Long-Term (≥25 Years) Kidney Allograft Survivors: Retrospective Analysis at a Single Center

INTRODUCTION

Despite great improvements in the short-term patient and kidney graft survival, the long-term morbidity and mortality in kidney transplant recipients still remains a significant problem. The aim of the study was to evaluate the impact of both donor and transplant recipient factors, as well as renal function indices on the very long-term (>25 years) kidney allograft survival.

MATERIAL AND METHODS

Retrospective analysis was performed on the data of 41 kidney transplant recipients (KTR), group A: follow-up = 25 years, 20 KTR, 10 male, mean age (mean [M] ± standard deviation [SD]): 34.6 ± 12.6 years, 14 living donors (LD), 6 cadaveric donors (CD); group B: follow-up > 25 years, 21 KTR, 16 male, mean age (M ± SD): 30.86 ± 12.37 years, 14 LD, 7 CD). Kidney graft origin, post-kidney transplantation diabetes mellitus, HLA compatibility, delayed graft function, and acute rejection episodes were also analyzed retrospectively. Statistical analysis with Mann-Whitney test and Kaplan-Meier survival analysis was performed (SPSS 20.0 for Windows).

RESULTS

The mean age of CDs was lower than that of LDs: CD mean age (M ± SD): 23.84 ± 16.26 years vs LD mean age: 52.75 ± 12.42 years (P < .001). Cadaveric kidney graft was associated with better renal allograft function 10, 15, and 25 years post kidney transplant. None of the other factors analyzed reached statistical significance between the 2 groups.

CONCLUSION

The age of the donor and the kidney graft origin are important co-factors of the very long-term kidney allograft survival.

Simultaneous pancreas-kidney transplantation: initial results from a center in Greece

AIM

The outcome of simultaneous pancreas-kidney transplantation (SPK) in type 1 diabetes has dramatically improved in recent years. We report the initial results of our SPK program.

PATIENTS AND METHODS

From 2008 to 2010, we performed and prospectively obtained data on 4 SPKs in 4 type 1 diabetic patients with chronic renal failure. The recipients were 3 men and 1 woman, of overall mean age of 40.75 ± 4.78 years, mean time from diabetes diagnosis of 27 ± 15 years, and time on dialysis of 3.5 ± 0.57 years. All grafts were procured from multiorgan brain-dead donors of mean age 26 ± 8.16 years and mean body weight of 74 ± 4.34 kg. The pancreatic grafts were transplanted first into the right iliac fossa with mean cold ischemia times of 10.62 ± 3.09 hours for the pancreatic and 14.00 ± 2.97 hours for the renal grafts. Pancreas arterial inflow was re-established by an end-to-side anastomosis of an extension Y-graft to the recipient right iliac artery. The portal vein was sutured to the iliac vein directly. The exocrine secretions of the pancreas were managed by duodenojejunostomy extraperitoneally (n = 3) or intraperitoneally (n = 1). The ureteral anastomosis was performed using the Taguchi technique.

RESULTS

After SPK, endocrine pancreatic function was immediately restored in all patients. Insulin administration was stopped within the first 24 hours after surgery. Two patients displayed delayed renal graft function necessitating dialysis for 9 and 23 days, respectively. The postoperative course was prolonged with a mean hospital stay of 82 ± 1 day. At a 31.75 ± 9.03 months follow up all patients are alive with functioning grafts.

CONCLUSION

Our experience with SPK, although limited, has shown encouraging results over a short follow-up period.

Epidemiologic trends in lung cancer over two decades in Northern Greece: an analysis of bronchoscopic data

BACKGROUND AND AIM

The relative frequency of histological subtypes of lung cancer in Europe has changed dramatically during the 20th century. The aim of this study was to explore the changing epidemiology of lung cancer in Northern Greece over the last two decades.

METHODS

From the extensive database of the Bronchoscopy Unit of the G. Papanicolaou General Hospital, Thessaloniki, Greece, we identified all patients with a histologic and/or cytologic report positive for lung cancer over two consecutive decades.

