- Email: [email protected]
Metastatic squamous cell cancer after psoralen photochemotherapy
between the
Scylla of thrombosis and the Charybdis of bleeding in long-term use. We did not seek to minimise the potentially disastrous consequences of warfarin use, nor did we conclude, as Ginsberg and Barron imply, that warfarin is not associated with embryopathy. This hazard is well known though probably exaggerated, but was not seen in our 46 women with first-trimester exposure, which is in accord with other case series. Ginsberg and Barron suggest that embryo abnormalities were missed and that the finding of embryopathy depends on the "keenness" with which it is sought. They ignore the suggestion that women with a low dose requirement for warfarin are at less risk of fetal damage than those who need a high dose, and eventually fall back on the manufacturer’s guidelines that these compounds are "contraindicated during pregnancy". These guidelines are presumably based on the frequently expressed recommendations of protagonists of heparin, such as
Ginsberg. As for bioprostheses, here the data are good; yet Ginsberg and Barron challenge the reality of the accelerated deterioration of these valves in pregnant women and ignore the risks of re-operation and irrelevantly dwell on the unsuitability of mechanical valves for women with bleeding diatheses-not an aspect that is in dispute. Celia M Oakley Royal Postgraduate Medical School,
1 2
Hammersmith
Hospital,
London W12 ONN, UK
Sbarouni E, Oakley CM. Outcome of pregnancy in women with valve prostheses. Br Heart J 1994; 71: 196-201. Hanania G, Thomas D, Michel PL, Garbarz E, Age C, Acar J. Pregnancy in patients with valvular prostheses—Retrospective Cooperative Study in France (155 cases). J Arch Coeur Vaiss 1994; 87: 429-37.
SIR—Ginsberg and Barron mention the administration of heparin intravenously as an alternative to the subcutaneous route in pregnant women with prosthetic heart valves. We have seen a 32-year-old woman with a Starr-Edwards mitral valve prosthesis (implanted at the age of 22 after rheumatic fever in childhood) in whom an unplanned 7week pregnancy was identified and who was admitted for conversion from warfarin to heparin. A cannula was inserted in the dorsum of the left hand after an initial unsuccessful attempt. 8 days later the cannula site became sore, and on day nine the patient became pyrexial when the cannula was removed. Culture was not done. A missed abortion was dignosed and she had an evacuation of retained products of conception on day 10 with administration of ampicillin and gentamicin at induction followed by intravenous (iv) coamoxiclav. Four sets of blood cultures taken on days 10, 11, and 12 after insertion of the cannula grew Staphylococcus aureus. Examination of the products of conception did not show any evidence of infection. Infection of the prosthetic mitral value was thought to be the most likely cause for the persistent bacteraemia and the cannula in the left hand was regarded as the most probable site of entry. She responded to treatment and was discharged well after parenteral antibiotics for 6 weeks. We suggest that the intravenous route should be avoided whenever possible in such patients because it provides a possible site of entry for bacteria that can infect prosthetic valves. Coagulase-negative staphylococci and S aureus are the bacteria most commonly associated with intravascular catheter infections, with severe complications being commoner if S aureus is implicated.’ If insertion of a peripheral iv line is deemed essential in a patient with a prosthetic device, then special attention should be paid to measures that can reduce the risk of infection, such as 1644
aseptic procedures and the use of sterile gloves.2 Removal of the intravenous line within 2-3 days of insertion can also help to reduce the risk of line infection.’ GE
Bignardi, S Barrett, R Foale, N Spyrou
Departments of Microbiology and Cardiology, St Mary’s Hospital, London W2 1NY, UK 1
2
3
Arnow PM, Quimosing EM, Beach M. Consequences of intravascular catheter sepsis. Clin Infect Dis 1993; 16: 778-84. Maki DG. Infection caused by intravascular devices: pathogenesis, strategies for prevention. In: Maki DG, ed. Improving catheter site care. London: Royal Society of Medicine, 1991: 3-27. Fry DE, Fry RV, Borzotta AP. Nosocomial blood-borne infection secondary to intravasular devices. Am J Surg 1994; 167: 268-72.
