flow priapism for > 48 h, failure to maintain complete detumescence after management, and marked penile fibrosis during the follow-up are the most significant risk factors responsible for erectile dysfunction, with failure to achieve complete detumescence the most detrimental.     

Preoperative concurrent chemotherapy and radiation therapy in cervix cancer: preliminary results

This is a retrospective study of patients treated for cervix cancer staged IB2, IIA or IIB with bulky tumor (> 4cm). Treatment was concurrent radiotherapy (45Gy with 1,8Gy daily fraction) and chemotherapy (5 cycles of Platinum 40mg/m2/week). All patients underwent Brachytherapy (15Gy on the reference isodose according to Paris system) followed by surgery (radical abdominal hysterectomy and bilateral pelvic lymphadenectomy: Piver 3) Between October 1999 and December 2002, forty five patients were treated in this protocol. Median age was 46 years (21- 68). Histology was squamous cell carcinoma in 93% and glandular carcinoma in 7%. Average external radiation dose was 44Gy (20-50). Ninety three percent of patients had at least 3 cycles of chemotherapy and 46,5% received the planned 5 cycles. On the operative specimens, there was 62,5% complete response and only 7 pelvic node involvement (17,5%). Four postoperative complications were noted (one vascular injury, one urinary fistula, one phlebitis and one lymph collection). Preoperative combined radiotherapy and chemotherapy in the early bulky stages of uterine cervix cancer is well tolerated and "gives" a high rate of sterilisation. There was no increase in surgical morbidity.     

P53 mutations in hepatocellular carcinoma patients in Egypt

The p53 gene plays a major role in hepatocellular carcinoma (HCC). Acquired mutations may provide clues to etiology, as some carcinogenic agents are associated with specific genetic changes in p53. Our aim was to analyze the spectrum of p53 mutations in tumor tissues from subjects with HCC in Egypt, where there is a rising incidence of HCC due to hepatitis C virus (HCV). We collected tumor tissues from 41 subjects with HCC diagnosed at the National Cancer Institute of Cairo University during 2000-2003. Sequence mutations were analyzed by the Affymetrix GeneChip technique. HCV RNA was detected in the sera of 37 subjects (90%). Only one patient had a current HBV infection. A total of 17 of the 41 subjects (41%) had p53 mutations. Thirteen of these were in exon 7, of which 10 were in codon 249, but only 8 of the 10 were the R249S mutation, previously reported to be associated with aflatoxin exposure. The other three exon 7 mutations were found in codons 232, 242 and 248. A total of three mutations were detected in exon 5 codons 133, 144 and 176. One mutation was detected in exon 8 codon 275. Unlike previous studies, this population is characterized by a high prevalence of chronic HCV infection. The presence of the R249S mutation in exon 7 may indicate that these subjects with HCC have been exposed to aflatoxin (AFB1), and further investigation is in progress to measure AFB1-albumin adducts in the sera of these subjects.     

Epidemiology of esophageal cancer in Iran,with special reference to nutritional and cultural aspects

A multidisciplinary epidemiological investigation was instituted to find clues to the peculiar geographical distribution of esophageal cancer in the Caspian Littoral of Iran, where in some Turkoman villages, the incidence is among the highest in the world. This article reviews the findings concerning cultural habits, dietary patterns, staple food items, environmental exogenous carcinogens, and cocarcinogens in both high- and low-incidence areas, and their possible association with the disease. This is a good example of the importance of international cooperation in epidemiologic investigations.     

How often do patients undergo repeat PET or PET/CT examinations? Experience from a UK institution

BACKGROUND AND AIM: According to the report of the Intercollegiate Standing Committee on Nuclear Medicine, the UK requires 40-60 positron emission tomography (PET) machines in the next decade (Intercollegiate Standing Committee on Nuclear Medicine). Positron Emission Tomography: a Strategy for Provision in the UK. London: Royal College of Physicians of London; 2003, pp. 1-9). This figure is based mainly on patients receiving only one examination and restricting the clinical indication to three primary diagnoses. The aim of this study was to assess the appropriateness of this figure and the assumptions made in the Intercollegiate report on UK PET provision. METHODS: We examined retrospectively our institution's entire PET and PET/computed tomography (CT) database, which spans 4 years and 9 months. We recorded the number of patients who received repeat examinations. RESULTS: Reports were available for 3354 PET/CT or PET-only studies; 418 of 2268 patients (18.4%) received at least one repeat PET/CT examination. The three main indications for PET examination in the Intercollegiate report only accounted for approximately 60% of the examinations undertaken. CONCLUSION: Our records suggest that basing the UK's future PET provision on a single examination and on three clinical indications only is no longer realistic.     

Prevalence of Helicobacter pylori, gastric myoelectrical activity, gastric mucosal changes and dyspeptic symptoms before and after laparoscopic cholecystectomy

BACKGROUND/AIMS: Cholecystectomy may lead to anatomic and functional alterations which eventually induce reflux of duodenal contents with its sequlae. The aim of this study is to evaluate the prevalence of Helicobacter pylori (H. pylori), gastric myoelectrical activities and gastric mucosal changes before and after laparoscopic cholecystectomy. METHODOLOGY: This prospective study has been carried out on 46 patients (20 M & 26 F) with mean age 41.7+/-0.2 years for whom laparoscopic cholecystectomy for gallstones was carried out. Prior to the operation and 1 year after, all patients were subjected to clinical assessment, upper gastrointestinal endoscopy, histopathology of antral mucosa, reflux gastritis score, detection of H. pylori and electrogastrography. RESULTS: There was an increase in the postoperative suggestive symptoms of reflux gastritis compared to the preoperative: epigastric pain increased from 8 (17.4%) to 11 (23.39%) patients, nausea increased from 6 (13%) to 12 (26.1%) and bilious vomiting increased from 3 (6.5%) to 11 (23.9%) patients. Mild antral gastritis was detected endoscopically before laparoscopic cholecystectomy in 20 patients (43.5%) and increased to 27 patients (58.7%) after surgery. Meanwhile, severe antral gastritis and erosions were only detected after the operation in 10 (21.7%) patients, respectively. The histological results showed an increase of the histopathologic score of reflux gastritis after cholecystectomy from 4.28 (+/-1.56) to 9.28 (+/-1.99) (p<0.001). Active chronic superficial gastritis decreased from 23 (50%) to 13 (28.2%) patients while the inactive form increased from 15 (32.6%) to 23 (50%) patients. Also, chronic atrophic gastritis, intestinal metaplasia and dysplasia were detected postoperatively in 4 (8.6%) patients. The incidence of H. pylori infection was decreased from 32 (69.6%) to 19 (41.3%) patients (p<0.0001). Electrogastrography abnormal frequency decreased in fasting from 26.1% to 8.7% (p<0.001), and postprandial from 16.9% to 4.4% recording (p<0.002). On the other hand, there was an increase in the number of patients with decreased electrogastrography amplitude after a meal from 4.3% to 28.3% (p<0.0001). CONCLUSIONS: Our study shows that dyspeptic symptoms, endoscopic and histologic gastric changes as well as electrogastrography abnormalities are present before and increase after cholecystectomy; meanwhile H. pylori colonization in gastric mucosa is decreased after cholecystectomy.