RESULTS

Between 1/1/1986 and 31/12/2005 we identified 9981 patients with specimens positive for lung cancer. A significant increase in mean patient age was observed during the second decade (64.8 +/- 9.4 vs. 62.1 +/- 8.9, p=0.001). Men developed lung cancer ten times more often than women. The predominant histological type was squamous cell cancer in males (4203 cases, 45.7%) and adenocarcinoma (418 cases, 52.6%) in females. The number of lung cancer cases was significantly higher during the second decade compared to the first decade (5766 cases [57.8%] vs. 4215 cases [42.2%], respectively, p<0.001). There was a significant decrease in the percentage of squamous cell carcinoma in males in the second decade (2317 cases [44.1%] vs. 1886 cases [48.0%], p<0.001), and an increase in adenocarcinoma (1021 cases [19.4%] vs. 609 [11.6%], p<0.001). In females, the relative incidence of adenocarcinoma was decreased and that of squamous cell carcinoma was increased, but not significantly. There was no obvious change in the incidence of small cell lung cancer. Neoplastic lesions were most often located in the upper lobes.

CONCLUSION

The number of lung cancer cases has increased in the last decade. Squamous lung cancer appears to be decreasing in men and increasing in women. Adenocarcinoma appears to be increasing in men and decreasing in women. There appears to be no change in small cell lung cancer. During the second decade there has been a significant decrease in the male: female ratio.

The evolution of the role of liver transplantation in treating alcoholic cirrhosis in Greece

BACKGROUND

Liver transplantation represents the main treatment for alcoholic cirrhosis. The goal of this article is to review the results of liver transplantation for alcoholic cirrhosis in Greece over the last 2 decades.

METHODS

Among 247 patients who underwent liver transplantation between 1991 and 2007, 34 (13.7%) experienced alcoholic cirrhosis as the primary diagnosis. We reviewed their demographic data, stage of liver disease, and outcomes regarding survival via a Kaplan-Meier curve. Also we analyzed the causes of death and the postoperative complications.

RESULTS

Mean Model for End-Stage Liver Disease (MELD) score was 18.4. Other diagnoses included hepatitis C virus (HCV; 23.5%), hepatitis B virus (HBV; 14.7%), and hepatocellular carcinoma (8.8%). Eleven patients died the most frequent causes being primary graft nonfunction (n = 3), hepatic artery thrombosis (n = 2), sepsis (n = 2), and portal vein thrombosis (n = 2). Complications included rejection (32.4%), infection (26.5%), hepatic graft dysfunction (11.8%), and recurrent HCV, recurrent HBV, and renal failure (8.8% each). Recurrence of alcoholism was observed in 3 patients (8.8%) with mild effects on liver function tests. There has been a significant increase in the number of liver transplantations for alcoholic cirrhosis in the last 6 years, namely 25 patients versus 9 in the previous 10 years.

CONCLUSIONS

We observed a significant increase in the frequency of alcoholic cirrhosis leading to liver transplantation in the last several years in Greece.

Outcomes of kidney transplantation in Greek and Albanian patients: a single centre experience

BACKGROUND AND AIM

It has been reported that racial and ethnic (genetic make up), as well as socioeconomic differences may affect the results of kidney transplantation. Socioeconomic factors are quite difficult to differentiate from genetic factors. It is not surprising that a group with poorer access to health care, less private insurance and less income does less well with serious medical problems. The aim of this study was to compare the outcomes of kidney transplantations in Greek (G) and Albanian (A) patients.

PATIENTS AND METHODS

Twenty nine transplanted patients of Albanian ancestry were matched with 29 Greek patients retrospectively. Their mean age was 34 (G) and 31 (A) years, there were 21 men and 8 women in each group (G, A) and they received 26 kidneys from living related donors and 3 kidneys from cadaveric donors respectively. Arterial blood pressure (ABP), body weight (BW), serum creatinine, serum total protein and albumin, total cholesterol, HDL-cholesterol and triglycerides, 24 hour proteinuria were measured on 7th, 15th postoperative day, 1st , 3rd , 6th month and 1st year after transplant. BMI was calculated before and 1 year after transplantation and acute rejection episodes were recorded too. Methylprednizolone (MP), cyclosporine (CsA) dose /kg BW were calculated at baseline, 1, 3, 6, 12 months after transplant. Cumulative patient and graft survival at 1 and 5 years were calculated too.

