Prognostic significance of metastatic lymph node ratio in T3 gastric cancer

The fifth International Union Against Cancer tumor node metastasis (UICC TNM) classification, based on the number of metastatic lymph nodes (LN), has proved to be a reliable and objective method for predicting the prognosis of patients with gastric cancer. However, the prognosis of patients with T3 gastric cancer is still heterogeneous. This study was carried out to investigate the validity of metastatic LN ratio as a prognostic factor in T3 gastric cancer. A retrospective analysis was performed on a total of 833 patients that had either T3N1M0 (n = 504) or T3N2M0 (n = 329) gastric cancer by the fifth UICC classification. A preliminary analysis revealed the cutoff values for T3N1M0 to be 10% and for T3N2M0 to be 25%. The mean metastatic LN ratio was 9.0% for T3N1M0 cancer and 26.9% for T3N2M0 cancer. For the T3N1M0 stage, the patients who showed less than 10% of the metastatic LN ratio were grouped as N1-low with the others grouped as N1-high. For the T3N2M0 stage group, those who had less than 25% of the metastatic LN ratio were grouped as N2-low, the remainder as N2-high. The metastatic LN ratio decreased in proportion to the extent of lymphadenectomy and it increased in relation to the increasing scale of the fourth N classification. The rates of recurrence were significantly different according to the metastatic LN ratio in N1 and N2 classification of the fifth UICC classification (p < 0.05). The 5-year survival rates after gastrectomy decreased significantly by increasing the metastatic LN ratio in both T3N1M0 cancers (p =0.0026) and T3N2M0 cancers (p = 0.0057). The metastatic LN ratio was an independent risk factor for recurrence and poor prognosis. Our data suggest that the metastatic LN ratio is a significant prognostic factor for T3 gastric cancer. Furthermore, the application of the metastatic LN ratio can provide information not only about the extent of LN metastasis but also about the extent of lymphadenectomy in T3 gastric cancer.

Lymph node recovery from colorectal tumor specimens: recommendation for a minimum number of lymph nodes to be examined

Lymph node involvement is the most important prognostic factor for patients who have undergone radical surgery for colorectal carcinoma. An accurate examination of the surgical specimens is mandatory for the correct assessment of the lymph node status of the tumor. The risk of understaging is particularly high for patients with tumors classified as Dukes B (TNM stage II). The aim of this study was to determine if a specified minimum number of lymph nodes examined per surgical specimen could have any effect on the prognosis of patients who had undergone radical surgery for Dukes B colorectal cancer. Between 1988 and 1995 a total of 140 patients underwent radical resection of Dukes B colorectal cancer by the same surgeon (C.C.). The relation between clinicopathologic variables and survival was estimated using the Kaplan-Meier method. The Cox proportional hazard regression model was used to identify the variables that can independently influence survival. A median of 12 lymph nodes (range 3-38) was examined per tumor specimen. The 5-year survival rate of Dukes B patients who had had eight or fewer lymph nodes examined after surgery was 54.9%, whereas the survival rate for those who had had nine or more lymph nodes examined was 79.9% (p < 0.001). Cox regression analysis identified the number of lymph nodes as the only independent prognostic factor (p = 0.01). Seventy patients with one to four metastatic lymph nodes (Dukes C patients) who had been operated on during the same period were included in the survival analysis for comparison. The 5-year survival rate of the Dukes B patients with eight or fewer lymph nodes examined was similar to that of the 70 Dukes C patients (54.9% and 51.8%, respectively). Examination of eight or fewer lymph nodes in Dukes B colorectal patients may be considered a high risk factor for missing positive lymph nodes in the surgical specimens. Our results suggest that harvesting and examining a minimum of nine lymph nodes per surgical specimen may be sufficient for reliable staging of lymph node-negative tumors.