SiR-We offer our comments on Ginsberg and Baron’s commentary. First, bioprosthetic valves deteriorate at an accelerated rate not only during pregnancy-they generally degenerate much more rapidly in the young. This accelerated rate of primary tissue degeneration rapidly declines with advancing age of the recipient.’1 The occurrence of early degeneration of bioprosthetic valves in children and young adults a few years after implementation as a result of calcification is widely recognised.2-4 Second, pregnancy after heart valve replacement is seriously affected, with considerable complications and danger for the mother and risk for the fetus. We therefore inform all our young female patients before heart valve replacement about the potential complications during subsequent pregnancy. We recommend that they prevent further pregnancies after valve operation by oral contraception or sterilisation by tubal ligation. Staying childless improves life expectancy and life quality in young women after mechanical/biological valve replacement. There are permanent changes in the development, fixation, and preservation methods of biological devices. Long-term results for newer prostheses, such as stentless bioprostheses are still not available, despite encouraging early experience for calcification and degeneration.
Herwig Antretter, Johannes Bonatti Department of Cardiac Surgery, University of Innsbruck School of Medicine, 6020 Innsbruck, Austria 1
2
3
4
Blackstone EH, Kirklin JW. Death and other time-related events after valve replacement. Circulation 1985; 72: 753-67. Gabbay S, Kaddam P, Factor S, Cheung TK. Do heart valves degenerate for metabolic or mechanical reasons? J Thorac Cardiovasc Surg 1988; 95: 208-15. Williams JB, Karp RB, Kirklin JW. Considerations in selection and management of patients undergoing valve replacement with glutaraldehyde-fixed porcine bioprostheses. Ann Thorac Surg 1980; 30: 247-58. Amidi M, Ferson PF, Labuda MJ, Melhem MS. Early manifestation of noncalcific aortic stenosis after porcine valve replacement. Ann Thorac Surg 1990; 49: 471-72.
Metastatic squamous cell
cancer
after
psoralen photochemotherapy SiR-Lewis and colleagues (Oct 22, p 1157) report metastatic squamous cell carcinoma in a patient receiving psoralen photochemotherapy (PUVA). Since 1976, the PLTVA Follow-up Study has followed the original cohort of 1380 patients with psoriasis who were given PUVA to monitor the long-term safety of this treatment. Not noted by Lewis was the report earlier this year of metastatic squamous cell cancer in 7 of these patients.’1 Of particular concern to us was the occurrence of metastatic disease in 3 patients during the most recent 2 of
the 16 years of follow-up completed so far. These 3 patients had had high doses of PUVA (252-645 treatments) and were under 60 years of age. 1 has recently died from her metastases. These observations increased our concern that the risk of metastatic squamous cell cancer in association with tumours that develop many years after first exposure to PUVA or after high levels of exposure to PUVA might be
Gianturco Z stent (Cook, Inc, Bloomington, IN, USA). Siremobil 2000 (Siemens, Erlangen, Germany) C-arm was used for intraoperative imaging. The 22 F delivery system was introduced via a common femoral arteriotomy. A Wallstent (Schneider, Europe AG, Zurich, Switzerland) was deployed to support the graft, prevent angulation, and maintain patency. The left common iliac artery was occluded with embolisation coils (William Cook, Denmark). A right to left femorofemoral bypass was done with a 10 mm Dacron graft (USCI, Glens Falls, NY, USA) to restore blood flow to the left system. Completion arteriography showed good flow through the aortic graft and the cross-over graft with no perigraft leakage or reflux of contrast beyond the coils into the aneurysm. The procedure was completed in 150 min without any complication. The patient was able to resume normal diet and mobility within 48 h of the procedure. A duplex scan on the sixth postoperative day showed good flow through the graft with no leakage into the aneurysm and the patient was discharged on the following
increasing. The PUVA Follow-up Study continues its investigation of this unique cohort. One of the primary objectives is to assess the final incidence of squamous cell cancer as well as the risk of metastases from tumours that develop in association with PUVA. Our most recent observations reinforce the statements we expressed 15 years ago ... "the benefit of PUVA for patients with psoriasis should be weighed against the possible risks associated with photochemotherapy". Robert S Stern Harvard Medical School, Beth Israel Hospital, Boston, MA 02215, USA
1
2
RS, Laird N. The carcinogenic risk of treatments for severe psoriasis. Photochemotherapy Follow-up Study. Cancer 1994; 73: Stem
2759-64. Stern RS, Thibodeau LA, Parrish JA, Fitzpatrick TB. Skin cancer after PUVA treatment for psoriasis. N Engl J Med 1979; 301: 555.
