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In a patient with advanced pancreatic cancer, with a hypercoagulable state, a complete clinical response was obtained with a mitomycin-based regimen plus adjunctive heparin. The patient converted from a partial response to a complete response with the addition of heparin, raising the possibility that heparin was somehow involved in the process. Recent studies have reported prolongation of survival in patients with cancer who were given heparin along with chemotherapy. The known antiangiogenic and antiproliferative action of heparin may explain this possible synergism. If heparin is, in fact, synergistic with cytotoxic cancer drugs, a fertile field of investigation is open to cooperative groups, especially because long-term heparin therapy is now feasible and safe, the low-molecular-weight heparins even more so.

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The author presents seven patients with diabetes and cites from the literature seven patients with diabetes with probable enhanced 5-fluorouracil toxicity. In the author's seven patients, the amount of toxicity was directly related to the degree of hyperglycemia. In three of these patients who had the most severe hyperglycemia, toxicity was overwhelming, and led to death in two patients. In the 1960s, researchers showed, in a series of in vitro experiments, that glucose increased the cytotoxicity of 5-fluorouracil. The author concludes that patients whose diabetes is poorly controlled are at increased risk for severe 5-fluorouracil toxicity. New labeling instructions should advise caution in using 5-fluorouracil in patients with diabetes.

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Carcinoembryonic antigen (CEA) testing is a valuable adjunct in the overall management of patients who have non-small-cell lung cancer, especially when selecting surgical candidates for curative lung resection and in cases where the diagnosis is in doubt. Carcinoembryonic antigen levels above 50 strongly suggest advanced-stage cancer and should discourage lung resections in otherwise suitable cases. Carcinoembryonic antigen testing can enhance problem solving in difficult cases and help prevent needless invasive interventions.

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A > 50% incidence of Kaposi's sarcoma (KS) of the gastrointestinal tract has been seen in acquired immunodeficiency syndrome (AIDS) patients with cutaneous KS. Although gastrointestinal Kaposi's sarcoma (GIKS) is usually asymptomatic, hemorrhages from the oral cavity, esophagus, stomach, and large bowel have occurred in this disease. We describe a patient with acute, massive gastrointestinal hemorrhage from GIKS confined to the small bowel who was treated with chemotherapy, surgery, and radiation. To the best of our knowledge, this is the first reported case of AIDS-related GIKS limited to the small bowel. Although chemotherapy is generally used successfully to palliate diffuse GIKS, we report that radiation was an effective modality that rapidly resulted in resolution of considerable local bleeding and could be used in such cases as an alternative to surgery. Details of this case history, including radiographs, are presented.

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One hundred twenty-one patients with metastatic adenocarcinoma of the breast were randomized to concurrent combination therapy or single-drug chemotherapy administered sequentially. Although response frequency and duration of response were significantly increased in patients receiving the combination regimen, survival was not significantly prolonged when compared to those receiving sequential treatment. For the 69 patients free of liver metastasis, median survival was comparable in both treatment arms (14.4 months sequential versus 12.8 months combination). These results indicate that a large subset of patients with metastatic breast cancer may benefit from less aggressive therapeutic regimens. Furthermore, these results illustrate that conclusions of chemotherapy trials in breast cancer based only on response frequency and duration of response represent preliminary results subject to change when final survival information becomes available.

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A 26-year-old man, acutely ill with fever, anemia, and hepatomegaly, was found to have an epidermoid carcinoma by percutaneous needle biopsy of a left apical lung mass. Following resection of the necrotic tumor, fever, anemia, and hepatomegaly disappeared. The patient is alive with no evidence of cancer 30 months later.

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A patient with biopsy-proven papular mucinosis, plus the characteristic IgG lambda light chain paraproteinemia, also developed a severe proximal myopathy, seronegative inflammatory polyarthritis, and marked eosinophilia. Muscle enzymes were elevated, EMG was compatible with polymositis, and muscle biopsy revealed an atypical necrotizing vacuolar myopathy. Synovial biopsy revealed an inflammatory synovitis with Class II synovial fluid. No mucin deposition was detectable in muscle or synovium. During 7 years of observation, corticosteroids and various immunosuppressive agents were successively administered with little benefit. Recently, weekly intravenous methotrexate and low-dose oral corticosteroids have resulted in clinical and laboratory improvement. It is suggested that the pathology in papular mucinosis may include serious rheumatic manifestations in addition to the cutaneous involvement.

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110 patients with far advanced head and neck squamous or testicular carcinoma were treated with bleomycin given by intravenous (i.v.) or intramuscular (i.m.) injection according to a randomized assignment. While responses were observed more frequently in patients treated by the intramuscular route, no superiority can be attributed clearly to intramuscular therapy. Responses were seen in 6.2% of head and neck squamous carcinoma patients (5/81; i.m. 3/38, 8%; i.v. 2/41, 5%) while 14% of testicular tumors responded (4/29; i.m. 4/13, 29%; i.v. 0/16, 0%). Toxicity was, in general, manageable.

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A patient with functioning islet cell carcinoma is described who had amelioration of her hypoglycemia during the development of ectopic ACTH syndrome. Moon facies and hyperkalemic metabolic acidosis were also present in this patient, features uncommonly seen in the actopic ACTH syndrome. At autopsy, she was found to have active tuberculosis. Prophylactic antituberculous therapy should be given to high-risk patients with the ectopic ACTH syndrome. High doses of ACTH may be palliative in refractory hypoglycemic states.

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Three patients with advanced breast cancer are described who developed lymphangitic pulmonary metastases with normal chest x-rays and abnormal perfusion lung scans. The abnormal lung scans can probably be attributed to embolization of the pulmonary vasculature, first described in association with lymphangitic pulmonary metastases in 1903. The importance of recognizing this condition in patients with breast cancer is shown by their frequently good responses to combination chemotherapy.

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