Outcome in patients with lung cancer found retrospectively to have had evidence of disease on past lung cancer mass screening roentgenograms

This study enrolled 143 asymptomatic patients with lung cancer detected by mass screening during an 8-year period (January 1, 1993 to December 31, 2000) and who had received a lung cancer mass screening roentgenogram one year before the disease was found. There was no difference between the 5-year survival rates in patients with one-year delayed detection of lung cancer (n=62) and in patients without (n=81) (46 vs. 58%, log rank: P=0.1330, Wilcoxon: P=0.1008). However, according to the tumor size on the overlooked chest roentgenogram, the outcome in stage I+II patients with missed tumors >20 mm in dimension (n=20) was worse than those with missed tumors <10 mm (n=24) or those with missed tumors 10-20 mm (n=18) (40 vs. 82 or 81%, log rank: P=0.0047, Wilcoxon: P=0.0010). All missed tumors in the lung field that did not overlap thoracic components were <10 mm in dimension and appeared as patchy ground-glass opacities, and they could not have been recognized if there was no other information that the tumor developed in that location. This might also be related to the lack of mortality effectiveness of previous lung cancer mass screening problem. Although it may be difficult to find the tumors <10 mm on a chest roentgenogram on mass screening, one-year delayed detection of lung cancer < or = 20 mm will not affect the prognosis.

A 3-week schedule of gemcitabine plus cisplatin as induction chemotherapy for Stage III non-small cell lung cancer

BACKGROUND

Our aim was to explore the activity and feasibility of gemcitabine plus cisplatin as induction chemotherapy in patients with Stage IIIA N(2) and selected IIIB non-small cell lung cancer (NSCLC).

PATIENTS AND METHODS

From September 1997 to July 2000, 70 chemonaive patients with Stage III NSCLC, median age of 64 years, World Health Organization performance status 0, 1, or 2, and the ability to tolerate a pneumonectomy entered the study and received gemcitabine 1250 mg/m(2) on days 1 and 8 and cisplatin 70 mg/m(2) on day 2 every 3 weeks. After three cycles of induction chemotherapy, patients underwent resection or radiotherapy.

RESULTS

Responses were seen in 40 of the 69 assessable patients, for an intent-to treat overall response rate of 57.1% (95% confidence interval, 45-62%), with 4.2% complete response. Response rates were 68 and 35% in patients with Stage IIIA and IIIB disease, respectively. The overall pathological CR rate after induction chemotherapy was 3%, with an overall pathological downstaging rate of 20%. Median survival for all patients was 14.5 months, with an estimated 1-year survival rate of 67% (95% CI, 54.3-79.5%). The estimated time to treatment failure was 12.6 months. Grade 3/4 thrombocytopenia was the main hematologic toxicity, occurring in 26% of patients, but was not associated with life-threatening bleeding. Febrile neutropenia was rare and other severe non-hematologic toxicities were uncommon.

CONCLUSIONS

The 3-week schedule of gemcitabine plus cisplatin is highly active as induction chemotherapy in Stage IIIA N(2) unresectable NSCLC. This suggests a need for a multimodality approach upfront, such as concurrent chemoradiation therapy, particularly in patients with Stage IIIB disease.

New therapeutic drugs in the management of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease remains a major health problem for which new and improved treatments are desperately needed. Recent trials strongly suggest that treatments are improving. Longer-acting bronchodilators will be more convenient and may have additional advantages. Combinations of bronchodilators may offer additive effects and, possibly, synergies. Inhaled glucocorticoids, although unable to alter the loss of forced expiratory volume in 1 second when used alone, may reduce exacerbation frequency and health status deterioration and improve mortality. These clinically meaningful goals represent end points not previously targeted in chronic obstructive pulmonary disease drug development. Moreover, inhaled glucocorticoids may offer benefits in combination with long-acting beta-agonists. Finally, new classes of agents such as the phosphodiesterase inhibitors are on the horizon. The prospect for better treatment of chronic obstructive pulmonary disease looks brighter than ever. Caution is required, however. Much of the excitement has been generated by small studies, presented only in abstract form, and as yet unpublished work. Therapeutic recommendations will require publication of appropriately designed and adequately powered clinical trials.

Neoadjuvant chemotherapy with CPT-11 and cisplatin downstages locally advanced gastric cancer