Emergency endovascular repair of leaking
10000 patients die from ruptured abdominal aortic aneurysm in England and Wales each year.’ Many die before reaching hospital and the mortality after surgical repair remains nearly 50%.5 Feasibility of endovascular repair of leaking aneurysm has now been shown. Careful evaluation is required but this development offers hope for a reduction in morbidity and mortality from ruptured aortic aneurysm.
aortic aneurysm SIR—Technical feasibility of endovascular repair of infrarenal abdominal aortic aneurysm without laparotomy and aortic clamping has now been established with straight aorto-aortic,’ bifurcated aorto-iliac,2 and straight aorto-iliac grafts3 over the past four years. However, endovascular repair has so far been restricted to a small number of nonleaking aneurysms as an elective procedure. We report a case of successful endovascular repair of a leaking abdominal aortic aneurysm. A 61-year-old male presented on Oct 29, 1994, with abdominal and back pain to the City Hospital in Nottingham; ultrasound showed a 6 cm aneurysm with a large perianeurysmal haematoma. He was transferred to the University Hospital in a haemodynamically stable state. A computed tomography scan was done to assess the feasibility of endovascular repair (figure) and the procedure was started within 1 h of arrival in the hospital. Endovascular repair was carried out by use of a prosthesis comprising a 24 mm neck Verisoft graft (Meadox, Oakland, NJ, USA) and modified
Figure: Computed tomography
day. Nearly
showing 6-5 cm x 5.4 large haematoma outside
scan
abdominal aortic aneurysm with aneurysm on left side
cm
S W Yusuf, S C Whitaker, T A M Chuter, P W Wenham, B R Hopkinson Department of Vascular Surgery, University Hospital, Nottingham NG7 2UH, 1
2
3
4
5
UK
Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg 1992; 5: 491-99. Yusuf SW, Baker DM, Chuter TAM, Whitaker SC, Wenham PW, Hopkinson BR. Transfemoral endoluminal repair of abdominal aortic aneurysm with bifurcated graft. Lancet 1994; 344: 650-51. May J, White G, Waugh R, Yu W, Harris J. Treatment of complex abdominal aortic aneurysms by a combination of endoluminal and extra-luminal aorto-femoral grafts. J Vasc Surg 1994; 19: 44-49. Greenhalgh RM. Prognosis of abdominal aortic aneurysms. BMJ
1990; 301: 136. Bergqvist D, Bengtsson H. Ruptured abdominal aortic aneurysm: who should be operated upon? In: Greenhalgh RM, ed. Emergency vascular surgery. London: WB Saunders, 1992; 171-82.