RESULTS

Patient survival at 1 and 5 years was 100% / 93.1% and 100% /93.1% respectively (p: NS). Graft survival at 1 and 5 years was 100% / 93.10% and 93.75% / 86.45% respectively (p: NS). BW (but not BMI) and total cholesterol levels in Greek patients were higher compared to those of Albanian patients during the 1st post transplant year (p: 0.044 and p: 0.021 respectively). MP dose in A patients was higher during the first year (p: 0.05).

CONCLUSION

Patients and graft survival do not present difference between G and A patients. There is significant difference on cholesterol profile between G and A patients. A larger number of transplants are possibly needed to allow us to draw firm conclusions.

Liver transplantation outcomes in patients with cirrhosis and hepatocellular carcinoma: experience of a single center in a viral hepatitis endemic area

Our center has performed 205 orthotopic liver transplantations (OLT) in 201 patients. Hepatocellular carcinoma (HCC) was discovered in 32 (15%) patients, 5 of whom were diagnosed incidentally in recipient explants. The main underlying diagnosis was viral hepatitis (n = 28; 87.5%). Most patients (17; 53.1%) were diagnosed as having Child class B cirrhosis. Single tumors measuring <3 cm were diagnosed in 29 (90.6%) patients. Downstaging chemoembolization was performed in 7 (21.8%) patients. Preoperative aFP levels were normal in 20 (62.5%) patients. In the rest (n = 12; 37.5%), aFP levels normalized immediately after the OLT. In the latter group, 2 patients had a delayed (2 years) postoperative increase in aFP levels; both patients had tumor recurrence in the graft. All patients with hepatitis B received antiviral treatment with HBIG and lamivudine. There were 9 deaths (28.1%) in the immediate postoperative period (<30 days). One-year survival rate was 62.5% (n = 20). Actuarial 5-year survival rate was 55%, and actuarial 10-year survival rate was 40%. In conclusion, OLT has become the standard treatment for patients diagnosed with HCC in a population that shows cirrhosis most of the time to be secondary to viral hepatitis, provided that recipients are selected according to the size of the neoplasm and that they receive adequate antiviral prophylaxis.

The administration of cisapride as an adjuvant to PEG-electrolyte solution for colonic cleansing: a double-blind randomized study

BACKGROUND/AIMS

Traditional bowel preparation before colonoscopy involves lavage with approximately 4L of polyethylene glycol (PEG)-electrolyte solution. Only a few studies have been published evaluating the use of cisapride in routine bowel preparation.

METHODOLOGY

We conducted a blinded, placebo-controlled trial with the prokinetic agent, cisapride, in addition to standard PEG-electrolyte lavage. Of 115 patients undergoing colonoscopy, 58 were randomized (double-blind) to PEG plus cisapride (10 mg per os thrice per day three days before the procedure and one 10-mg dose on the morning of the procedure) and 57 to PEG plus a placebo of identical appearance. The adequacy of the preparation was scored on a four-point grading scale for each anatomic-segment and for the overall impression. A questionnaire was also used to assess each patient's symptoms during lavage.

RESULTS

The difference in the overall score between the two groups was not significant (p=0.21). The quality of bowel preparation was significantly better in transverse (p=0.001), ascending (p=0.0053), and cecum (p=0.0001) in the cisapride group than in the placebo group. The differences in symptoms scores between the two groups were not significant in nausea, abdominal cramps and bloating but there was improvement in symptom score of vomiting in cisapride group (p=0.0422).

CONCLUSIONS

The administration of cisapride to patients undergoing colonic lavage may be an effective adjuvant to PEG-electrolyte solution particularly with respect to increase patient acceptability.

Needle-knife papillotomy: a safe and effective technique in experienced hands

BACKGROUND/AIMS

Results from studies evaluating needle-knife papillotomy are conflicting. The aim of this retrospective study was to assess the safety and efficacy of needle-knife papillotomy as a precut procedure to achieve biliary access during ERCP.