We examined the role of neoadjuvant therapy in downstaging locally advanced gastric cancer. Preoperative staging was performed with a combination of CT scans, endoscopic ultrasonography and/or laparoscopy, and laparoscopic ultrasonography. Patients with T > or =3 tumors and/or node-positive disease by preoperative clinical staging were eligible for entry. Neoadjuvant therapy consisted of two cycles of CPT-11 (75 mg/m(2)) with cisplatin (25 mg/m(2)) weekly four times every 6 weeks. This was followed by resection with D2 lymph node dissection and two cycles of intraperitoneal chemotherapy with floxuridine and cisplatin. Twenty-two patients were entered into the study (4 with T3N0 disease and 18 with T3N1 disease). Induction chemotherapy was well tolerated with major toxicities being neutropenia and diarrhea. A median of 78%/75% of the planned dosage of CPT-11/cisplatin was delivered. Two patients withdrew consent during the first cycle and were lost to follow-up. One patient progressed to stage IV disease during induction chemotherapy and did not undergo surgery. Nineteen patients underwent surgery. One patient had undetected stage IV disease (liver) and underwent a palliative R2 resection. Of the 18 remaining patients, 17 had curative R0 resections and one had a palliative R1 resection. A median of 21 lymph nodes (range 1 to 121) were examined histologically. There was one postoperative death. Surgical morbidity did not appear to increase after the neoadjuvant regimen. The median postoperative length of hospital stay was 9 days (range 3 to 75 days). Postoperative pathologic staging yielded 16% T3 lesions compared to 85% before treatment based on clinical staging; postoperative American Joint Committee on Cancer staging yielded 37% stage IIIA disease compared to 70% stage IIIA before treatment. With a median follow-up of 15 months, median survival has not yet been reached. We conclude that CPT-11-based neoadjuvant therapy downstages locally advanced gastric cancer. Further follow-up is necessary to determine the ultimate impact of this combination therapy on recurrence and survival.

[Evaluation of the complementary drug Factor AF2 as a supportive agent in management of advanced urothelial carcinoma. Prospective randomized multicenter study]

This is a prospective randomized multicenter trial for evaluation of the biological response modifier Factor AF2 in advanced urothelial cancer treated with chemotherapy. Main aim of the study was the analysis of supportive effects. Additionally patients were examined with regard to tumor response, time to progression and survival. 106 patients with advanced urothelial cancer received chemotherapy with cisplatin and methotrexate. They were randomized for additional Factor AF2 (500 mg i.v., given at days 0-3, 7-10 and 11-14). Myelotoxicity was more common and severe in the group without Factor AF2 reaching statistical significance. Gastrointestinal side effects occurred in both groups, though grade III to IV toxicity was more common without Factor AF2. Overall remission rate was 38%, median survival 33 weeks, mean time to progression 20 weeks. There was no significant difference between the two groups with or without Factor AF2.

Stem cell transplantation for Hodgkin's disease: a review of the literature

High-dose chemotherapy followed by autologous peripheral-blood stem cell transplantation has resulted in long-term disease-free survival of 30%-60% in selected patients with refractory and relapsed Hodgkin's disease. In addition, a significant reduction in early transplant-related mortality in more recent studies has led to the widespread acceptance of autografting. Comparatively few studies of allografting for Hodgkin's disease have been performed. Although no prospective randomized trials have been performed, historical results show a significantly lower relapse rate when allografting results are compared to autografting results. These results suggest that a graft-versus-Hodgkin's disease effect may exist. Unfortunately, the lower relapse rate following allografting is offset by higher transplant-related mortality. The use of low-intensity nonmyeloablative regimens for allografting may harness a graft-versus-Hodgkin's disease effect with less morbidity and mortality than that observed following conventional allografting.

Clinical features of hypertrophic cardiomyopathy in the young

BACKGROUND

We analysed the experience with hypertrophic cardiomyopathy in two paediatric centres to establish the differences from older patients.

METHODS

Out of 45 young patients seen from 1974 to 1999, we included 38. Criterions for exclusion were secondary forms, or association with severe congenital cardiac disease which could alter the outcome.

RESULTS

The patients presented at the age of 5.7 years, and were followed for 7.0 years. The 34 patients referred because of a murmur or cardiomegaly were older than the four with heart failure, presenting at 6.2 as opposed to 2.1 years of age, p = 0.08. Of the patients, 29 (76%) had primary cardiomyopathy, while 9 (24%) had secondary forms associated with Noonan's and LEOPARD syndromes. Familial tendency was ascertained in 7 patients (18%). The septal thickness in mm/m2 at presentation was greater in patients under 2 years than in older children (29 vs 18, p = 0.02). Obstructive hypertrophic cardiomyopathy was found in 17 patients (45%), with six of these having mild associated congenital cardiac defects. Nine had symptomatic arrhythmias. Overall, treatment was medical in 31, with DDD pacing used in 5, and surgery, radiofrequency ablation, and transplantation in one patient each. Total mortality was 24%, at a rate of 4.3% per year. Four patients died in heart failure and 5 had sudden death. Those in failure were significantly younger (p = 0.01).

