No abstract

Background: Oral mucositis, a debilitating side-effect of chemotherapy, is difficult to prevent or treat. The aim of this study was to characterize the histological and ultrastructural change in the human oral mucosa following cytotoxic chemotherapy. Methods: Oral buccal mucosa biopsies were taken from four volunteers and 20 cancer patients. Each patient had one biopsy prior to chemotherapy and a second biopsy at varying intervals after chemotherapy. Biopsies were assessed histologically and ultrastructurally. Results: Apoptosis increased in the basal layer in the first 3 days after chemotherapy, began to decline at 6 days, but never returned to levels of volunteers by 11 days after treatment. Ultrastructural changes included increased intercellular fibres in basal layer cells, cytoplasmic vacuolation, loss of membrane contact with neighboring cells, multinucleation of suprabasal cells and loss of cellular cytoplasm. These changes persisted in prechemotherapy biopsies in patients who had prior chemotherapy. Conclusions: Apoptosis occurs early, and persists in the basal layer of the buccal mucosa after chemotherapy. Ultrastructural changes were present and remained up to 11 days after chemotherapy.

An investigation into plasma calcium concentrations and the biochemical factors which regulate it in vegetarian Asian subjects without clinical or radiological features of osteomalacia revealed the presence of low serum 25-hydroxyvitamin D concentrations and elevated PTH concentrations, even in the presence of calcium levels in the normal range (up to 2.35 mmol/liter). These elevated PTH concentrations, though not as high as those in osteomalacic patients with hypocalcemia, often persisted despite treatment with vitamin D, normalization of 25-hydroxyvitamin D, and an increase in calcium concentrations. In one patient the PTH concentration remained high even when the plasma calcium concentration became supranormal. Therefore, secondary hyperparathyroidism is commonly associated with vegetarianism, and may play an important role in maintaining calcium concentrations within the normal range. Persistent elevation of PTH despite normalization of 25-hydroxyvitamin D also points to autonomous PTH hypersecretion, which may result in osteolysis in the long term, and raises the question of the need for vitamin D supplementation in vegetarians with low dietary intake of vitamin D.

Gram-positive organisms are the predominant pathogens in febrile neutropenic episodes at the RDH. Standard empirical therapy with an extended-spectrum penicillin and an aminoglycoside remains appropriate, with the addition of vancomycin when clinical status fails to improve. When practising in the Top End, particular consideration should be given to skin integrity and scabies and testing for Strongyloides in Aboriginal patients.

Standard treatment for locally advanced anal cancer is chemoradiotherapy with mitomycin C and fluorouracil. However, infusional fluorouracil requires central venous catheter placement potentiating risk of infection and thrombosis. Capecitabine which is an oral tumor activated fluoropyrimidine carbamate is an established treatment alternative to infusional fluorouracil for patients with gastrointestinal cancers. Areas covered: This review examines and discusses the current evidence for substitution of Capecitabine for infusional fluorouracil in locally advanced anal cancer. Two phase II studies, one phase I study and three retrospective reviews were identified. The rate of complete response and locoregional control with the use of Capecitabine in all of these studies ranged from 77% to 89.1% and 79% to 94% respectively, and these results are comparable with prior pivotal studies. The main toxicity with radiation and Capecitabine is radiation dermatitis occurring in 23% to 63% of patients. Despite high rates of radiation dermatitis, treatment completion rates were high, suggesting that it is a well tolerated protocol. Expert commentary: Capecitabine has been used widely in other gastrointestinal cancers, including rectal cancer in chemo-radiotherapy protocols, with proven efficacy and safety and could be a reasonable treatment alternative to fluorouracil in locally advanced anal cancer.