Parity and Down’s syndrome SIR-In your Aug 27 news item, Fishman comments on Israeli investigators’ recommendation to their public health authorities to offer free prenatal diagnosis for Down’s syndrome to multiparous women. Haddow and Palomaki (Oct 1, p 956) criticise that recommendation on the basis of second-trimester pregnancy data. The Israeli proposal, which was based on the observation of a 15% increased risk of Down’s syndrome for parity of 6 and over (after correction for maternal age), prompted us to analyse our data from the Latin American Collaborative Study of congenital Malformations (ECLAMC). Our study included 2048 newborn infants with Down’s syndrome and 37 425 non-malformed newborn babies, who were paired (one-to-one) with all malformed infants from the same sample of births registered in 1967-91. As in the Israeli sample, maternal age was grouped in 5year intervals and parity in three categories: 1, 2-5, and 6 and higher. For parity 6 or more group, the weighted odds ratio (Mantel-Haenszel) was 1-14 (95% CI 1-01-1-30, Cornfield). Thus, our Latin American sample shows an increased risk of Down’s syndrome (14%) that is almost 1645
Scylla of thrombosis and the Charybdis of bleeding in long-term use. We did not seek to minimise the potentially disastrous consequences of warfarin use, nor did we conclude, as Ginsberg and Barron imply, that warfarin is not associated with embryopathy. This hazard is well known though probably exaggerated, but was not seen in our 46 women with first-trimester exposure, which is in accord with other case series. Ginsberg and Barron suggest that embryo abnormalities were missed and that the finding of embryopathy depends on the "keenness" with which it is sought. They ignore the suggestion that women with a low dose requirement for warfarin are at less risk of fetal damage than those who need a high dose, and eventually fall back on the manufacturer’s guidelines that these compounds are "contraindicated during pregnancy". These guidelines are presumably based on the frequently expressed recommendations of protagonists of heparin, such as
Ginsberg. As for bioprostheses, here the data are good; yet Ginsberg and Barron challenge the reality of the accelerated deterioration of these valves in pregnant women and ignore the risks of re-operation and irrelevantly dwell on the unsuitability of mechanical valves for women with bleeding diatheses-not an aspect that is in dispute. Celia M Oakley Royal Postgraduate Medical School,
1 2
Hammersmith
Hospital,
London W12 ONN, UK
Sbarouni E, Oakley CM. Outcome of pregnancy in women with valve prostheses. Br Heart J 1994; 71: 196-201. Hanania G, Thomas D, Michel PL, Garbarz E, Age C, Acar J. Pregnancy in patients with valvular prostheses—Retrospective Cooperative Study in France (155 cases). J Arch Coeur Vaiss 1994; 87: 429-37.
SIR—Ginsberg and Barron mention the administration of heparin intravenously as an alternative to the subcutaneous route in pregnant women with prosthetic heart valves. We have seen a 32-year-old woman with a Starr-Edwards mitral valve prosthesis (implanted at the age of 22 after rheumatic fever in childhood) in whom an unplanned 7week pregnancy was identified and who was admitted for conversion from warfarin to heparin. A cannula was inserted in the dorsum of the left hand after an initial unsuccessful attempt. 8 days later the cannula site became sore, and on day nine the patient became pyrexial when the cannula was removed. Culture was not done. A missed abortion was dignosed and she had an evacuation of retained products of conception on day 10 with administration of ampicillin and gentamicin at induction followed by intravenous (iv) coamoxiclav. Four sets of blood cultures taken on days 10, 11, and 12 after insertion of the cannula grew Staphylococcus aureus. Examination of the products of conception did not show any evidence of infection. Infection of the prosthetic mitral value was thought to be the most likely cause for the persistent bacteraemia and the cannula in the left hand was regarded as the most probable site of entry. She responded to treatment and was discharged well after parenteral antibiotics for 6 weeks. We suggest that the intravenous route should be avoided whenever possible in such patients because it provides a possible site of entry for bacteria that can infect prosthetic valves. Coagulase-negative staphylococci and S aureus are the bacteria most commonly associated with intravascular catheter infections, with severe complications being commoner if S aureus is implicated.’ If insertion of a peripheral iv line is deemed essential in a patient with a prosthetic device, then special attention should be paid to measures that can reduce the risk of infection, such as 1644
aseptic procedures and the use of sterile gloves.2 Removal of the intravenous line within 2-3 days of insertion can also help to reduce the risk of line infection.’ GE
Bignardi, S Barrett, R Foale, N Spyrou
Departments of Microbiology and Cardiology, St Mary’s Hospital, London W2 1NY, UK 1
2
3
Arnow PM, Quimosing EM, Beach M. Consequences of intravascular catheter sepsis. Clin Infect Dis 1993; 16: 778-84. Maki DG. Infection caused by intravascular devices: pathogenesis, strategies for prevention. In: Maki DG, ed. Improving catheter site care. London: Royal Society of Medicine, 1991: 3-27. Fry DE, Fry RV, Borzotta AP. Nosocomial blood-borne infection secondary to intravasular devices. Am J Surg 1994; 167: 268-72.