CONCLUSIONS

Hypertrophic cardiomyopathy in the young is characterized by referral for murmur or heart failure; frequent secondary forms; the obstructive variant being as common as the non-obstructive form; a mortality rate similar to that for adults attending tertiary centres; and less frequent familial forms than in older populations.

Ovarian carcinoma associated with pregnancy. A review of 9 cases

BACKGROUND

The purpose of this study was to review patients with ovarian cancer in pregnancy, the effectiveness of the available methods of treatment and their prognosis.

METHODS

A retrospective review of all women diagnosed to have cancer of the ovary associated with pregnancy who delivered at the authors' hospitals between January 1976 and December 2000. The demography, clinical presentation, time and mode of diagnosis, treatment, pregnancy outcome and maternal survival were noted.

RESULTS

The incidence of ovarian carcinoma in pregnancy in the series was 0.08/1000 deliveries. Of the 9 patients, 7 had epithelial cancers; 4 serous cystadenocarcinoma, 2 mucinous cystadenocarcinomas and one undifferentiated cancer. One patient each had dysgerminoma and granulosa cell tumor. Six patients were in FIGO stage Ia, one Ic, one IIa. One patient was in stage III. Five patients were treated by unilateral salpingo-oophorectomy during pregnancy. Three patients had total abdominal hysterectomy, bilateral salpingo-oophorectomy and omentectomy followed by chemotherapy. Debulking of the tumor was done in a patient in stage III with subsequent chemotherapy. This patient died 13 months from the time of diagnosis of the tumor. The overall 5-year survival rate in the series was 78% and 100% for stage Ia.

CONCLUSIONS

Association of ovarian cancer with pregnancy is a rare occurrence. Early diagnosis and appropriate treatment offers the best prognosis for the patient. The higher survival rates in the series was attributed to a larger number of patients in stage I of the disease and 2 patients with a germ cell tumor and dysgerminoma which have the best prognosis. Aggressive postoperative chemotherapy also contributed to the better outcome.

[Clinical study of double primary cancer involving the lung in resected cases]

Among all cases of surgically resected lung cancer, there were 56 cases (16.1%) of double primary cancer. The common sites of the other primary cancer was the stomach (19 cases), followed by large intestine (9 cases), urinary bladder (7 cases) and pharinx-larynx (7 cases). One patient had triple cancers. In all cases of double primary cancer, 46 cases were metachronous, 10 of which were cases of initial lung cancer. The 5-year survival rate of double primary cancer was 39.7%. Good result was obtained in metachronous cases with initial lung cancer. Most of prognosis of double primary cancer was determined by that of lung cancer. In more than half of initial cancer, the second primary cancer was detected by symptoms. So, special attention to the possibility of double primary cancer in patients with resected lung cancer is necessary for improvement of prognosis.

[Analysis of 36 cases of severe craniocerebral injuries complicated by severe thoracic trauma]

By analyzing 36 cases of severe craniocerebral injuries complicated by severe thoracic trauma that were treated in our hospital from September 1997 to September 2001, the author concludes that immediate management of thoracic trauma and timely correction of hypoxemia are of paramount significance.

Congenital diaphragmatic hernia in 120 infants treated consecutively with permissive hypercapnea/spontaneous respiration/elective repair

BACKGROUND/PURPOSE

Poor prognosis (approximately 50% survival rate and significant morbidity) traditionally has been associated with congenital diaphragmatic hernia (CDH). The authors reviewed a single institution experience and challenged conventional wisdom in the context of a care strategy based on permissive hypercapnea/spontaneous respiration/elective repair.

METHODS

From August 1992 through February 2000, all infants with CDH and (1) respiratory distress requiring mechanical ventilation, (2) in-born or (3) transferred preoperatively within hours of birth are reported. All respiratory care strategy used permissive hypercapnea/spontaneous respiration and combined with elective repair. Arterial blood gas values and concomitant ventilator support were recorded. Outcome markers were (1) need for extracorporeal membrane oxygenation ECMO, (2) discharge to home, (3) supplemental oxygen need at discharge, and (4) influence of non-ECMO ancillary therapies (surfactant, nitric oxide, high-frequency oscillatory ventilation).