METHODOLOGY

During a period of seven years, ERCP was performed 938 times. During this time, needle-knife papillotomy was carried out in 68 patients, with complete follow-up obtained in all patients. The follow-up concentrated on the safety and efficacy of the procedure and short-term complications.

RESULTS

Cannulation of the common bile duct was successful immediately after needle-knife papillotomy in 44 patients (66%), during a second ERCP in 18 patients (26%), and in a third ERCP in 2 patients (3%) achieving a total cannulation rate of 94%. There were no needle-knife papillotomy related deaths. Complications included bleeding in 5 patients (7%), and pancreatitis in 3 patients (4%). All complications were managed conservatively.

CONCLUSIONS

Our experience indicates that needle-knife papillotomy is a versatile, effective and safe technique of gaining biliary access in patients in whom deep cannulation proves impossible and biliary access is considered essential.

The effect of indwelling endoprosthesis on stone size or fragmentation after long-term treatment with biliary stenting for large stones

BACKGROUND

Endoscopic biliary stenting is often used for large or difficult common bile duct (CBD) stones, but the effect of indwelling endoprosthesis on size or fragmentation of stones after long-term treatment with biliary stenting has not been formally established. We compared the stone size or fragmentation of common bile duct stones after a long period of biliary stenting.

METHODS

Endoscopic biliary endoprosthesis was performed for 49 high-risk patients with CBD stones too large or difficult to be extracted by conventional endoscopic means. Bile duct drainage was established in all the patients without complications. Of the patients, 24 died with endoprosthesis in situ all from causes unrelated to biliar disease; 22 underwent a second and three patients a third attempt at stone extraction. The largest stone diameter was >12 mm in all patients.

RESULTS

In 11 of 25 patients (44%) the endoprosthesis allowed resolution of the problem of unextractable common bile duct stones. Four patients showed no existence of stent, and ERCP complete stone clearance from the CBD on programmized appointment after endoprosthesis insertion. Reduced size or fragmentation of stones was obtained in seven patients, and the stones could be removed endoscopically. The remaining 14 patients demonstrated no significant change in the size or fragmentation of their stones, and endoprostheses were replaced.

CONCLUSIONS

These results suggest that endoscopic endoprosthesis for large or difficult CBD stones is an effective method to clear the duct in selected cases, as well as an important definitive treatment in high-risk patients.

Double Dieulafoy-like lesion in the stomach

Dieulafoy's lesion is an uncommon cause of major gastrointestinal bleeding and may be difficult to recognize. It consists of an arteriole that protrudes through a tiny mucosal defect usually within 6 cm of the gastroesophageal junction on the lesser curve of the stomach. Despite widespread awareness of this entity, it remains a diagnostic challenge for gastroenterologists because of its small size and hidden location. Emergency endoscopy is the most effective method of diagnosing the disease. We report a patient, with double Dieulafoy-like lesion, who was successfully treated endoscopically using hemostatic clip application. The characteristics of the Dieulafoy's lesion, its current diagnosis, and its treatment are discussed.

Black esophagus induced by severe vomiting in a healthy young man

Black esophagus is an uncommon entity that has been described only a few times previously. It is defined as a dark pigmentation of the esophagus associated with histologic mucosal necrosis. Most cases have no known etiology, although ischemia, nasogastric tube trauma, infection, gastric outlet obstruction, gastric volvulus, and hypersensitivity to antibiotics have all been suggested as possible causes. Herein we report the case of a young, healthy, athletic man who developed black esophagus due to severe vomiting after alcohol overindulgence and summarize the other published cases to date.

Needle-knife sphincterotomy

Choledochocele, now classified as choledochal cyst type III, is a rare anomaly of the terminal biliary tree causing abdominal pain, pancreatitis, and obstructive cholestasis. Traditionally, the therapy for this malformation has been surgery. Recently, endoscopic therapy has been used alternatively for the treatment of choledochocele mainly in adults. We report two patients with recurrent episodes of acute pancreatitis found to be caused by a large choledochocele; both patients were treated by needle-knife sphincterotomy without complications. They remained asymptomatic at 1 and 2 years' follow-up, respectively. Despite the fact that the risk of bleeding seems to be higher using needle-knife sphincterotomy, when the Choledochocele is large, our experience suggests that needle-knife sphincterotomy can be performed accurately and safely. Further studies are necessary to confirm the safety and effectiveness of needle-knife sphincterotomy in large choledochocles.