SiR-We offer our comments on Ginsberg and Baron’s commentary. First, bioprosthetic valves deteriorate at an accelerated rate not only during pregnancy-they generally degenerate much more rapidly in the young. This accelerated rate of primary tissue degeneration rapidly declines with advancing age of the recipient.’1 The occurrence of early degeneration of bioprosthetic valves in children and young adults a few years after implementation as a result of calcification is widely recognised.2-4 Second, pregnancy after heart valve replacement is seriously affected, with considerable complications and danger for the mother and risk for the fetus. We therefore inform all our young female patients before heart valve replacement about the potential complications during subsequent pregnancy. We recommend that they prevent further pregnancies after valve operation by oral contraception or sterilisation by tubal ligation. Staying childless improves life expectancy and life quality in young women after mechanical/biological valve replacement. There are permanent changes in the development, fixation, and preservation methods of biological devices. Long-term results for newer prostheses, such as stentless bioprostheses are still not available, despite encouraging early experience for calcification and degeneration.
Herwig Antretter, Johannes Bonatti Department of Cardiac Surgery, University of Innsbruck School of Medicine, 6020 Innsbruck, Austria 1
2
3
4
Blackstone EH, Kirklin JW. Death and other time-related events after valve replacement. Circulation 1985; 72: 753-67. Gabbay S, Kaddam P, Factor S, Cheung TK. Do heart valves degenerate for metabolic or mechanical reasons? J Thorac Cardiovasc Surg 1988; 95: 208-15. Williams JB, Karp RB, Kirklin JW. Considerations in selection and management of patients undergoing valve replacement with glutaraldehyde-fixed porcine bioprostheses. Ann Thorac Surg 1980; 30: 247-58. Amidi M, Ferson PF, Labuda MJ, Melhem MS. Early manifestation of noncalcific aortic stenosis after porcine valve replacement. Ann Thorac Surg 1990; 49: 471-72.
Metastatic squamous cell
cancer
after
psoralen photochemotherapy SiR-Lewis and colleagues (Oct 22, p 1157) report metastatic squamous cell carcinoma in a patient receiving psoralen photochemotherapy (PUVA). Since 1976, the PLTVA Follow-up Study has followed the original cohort of 1380 patients with psoriasis who were given PUVA to monitor the long-term safety of this treatment. Not noted by Lewis was the report earlier this year of metastatic squamous cell cancer in 7 of these patients.’1 Of particular concern to us was the occurrence of metastatic disease in 3 patients during the most recent 2 of
the 16 years of follow-up completed so far. These 3 patients had had high doses of PUVA (252-645 treatments) and were under 60 years of age. 1 has recently died from her metastases. These observations increased our concern that the risk of metastatic squamous cell cancer in association with tumours that develop many years after first exposure to PUVA or after high levels of exposure to PUVA might be
Gianturco Z stent (Cook, Inc, Bloomington, IN, USA). Siremobil 2000 (Siemens, Erlangen, Germany) C-arm was used for intraoperative imaging. The 22 F delivery system was introduced via a common femoral arteriotomy. A Wallstent (Schneider, Europe AG, Zurich, Switzerland) was deployed to support the graft, prevent angulation, and maintain patency. The left common iliac artery was occluded with embolisation coils (William Cook, Denmark). A right to left femorofemoral bypass was done with a 10 mm Dacron graft (USCI, Glens Falls, NY, USA) to restore blood flow to the left system. Completion arteriography showed good flow through the aortic graft and the cross-over graft with no perigraft leakage or reflux of contrast beyond the coils into the aneurysm. The procedure was completed in 150 min without any complication. The patient was able to resume normal diet and mobility within 48 h of the procedure. A duplex scan on the sixth postoperative day showed good flow through the graft with no leakage into the aneurysm and the patient was discharged on the following
increasing. The PUVA Follow-up Study continues its investigation of this unique cohort. One of the primary objectives is to assess the final incidence of squamous cell cancer as well as the risk of metastases from tumours that develop in association with PUVA. Our most recent observations reinforce the statements we expressed 15 years ago ... "the benefit of PUVA for patients with psoriasis should be weighed against the possible risks associated with photochemotherapy". Robert S Stern Harvard Medical School, Beth Israel Hospital, Boston, MA 02215, USA
1
2
RS, Laird N. The carcinogenic risk of treatments for severe psoriasis. Photochemotherapy Follow-up Study. Cancer 1994; 73: Stem
2759-64. Stern RS, Thibodeau LA, Parrish JA, Fitzpatrick TB. Skin cancer after PUVA treatment for psoriasis. N Engl J Med 1979; 301: 555.