RESULTS

One hundred twenty consecutive infants were reviewed. Overall survival rate was 75.8%, but, excluding 18 of 120 not treated (6 lethal anomalies, 10 overwhelming pulmonary hypoplasia, 3 prerepair ECMO-related neurocomplications), 84.4% survived to discharge. A total of 67/120 were inborn. Non-ECMO ancillary treatments had no impact on survival rate. ECMO was used in 13.3%. Surgery was transabdominal; prosthetics were used in 7%. Tube thoracostomy was rare. Every inborn patient (n = 11) requiring a chest tube for pneumothorax died. Respiratory support before surgery was peak inspiratory pressure (PIP), 22, FIO(2),.43 with PaO(2), 66 torr; PaCO(2), 41 torr; and pH, 7.32. The survivors discharged on oxygen (n = 2) died at 4 and 7 months.

CONCLUSIONS

The majority of infants with life-threatening CDH treated with permissive hypercapnea/spontaneous respiration/elective surgery survive to discharge with minimal pulmonary morbidity.

The long term results of endoscopic surveillance of premalignant gastric lesions

BACKGROUND

A large proportion of patients attending open access endoscopy have histological and gross pathological findings that are potentially premalignant. The proportion of these patients who go on to develop malignancies and the timescale over which this occurs are uncertain.

AIMS

This study aims to discover the incidence of gastric cancers in this "high risk" group and to examine the potential for their early diagnosis and treatment.

PATIENTS

A total of 1753 patients attended open access endoscopy. From these, 166 patients with dysplasia, intestinal metaplasia, atrophic gastritis, foveolar hyperplasia, regenerative changes, polyps, or ulcers who agreed to undergo annual surveillance endoscopy were studied.

METHODS

Patients were endoscoped annually. Additionally, patients with ulcers were re-examined at two monthly intervals until ulcer healing. Cancers detected were treated by gastrectomy.

RESULTS

Twenty two of 1753 patients attending open access endoscopy had gastric cancer (1.3%). In the study population, 14 cancers were detected over 10 years (8.4 %). These were of an earlier stage than those detected at open access (stage I and II 67% v 23%; p<0.05) and five year survival was significantly higher (50% v 10%; p=0.006). In atrophic gastritis and intestinal metaplasia the risk of malignancy was 11%.

CONCLUSIONS

In patients with atrophic gastritis or intestinal metaplasia, annual surveillance can detect most new tumours at an early stage with a major improvement in survival. Potential benefits of such a surveillance programme are large and warrant further investigation in a multicentre randomised controlled trial.

IL-10 is critical for host resistance and survival during gastrointestinal helminth infection

Resistance to many intestinal nematodes is dependent on the induction of polarized type 2 cytokine responses, whereas type 1 responses can exacerbate these infections. The contributions of IL-4 and IL-13 to the development of resistance have been well described for a variety of intestinal parasites; however, the role of IL-10 has not been previously investigated. In this study we infected IL-10-, IL-10/IL-4-, IL-10/IL-12-, IL-4-, and IL-12-deficient mice with Trichuris muris to determine whether IL-10 contributes to the development of immunity. Interestingly, T. muris-infected IL-10-, IL-4-, and IL-10/IL-4-deficient mice failed to expel the parasite, and animals deficient in IL-10 displayed marked morbidity and mortality. In contrast, double IL-10/IL-12-deficient mice were completely resistant and mounted a highly polarized type 2 cytokine response, demonstrating that the increased susceptibility of IL-10-deficient mice was dependent on IL-12. Further study suggested that the susceptibility of IL-10- and IL-10/IL-4-deficient mice was probably attributable to a marked increase in type 1 cytokine production in those animals. The mortality observed in T. muris-infected IL-10- and IL-10/IL-4-deficient mice correlated with increased inflammation, loss of Paneth cells, and absence of mucus in the cecum. Interestingly, survival was enhanced in T. muris-infected IL-10/IL-4-deficient mice if a broad spectrum antibiotic was administered, suggesting that an outgrowth of opportunistic bacteria was contributing to the high degree of morbidity and mortality. Overall, these studies reveal a critical role for IL-10 in the polarization of Th2 responses, development of resistance during T. muris infection, and maintenance of barrier function in the colon.

Early complications after Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy: risk factors and management

BACKGROUND

Esophageal resection represents a major surgical and physiologic insult carrying major morbidity and mortality. We present the results of esophagectomy in a specialist unit with emphasis on early complications and their management.

STUDY DESIGN

From January 4, 1990 through January 6, 2000, 228 patients have undergone Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy for malignancy under the care of one surgeon. The median age was 64 years (range 39 to 77 years), with a male to female ratio of 2.3:1 and a predominance of adenocarcinoma (n = 146) compared with squamous cell carcinoma (n = 75) and other tumors (n = 7). Detailed prospective data were collected on preoperative status, operative parameters, and postoperative complications.

