Maeda K, Ueda M, Ohtaka H, Koyama Y, Ohgami M, Miyazaki H
Department of Surgery, Keio University Ise Keio Hospital, Mie, Japan.
Jpn J Clin Oncol. 1987 Sep;17(3):247-53.
An esophageal cancer patient with bilateral lungs and neck lymph nodes metastases received 24 mg of vincristine instead of vinblastine because of the similarity between the two names, and survived multiorgan derangement. Serious states of central and peripheral neuropathy with muscle atrophy, gastrointestinal disorder, bone marrow suppression and mucocutaneous involvement were all encountered. Although hypotension and syndrome of inappropriate secretion of antidiuretic hormone (SIADH) were not observed as vincristine's side actions, toxicity to the myocardium, which has not been documented, was suggested in our case. These toxic impairments, however, subsided clinically within a month, except for paresthesia in the peripheral extremities. The effectiveness of the chemotherapy was remarkable against both the esophageal cancer and the metastatic lesions. No unintentional overdose of a drug, needless to say, should happen, and in order to minimize its possibility, it would be advisable for chemotherapy to be administered only by an experienced physician who is able to check the dose and concentration.
一名患有双侧肺和颈部淋巴结转移的食管癌患者,由于长春新碱和长春花碱这两个名字相似,误将24毫克长春新碱当作长春花碱使用,结果出现多器官功能紊乱并存活下来。患者出现了严重的中枢和周围神经病变,伴有肌肉萎缩、胃肠道紊乱、骨髓抑制和皮肤黏膜受累。虽然未观察到长春新碱常见的低血压和抗利尿激素分泌不当综合征(SIADH)等副作用,但我们的病例提示存在未被记录的对心肌的毒性。然而,除了四肢末梢的感觉异常外,这些毒性损害在临床上一个月内消退。化疗对食管癌和转移病灶的疗效显著。当然,不应发生无意的药物过量情况,为尽量减少这种可能性,化疗最好仅由能够检查剂量和浓度的经验丰富的医生进行。