Emergency endovascular repair of leaking
10000 patients die from ruptured abdominal aortic aneurysm in England and Wales each year.’ Many die before reaching hospital and the mortality after surgical repair remains nearly 50%.5 Feasibility of endovascular repair of leaking aneurysm has now been shown. Careful evaluation is required but this development offers hope for a reduction in morbidity and mortality from ruptured aortic aneurysm.
aortic aneurysm SIR—Technical feasibility of endovascular repair of infrarenal abdominal aortic aneurysm without laparotomy and aortic clamping has now been established with straight aorto-aortic,’ bifurcated aorto-iliac,2 and straight aorto-iliac grafts3 over the past four years. However, endovascular repair has so far been restricted to a small number of nonleaking aneurysms as an elective procedure. We report a case of successful endovascular repair of a leaking abdominal aortic aneurysm. A 61-year-old male presented on Oct 29, 1994, with abdominal and back pain to the City Hospital in Nottingham; ultrasound showed a 6 cm aneurysm with a large perianeurysmal haematoma. He was transferred to the University Hospital in a haemodynamically stable state. A computed tomography scan was done to assess the feasibility of endovascular repair (figure) and the procedure was started within 1 h of arrival in the hospital. Endovascular repair was carried out by use of a prosthesis comprising a 24 mm neck Verisoft graft (Meadox, Oakland, NJ, USA) and modified
Figure: Computed tomography
day. Nearly
showing 6-5 cm x 5.4 large haematoma outside
scan
abdominal aortic aneurysm with aneurysm on left side
cm
S W Yusuf, S C Whitaker, T A M Chuter, P W Wenham, B R Hopkinson Department of Vascular Surgery, University Hospital, Nottingham NG7 2UH, 1
2
3
4
5
UK
Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg 1992; 5: 491-99. Yusuf SW, Baker DM, Chuter TAM, Whitaker SC, Wenham PW, Hopkinson BR. Transfemoral endoluminal repair of abdominal aortic aneurysm with bifurcated graft. Lancet 1994; 344: 650-51. May J, White G, Waugh R, Yu W, Harris J. Treatment of complex abdominal aortic aneurysms by a combination of endoluminal and extra-luminal aorto-femoral grafts. J Vasc Surg 1994; 19: 44-49. Greenhalgh RM. Prognosis of abdominal aortic aneurysms. BMJ
1990; 301: 136. Bergqvist D, Bengtsson H. Ruptured abdominal aortic aneurysm: who should be operated upon? In: Greenhalgh RM, ed. Emergency vascular surgery. London: WB Saunders, 1992; 171-82.
Parity and Down’s syndrome SIR-In your Aug 27 news item, Fishman comments on Israeli investigators’ recommendation to their public health authorities to offer free prenatal diagnosis for Down’s syndrome to multiparous women. Haddow and Palomaki (Oct 1, p 956) criticise that recommendation on the basis of second-trimester pregnancy data. The Israeli proposal, which was based on the observation of a 15% increased risk of Down’s syndrome for parity of 6 and over (after correction for maternal age), prompted us to analyse our data from the Latin American Collaborative Study of congenital Malformations (ECLAMC). Our study included 2048 newborn infants with Down’s syndrome and 37 425 non-malformed newborn babies, who were paired (one-to-one) with all malformed infants from the same sample of births registered in 1967-91. As in the Israeli sample, maternal age was grouped in 5year intervals and parity in three categories: 1, 2-5, and 6 and higher. For parity 6 or more group, the weighted odds ratio (Mantel-Haenszel) was 1-14 (95% CI 1-01-1-30, Cornfield). Thus, our Latin American sample shows an increased risk of Down’s syndrome (14%) that is almost 1645