RESULTS

Median ICU stay was 1 day (range 1 to 47 days) and the median postoperative hospital stay in patients surviving surgery (n= 219) was 13 days (range 9 to 159 days). There were 119 separate postoperative complications occurring in 45% of patients (102 of 228), comprising predominantly pulmonary morbidity. Major respiratory complications (17%) were significantly associated with poor preoperative spirometry (p = 0.002) and a history of smoking (p = 0.03). Seven percent of patients (16 of 228) suffered cardiovascular or thromboembolic complications. Major surgical complications occurred in 10% of patients (22 of 228) including mediastinal leaks in 4%. Isolated anastomotic leaks (2%) were successfully treated conservatively in all cases; extensive leaks from ischemic gastric conduits (1%) or gastrotomy dehiscence (1%) underwent further exploration and either local repair or resection and exclusion. Reoperation for hemostasis was required in 3% (6 of 228) and only 1% of patients (2 of 228) developed chyle leaks. Thirty-day mortality was 2%, rising to 4% for in-hospital mortality. The nine fatalities were significantly older (p = 0.02) than those who survived and 67% (6 of 9) had suffered primary surgical complications.

CONCLUSIONS

Overall morbidity after radical esophagectomy is high, but early recognition and aggressive management of complications can minimize subsequent mortality. Concentration of facilities and surgical expertise in specialist units together with more careful patient selection can decrease mortality further.

Predictors of hemorrhagic transformation in patients receiving intra-arterial thrombolysis

BACKGROUND AND PURPOSE

Hemorrhagic transformation (HT) is a major complication of intra-arterial (IA) thrombolytic therapy. Identifying significant predictors of hemorrhage after thrombolysis would be useful in guiding patient selection for IA treatment.

METHODS

Data were collected retrospectively on consecutive patients with acute focal cerebral ischemia within the anterior or posterior circulation who were treated with combined intravenous (IV)-IA or pure IA thrombolysis over an 8-year period at the UCLA Medical Center.

RESULTS

Eighty-nine patients were treated. Median baseline National Institutes of Health Stroke Scale (NIHSS) score was 16, and mean age was 69 years. Twenty-six patients received IA tissue plasminogen activator (tPA) only, 22 received IV-IA tPA, and 41 received IA urokinase only. Asymptomatic HT occurred in 29 patients (33%), minor symptomatic HT (1- to 3-point worsening in NIHSS score) occurred in 10 patients (11%), and major symptomatic HT (> or = 4-point worsening in NIHSS score) occurred in 6 patients (7%). The rate of any HT was similar in patients treated with pure IA thrombolysis (39%) versus combined IV-IA thrombolysis (41%). In pure IA cases, the rate of any HT was 50% with tPA versus 32% with urokinase (P=0.2). Eighty-six percent of the patients with HT versus 39% of the patients without HT were dead or disabled (modified Rankin score >2) at day 7 (P<0.0001). On multivariate analysis, independent predictors of any HT were higher NIHSS score, longer time to recanalization, lower platelet count, and higher glucose level. A model using these variables correctly predicted HT with positive predictive value 70% and overall accuracy 78%.

CONCLUSIONS

In this large series of IA thrombolysis, rates of HT were similar to those demonstrated in prior series and clinical trials. Higher NIHSS score, longer time to recanalization, lower platelet count, and higher glucose level were independent predictors of any HT.

Long-term results of lung volume reduction surgery

OBJECTIVE

Lung volume reduction surgery (LVRS) is effective in the short and intermediate term for the improvement of pulmonary function and subjective symptoms in selected patients with advanced emphysema. The purpose of this study was to examine the long-term functional results of LVRS and to investigate which subgroups would benefit in terms of long-term survival.

METHODS

All records of the patients who underwent LVRS between 1994 and, 1998 at our hospital were reviewed.