Acute recurrent pancreatitis associated with anomalous pancreaticobiliary ductal union and choledochal cyst of mixed type I plus II

Anomalous pancreatobiliary ductal union (APBDU) has a variety of presentations. We report the case of a 72-year-old woman who presented with recurrent episodes of acute pancreatitis that were found to be caused by the presence of an APBDU associated with an unusual choledochal cyst of mixed type I plus II. She underwent endoscopic sphincterotomy and has remained asymptomatic to the present time, 2 years after sphincterotomy. A discussion of the possible etiologies of choledochal cyst and pancreatitis due to APBDU is presented.

Biliary stricture due to neuroma after an innocent blunt abdominal trauma

A traumatic neuroma of the biliary tract is rarely associated with biliary obstruction. However, when it arises in the common bile duct (CBD) and is associated with obstructive jaundice, it is difficult to distinguish it from bile duct cancer. We describe a patient who developed obstructive jaundice and itching, due to CBD stricture, 8 years after innocent blunt abdominal trauma. The stricture was resected and hepatico-jejunal anastomosis was performed. Histological examination revealed a traumatic neuroma and a fibrous scar around the common bile duct. Symptoms disappeared following surgical removal of the lesion. Blunt abdominal injury may cause the late onset of a fibrous scar and traumatic neuroma in the common bile duct. To our knowledge, a traumatic neuroma of the biliary tract after blunt abdominal trauma has not been reported previously. We review the clinical picture of this relatively rare problem, along with its diagnosis, pathogenesis and treatment.

Colopathy associated with the systemic use of nonsteroidal antiinflammatory medications. An underestimated entity

BACKGROUND/AIMS

Adverse effects of NSAIDs (nonsteroidal antiinflammatory drugs) on the upper gastrointestinal tract and small intestine are well described. Evidence is also accumulating that implicate NSAIDs in inducing and exacerbating damage in the distal gastrointestinal tract. In this article we describe eight cases of colonic inflammation associated with nonsteroidal antiinflammatory drug administration; our aim is to stress the importance of an underestimated entity by clinicians.

METHODOLOGY

Over a five-year period at two clinics, eight cases of NSAID-colopathy have been diagnosed. Crohn's disease, ulcerative and infections colitis have been excluded from this analysis. In all these subjects a careful drug history has been taken in a prospective manner and colonic inflammation appeared to be directly related to NSAID administration. There was a time interval (mean: 20 months) between initiation of treatment with NSAID and presentation with diarrhea, rectal hemorrhage and tenesmus.

RESULTS

A correct diagnosis of colopathy associated with NSAIDs administration was made on careful drug history, pathological findings, stool cultures and biochemical changes which were insignificant, in contrast to the protracted troublesome symptoms. Resolution of symptoms was observed on discontinuation of NSAID medication.

CONCLUSIONS

Our report is further evidence that NSAIDs administration is associated with significant mucosal injury in the distal gastrointestinal tract, despite is underestimated by most physicians.

Treatment of proctalgia fugax with botulinum A toxin

Two recent studies described a temporal association between a high-amplitude and high-frequency myoelectrical activity of the anal sphincter and the occurrence of proctalgia, which suggest that paroxysmal hyperkinesis of the anus may cause proctalgia fugax. We describe a single case of proctalgia fugax responding to anal sphincter injection of Clostridium botulinum type A toxin. The presumed aetiology of proctalgia fugax is discussed and the possible mechanism of action of botulinum toxin (BTX) in this condition is outlined. Botulinum A toxin seems to be a promising treatment for patients with proctalgia fugax, and further trials appear to be worthwhile for this condition, which has been described as incurable.