RESULTS

Eighty-eight consecutive patients underwent LVRS during the period. There were 62 men and 26 women with an average age of 56.1 years (range 34-72 years). Eleven patients with alpha1-antitrypsin deficiency were included. The perioperative mortality rate (<90 days) was 2.3% (n=2). Total lung capacity (7.5+/-0.3 l) and residual volume (4.8+/-0.3 l) at 3 years remained lower than baseline (9.2+/-0.2 l, 6.5+/-0.2 l, each) (P<0.001). The mean forced expiratory volume in 1 s (FEV(1)) at 3 years (0.86+/-0.08 l) was higher than baseline (0.78+/-0.02 l), but the difference did not reach statistical significance. The FEV(1) of the patients with alpha1-antitrypsin deficiency and of those with respiratory bronchiolitis returned to baseline at one year after LVRS and showed further deterioration. Overall survival rate at 5 years was 71.0% with the mean length of follow-up of 54.2 months. The survival difference was statistically significant between patients with preoperative FEV(1) >or=28.5% and those with FEV(1)<28.5% (P=0.0152).

CONCLUSIONS

The improvement of total lung capacity and residual volume persisted long after the operation. Patients with alpha1-antitrypsin deficiency and those with bronchiolitis showed early deterioration of the lung function. Patients with higher preoperative FEV(1) had a survival benefit. The favorable long-term survival might justify LVRS for the treatment of selected patients with severe emphysema.

Stage I non-small cell lung carcinoma: really an early stage?

OBJECTIVE

We review our results on surgical treatment of patients with stage I non-small cell lung carcinoma and we attempted to clarify the prognostic significance of some surgical--pathologic variables.

METHODS

From 1993 to 1999, 667 patients received curative lung resection and complete hilar and mediastinal lymphadenectomy for non-small cell lung cancer. Of these, there were 436 Stage I disease (65%), of whom 144 T1N0 and 292 T2N0. No patients had pre- or postoperative radio- or chemotherapy. Prognostic significance of the following independent variables was tested using univariate (log-rank) and multivariate (Cox proportional-hazards) analysis: type of resection (sublobar vs lobectomy vs pneumonectomy), histology (squamous cell vs adenocarcinoma), tumour size (<or=3cm vs >3cm), histologic vascular invasion, visceral pleura involvement, positive bronchial resection margin, general T status.

RESULTS

Overall 5-year survival was 63%. In both univariate and multivariate survival analysis, significant prognostic factors were histology (adenocarcinoma 65% vs squamous cell carcinoma 51%), tumour size (<or=3cm 67% vs >3cm 46%), and the presence of negative resection margin. Five-year survival by general T status was 66% in T1N0 vs 55% in T2N0 disease (P=0.19).

CONCLUSIONS

Despite advances in early diagnosis and surgical technique, 5-year survival of stage I non-small cell lung carcinoma remains low as compared to survival of other solid organ neoplasm. Tumour size <or=3cm, adenocarcinoma histologic type and negative bronchial resection margins were associated with a more favourable outcome in our patient population. More effective multimodality treatments are needed to increase survival rates.

Intra-arterial delivery of p53-containing adenoviral vector into experimental brain tumors

Human tumor xenografts established in athymic rat brains were used to determine the feasibility of intravascular delivery of tumor suppressor genes to brain tumors. Both tumor size and number were compared to characterize the effect of tumor burden on tumor transduction efficacy by a control LacZ-containing adenoviral vector. Experiments with tumors grown in vivo for either 3, 5, or 7 days demonstrated that 5-day-old tumors provided the best target for vector infection and transgene expression by this mode of administration. Intra-arterial mannitol facilitated transduction efficiency. Tumor burden did not seem to affect transduction, while tumor location appeared to be an important factor. Based on these results, intra-arterial infusion of a p53-containing adenoviral vector was carried out and resulted in significant retardation of brain tumor growth 3 days after administration. Effects at longer time points were not as significant. These findings indicate that intra-arterial administration of adenoviral vectors containing p53 is efficient and can result in changes in tumor size, but that long-term control of tumor growth may require multiple adenoviral treatments.

Vertebrobasilar dissection: a possible role of whiplash injury in its pathogenesis