Combined treatment of hypercholesterolemia of renal transplant allograft recipients with fluvastatin and gemfibrozil

The aim of this study was to investigate the safety and efficacy of combined treatment with fluvastatin (F) and gemfibrozil (G) in hypercholesterolemic renal transplant recipients (RTR). Ten hypercholesterolemic (total cholesterol [TC] > 220 mg/dl) RTR (7 men) with mean age 44 years (range 25-56 years) who remained hypercholesterolemic after 3 months of treatment (period A) with fluvastatin (40 mg/d) continued taking the same dose of F plus G (600 mg/dl) for another 3-month period (B). Serum total cholesterol, high density lipoprotein cholesterol (HDL-C), LDL cholesterol (LDL-C), triglyceride, serum creatinine (creatinine phosphokinase (CPK), serum glutamic-oxaloacetic transaminase (SGOT), and serum glutamate pyruvate transaminase (SGPT) were measured before treatment and at the end of periods A and B. Mean TC levels were 360.30 +/- 62.42 mg/dl, 324.10 +/- 100.53 mg/dl, 270.80 +/- 67.77 mg/dl; mean LDL-C levels were 259.33 +/- 71.43 mg/dl, 219.60 +/- 81.31 mg/dl, 189.70 +/- 65.51 mg/dl; mean HDL-C levels were 37.10 +/- 11.68 mg/dl, 39.80 +/- 13.21 mg/dl, 41.00 +/- 12.94 mg/dl; mean triglyceride levels were 354.60 +/- 183.29 mg/dl, 349.30 +/- 242.94 mg/dl, 207.00 +/- 85.35 mg/dl before treatment and at the end of periods A and B, respectively. There was a statistically significant fall of serum TC (P = 0.002), LDL-C (P = 0.016), and triglyceride (P = 0.029) levels at the end of periods A and B. Kidney and liver function did not change. F and G combined treatment is safe and useful in patients who do not respond satisfactorily to monotherapy with F. Gemfibrozil augments the effect of F on TC, LDL-C, and triglyceride levels.

Pulmonary giant cell carcinoma: pathological entity or morphological phenotype?

AIMS

To evaluate the morphological spectrum and clinical significance of giant cell carcinoma and to assess the frequency of tumour giant cell production in a consecutive series of primary (non-giant cell) lung tumours.

METHODS AND RESULTS

Forty-six cases of giant cell carcinoma of the lung were collated from two centres over a 12-year period. Giant cell carcinoma was found to be associated with areas of clear cell carcinoma, spindle cell carcinoma and showed trophoblastic differentiation (syncytiotrophoblastic giant cells and beta-human chorionic gonadotrophin immunopositivity) in 57%, 34% and 26% cases, respectively. 'Pure' giant cell carcinoma was identified in five (11%) cases. Eleven of the tumours contained diastase-resistant periodic acid-Schiff positive material and were separately designated as giant cell adenocarcinomas. Areas of squamous cell and neuroendocrine differentiation (as determined by chromogranin A and Leu-7 immunopositivity) were not found. The median survival for giant cell carcinoma (excluding the giant cell adenocarcinomas) was 18 months. Median survival was not adversely affected by the extent of tumour giant cell formation or by the presence of trophoblastic differentiation. Of 200 consecutive non-small cell lung carcinomas, tumour giant cells constituting < 10% of the tumour were identified in 32% of adenocarcinomas and 26% of squamous cell carcinomas.

CONCLUSIONS

The presence of tumour giant cells in lung carcinoma does not, in itself, indicate a more aggressive tumour type, Giant cell carcinoma of the lung does not appear to be a distinct entity but a morphological phenotype expressed by a heterogenous group of tumours. We support and advocate the use of an encompassing term such as 'pleomorphic' or 'anaplastic' carcinoma for those tumours showing no specific differentiation pattern but which express diverse morphological features such as giant cell formation, clear or spindle cell change.