We reviewed 29 patients with vertebrobasilar dissections (VBD) to investigate the correlation between minor trauma and VBD and the clinical features of this trauma-related condition. Mean age was 43 years, with a male predominance (male/female ratio was 25/4). Seventeen patients presented with subarachnoid hemorrhage (SAH), and 12 with ischemic symptoms. Two patients presenting with ischemia had extracranial VBD (V3 segment). Angiographically, aneurysmal dilatation was observed in most SAH patients (13 patients) in contrast to narrowing or occlusion in most ischemic patients (10 patients). Among the 12 SAH patients treated with coil embolization or conservatively, five died, whereas all ischemic patients recovered well with anticoagulation and/or antiplatelet therapy. Seven patients had received minor or trivial head/cervical trauma, due to whiplash injury, minor fall, or during exercise, which were identified to precede with the lapse of some time (a few minutes or days) the onset of symptoms. All of these patients presented with ischemic symptoms, and they were younger than the other ischemic or SAH patients. The site of vertebral artery dissection was intracranial in four cases, extracranial in one case, and combined in two cases at the level of the V3 segment and the origin of the posterior inferior cerebellar artery. However, no SAH occurred. These clinicopathological findings, i.e. ischemia and angiographic narrowing/occlusion, suggest that dissections were subintimal. Therefore, it is believed that this minor or trivial trauma may primarily cause subintimal dissection with luminal compromise, leading to ischemic symptoms, rather than subadventitial or transmural dissection with aneurysmal dilatation, leading to SAH. This lesion may also occur in younger patients with a favorable outcome. Careful note should be made of patient for the early recognition of this disorder.

Increased early rejection rate after conversion from tacrolimus in kidney and pancreas transplantation

CONTEXT

A successful immunosuppression regimen for combined kidney and pancreas transplants is tacrolimus, mycophenolate mofetil, and prednisone. However, not all patients tolerate these immunosuppressants especially tacrolimus.

OBJECTIVE

To evaluate the efficacy of cyclosporine as a rescue agent for tacrolimus toxicity in combined kidney and pancreas transplants.

DESIGN

Retrospective.

SETTING

Single center.

PATIENTS

Thirty-five combined kidney and pancreas transplants were performed between July 1994 and January 1999. All patients were insulin dependent diabetics with end-stage renal disease. Twenty-eight (mean age: 36 years and 57% female) were available with at least 12 month follow-up.

INTERVENTIONS

Conversion to cyclosporine following renal (biopsy proven) or pancreatic dysfunction.

MAIN OUTCOME MEASURES

Toxicity, rejection rate, and patient/transplant organ survival.

RESULTS

Nineteen transplant recipients (68%) were continuously maintained on tacrolimus while nine (32%) required conversion to cyclosporine 75 +/- 20 days post-transplant. Reasons for conversion included: hyperglycemia (n=2), hemolytic-uremic syndrome (n=1), and severe tacrolimus nephrotoxicity (n=6). By 12 months post-transplant, the 19 patients maintained on tacrolimus had 5 rejections (26%). Three of the 9 patients (33%) converted to cyclosporine had an acute rejection prior to conversion. Seven of these 9 patients (78%; P=0.017 vs. patients maintained on tacrolimus) had rejections an average of 25 +/- 4 days post-conversion. Four of the 7 patients had no previous rejections prior to conversion. In spite of increased rejections, the 1- and 2-year patient/graft survivals were unchanged by converting.

CONCLUSIONS

Converting to cyclosporine from tacrolimus was associated with an increased risk of acute rejection especially within the first 30 days post conversion.

Albendazole chemotherapy for AIDS-related diarrhoea in Zambia--clinical, parasitological and mucosal responses

BACKGROUND

Albendazole reduces diarrhoea in African AIDS patients, but it is unclear if the clinical response to treatment reflects pathogen eradication and/or mucosal recovery.

METHODS

Adults with HIV-related persistent diarrhoea were treated with albendazole 800 mg twice daily for 14 days. Clearance of parasites was evaluated at 3 and 6 weeks by stool microscopy. At baseline and at 6 weeks duodenal biopsies were taken for electron microscopy (EM) and morphometry.

RESULTS

Ten (7%) of 153 patients had cryptosporidiosis, 54 (37%) had isosporiasis and 23 (16%) had microsporidiosis. By 3 weeks, these protozoa were cleared in 27 (46%) of 59 patients initially positive. By 6 weeks, 34 (39%) of 87 patients experienced complete clinical response, 18 (21%) partial response and 35 (40%) no response. Crypt depth increased by 15% over 6 weeks (P < 0.001), but villous height increased only in patients with complete response (median + 50 microm, interquartile range (IQR) 2-90, compared to patients with partial (+ 4 microm, IQR -15,41) or no response (-13 microm, IQR -2,12; P=0.008)). Fifteen patients died: body mass index < 17.5 kg/m(2) and crypt depth < 180 microm independently predicted death.

CONCLUSIONS

Albendazole therapy reduced the burden of protozoal infection and promoted mucosal recovery in patients with a complete clinical response.