Management of chemotherapy-related anaemia with low-dose recombinant human erythropoietin in patients with small cell lung cancer

We examined the efficacy of low-dose erythropoietin in the management of chemotherapy-related anaemia in patients with small cell lung cancer (SCLC). We gave recombinant human erythropoietin A (rHuEPO) to 63 SCLC patients, 30 with limited disease (LD) and 33 with extensive disease (ED) who underwent chemotherapy with carboplatin, etoposide and ifosfamide and had previously received blood transfusions for chemotherapy-related anaemia. rHuEPO was given at a dose of 2000 IU subcutaneously three times per week for 2 weeks after every chemotherapy cycle, starting 48 h after the end of chemotherapy. Before the use of rHuEPO, all patients in both groups had to be transfused after a mean of 5.5 CT cycles. In 64 CT cycles following administration of rHuEPO, only 5/30 LD patients (17%) had to be transfused in six cycles (9%). In 88 cycles following the use of rHuEPO, 7/33 ED patients (21%) had to be transfused in 11 cycles (12.5%). Haemoglobin values in patients with ED (but not those with LD) were significantly improved after rHuEPO administration on both day 14 and day 28 after chemotherapy. No adverse effects were recorded. rHuEPO considerably decreased the degree of anaemia and the need for blood transfusion at doses markedly lower (25-30 IU/kg body weight) than those reported in the literature so far (150 IU/kg body weight), without toxicity.

Interferon alpha-2a and combined chemotherapy as first line treatment in SCLC patients: a randomized trial

BACKGROUND

Interferons (IFNs) are known to act synergistically with antineoplastic agents when applied to SCLC cell cultures. This study was conducted in order to detect the clinical benefits, if any, of the addition of IFN-alpha in the induction chemotherapy (CT) of SCLC patients.

PATIENTS AND METHODS

Ninety previously untreated patients with SCLC were randomly assigned to receive either CT alone (arm A) or CT plus IFN alpha-2a in a dose of 3 MU/m2 twice weekly (arm B). CT for both arms consisted of carboplatin 420 mg/m2, etoposide 200 mg/m2 and ifosfamide 3.5 g/m2 or epirubicin 80 mg/m2 every 28 days for a total of eight cycles. Responding patients received primary site and prophylactic cranial irradiation and then had maintenance CT with cyclophosphamide 100 mg/m2/day for 20 days every month. Patients in arm B received IFN throughout these treatments.

RESULTS

Eighty-one patients were evaluable for response, 39 in arm A and 42 in arm B. Both arms were comparable in terms of age, performance status and extent of disease. Overall response rates were not significantly different between the two arms (90% vs. 86%), although complete response rate was higher in arm B (38% vs. 28%). More importantly, Kaplan-Meier analysis disclosed a clear survival benefit in the arm receiving IFN-alpha (P < 0.05). For limited disease the difference was even more significant (P < 0.0067), while for extensive disease no significant difference was found (P < 0.35). Fever, fatigue and anorexia were more frequent in arm B (P < 0.001), as also leukopenia (P < 0.01).

CONCLUSION

The addition of IFN-alpha to induction CT appears to confer a survival benefit to SCLC patients but optimal dosing schedule has yet to be defined.

Patient satisfaction with information provided at an outpatient clinic for respiratory diseases

A survey of 374 unselected patients attending the Respiratory Outpatient Department of a teaching hospital revealed that most patients reported receiving information about the treatment of their disease, but only one-quarter received information about its prognosis. Patients reported receiving satisfactory answers to their requests for information on most occasions, and the overall satisfaction rate with information offered was 88.3%. Patients who had attended the clinic on five or more occasions felt that they had received more information on all items compared with those with fewer than five visits, although the increase was statistically significant only for information on treatment. Patients over 75 years of age generally reported less information than younger patients. The great majority (88.4%) of patients preferred verbal information, but 23% also expressed a desire for written information as well. More attention should be paid to the needs of the elderly and to education about the nature and prognosis of disease. Printed material should also be more widely used.

Immunoglobulin deficiency and recurrent postmenopausal endometritis

Secretory immunoglobulin A is the principal immunoglobulin of mucosal surfaces and may be reduced in postmenopausal women because of estrogen deficiency. This can manifest as recurrent infections and may be a cause of undiagnosed postmenopausal bleeding. Regular serum immunoglobulin therapy is appropriate for these patients.

Pulmonary embolism and lupus anticoagulant in a woman with renal cell carcinoma

We report on a woman in whom pulmonary embolism and positive lupus anticoagulant occurred 9 months before the diagnosis of renal cell carcinoma. To our knowledge this association has been described previously with other malignant neoplasms but not with a renal tumor, and it may represent an autoimmune paraneoplastic event.