RESUMEN
Combined modality treatment for esophageal carcinoma seems to improve survival over surgery alone. Different combinations of cytotoxic drugs have been studied to improve antitumor efficacy and limit the toxicity of chemoradiotherapy (CRT) with inconsistent results. We present a prospective study of neoadjuvant CRT with or without paclitaxel in chemotherapy schedule. One hundred seven patients (93 males, 14 females), median age 59 years (range 44-76), with operable esophageal cancer were enrolled. They received the following neoadjuvant therapy: Carboplatin, area under curve (AUC) = 6, intravenously on days 1 and 22, 5-fluorouracil (5-FU), 200 mg/m(2)/day, continuous infusion on days 1 to 42, radiation therapy 45 grays/25fractions/5 weeks beginning on day 1. Forty-four patients (41%) were furthermore non-randomly assigned to paclitaxel 200 mg/m(2)/3 h intravenously on days 1 and 22. Nutritional support from the beginning of the treatment was offered to all patients. Surgery was done within 4-8 weeks after completion of CRT, if feasible. All patients were evaluated for grade 3 plus 4 toxicities: leukopenia (28%), neutropenia (30%), anemia (6%), thrombocytopenia (31%), febrile neutropenia (6%), esophagitis (24%), nausea and vomiting (7%), pneumotoxicity (8%). Seventy-eight patients (73%) had surgery and 63 of them were completely resected. Twenty-two patients (20%) achieved pathological complete remission, and additional 20 (19%) had node-negative and esophageal wall-positive residual disease. There were 10 surgery-related deaths, mostly due to pulmonary insufficiency. Twenty-nine patients were not resected, 15 for early progression, 14 for medical reasons or patient refusal. After a median follow-up of 52 months (range 27-80), median survival of 18.0 months and 1-, 2-, 3- and 5-year survival of 56.7, 37.5, 27.0 and 21% was observed in the whole group of 107 patients. Addition of paclitaxel to carboplatin and continual infusion of FU significantly increased hematologic and non-hematologic toxicity, but treatment results as overall survival or time to progression did not differ significantly in groups with and without paclitaxel. Patients achieving pathological complete remission or nodes negativity after neoadjuvant therapy had favorable survival prognosis, whereas long-term prognosis of node positive patients was poor. Distant metastases prevailed as a cause of the treatment failure. Factors significant for survival prognosis in multivariate analysis were postoperative node negativity, performance status, and grade of dysphagia. Addition of paclitaxel to carboplatin and continual FU significantly increased hematologic and non-hematologic toxicity without influencing efficacy of the treatment. This study confirmed improved prognosis of patients after achieving negativity of nodes. Distant metastases prevailed as cause of the treatment failure. Prospectively, it is important to look for a therapeutic combination with better systemic effect.
Asunto(s)
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Carboplatino/administración & dosificación , Neoplasias Esofágicas/cirugía , Fluorouracilo/administración & dosificación , Terapia Neoadyuvante , Paclitaxel/administración & dosificación , Adulto , Anciano , Antimetabolitos Antineoplásicos/administración & dosificación , Antineoplásicos/administración & dosificación , Antineoplásicos Fitogénicos/administración & dosificación , Carcinoma de Células Escamosas/tratamiento farmacológico , Carcinoma de Células Escamosas/radioterapia , Carcinoma de Células Escamosas/cirugía , Quimioterapia Adyuvante , Fraccionamiento de la Dosis de Radiación , Neoplasias Esofágicas/tratamiento farmacológico , Neoplasias Esofágicas/radioterapia , Esofagitis/etiología , Femenino , Estudios de Seguimiento , Humanos , Leucopenia/etiología , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Neutropenia/etiología , Estudios Prospectivos , Radioterapia Adyuvante , Inducción de Remisión , Tasa de Supervivencia , Trombocitopenia/etiología , Resultado del TratamientoRESUMEN
AIM: Metabolic acidosis is a regular sign of renal insufficiency. Conventional assessment of acid-base balance using Henderson-Hasselbalch equation does not make identification of the cause of metabolic disorders possible as the serum HCO3- concentration might only reflect changes to the overall plasma ion spectrum. Therefore, we used the Stewart-Fencl approach that is based on a more detailed physical and chemical analysis and that showed that changes to serum HCO3- concentration are closely related to parameters not usually monitored in connection to acid-base balance. PATIENT GROUP AND METHODOLOGY: We performed a single measurement of arterial or capillary blood pH and pCO2 in 69 non-dialysed patients with glomerular filtration rate ranging from 0.04 to 0.88 ml/s/1.73 m2 according to MDRD, standard calculation of serum HCO3- concentration using Henderson-Hasselbalch equation was carried out, and serum albumin and ion concentrations (Na+, K+, Cl, Pi) plus creatinine and urea concentrations were determined from venous blood. RESULTS: Metabolic acidosis was present in 47 patients ([S-HCO3-] < 22 mmol/l) with the mean [S-HCO3-] value of 19.6 mmol/l for the entire group. We proved a statistically significant correlation between [S-HCO3-] and [SID] (p < 0.001), and between [S-HCO3-] and the individual [SID] determining factors: [Na+-Cl-], [UA- ], [Pi-], [K+] (p < 0.01). CONCLUSION: Reduction in [S-HCO3-] in non-dialysed patients with reduced glomerular filtration is predominantly associated with a decrease in [Na+-Cl-] difference, the quantitative contribution of which to metabolic acidosis is more significant than the strong acids retention. In addition to [S-Cl-] increase, [S-Na+] reduction too has a major role in reducing the [Na+-Cl-] difference.
Asunto(s)
Acidosis/metabolismo , Tasa de Filtración Glomerular , Insuficiencia Renal/metabolismo , Equilibrio Ácido-Base , Adulto , Anciano , Anciano de 80 o más Años , Bicarbonatos/sangre , Femenino , Humanos , Concentración de Iones de Hidrógeno , Masculino , Persona de Mediana Edad , Insuficiencia Renal/complicaciones , Insuficiencia Renal/fisiopatología , Albúmina Sérica/análisis , Adulto JovenRESUMEN
The work is aimed at the occurrence of secondary malignancies after therapy for primary testicular tumors. The target of the work was determination of the number and type of secondary tumors, their effect on the survival and comparison of relative risk of the origination of secondary tumors depending on particular treatment modalities. Total of 313 patients with testicular tumors were assessed, who experienced orchiectomy in 1968 to 1998 with subsequent irradiation, chemotherapy or combination of the two modalities. Total of 22 secondary tumors, i.e. 7%, were found in the group. The relative risk of the secondary malignancy development was of 1.04. The median time till the secondary tumor occurrence was of 143 months. Total of 213 patients were subjected to radiotherapy, which was associated with enhanced risk of the secondary tumor development (RR = 8.38); the risk in 100 patients treated by chemotherapy was lower (RR = 0.38). The relative risk of the origination of the secondary malignancy located in the region of preceding irradiation is low (RR = 0.52). In the case of the occurrence of secondary malignancies, the median symptomless survival and the total survival decreased from 271 months to 187.3 and 199.8 months, respectively. Most patients with testicular tumors have favourable long-term prognosis and thus, it is desirable to know the risk of secondary malignancies and to include it into plan of long-term subsequent follow-up.
Asunto(s)
Neoplasias Primarias Secundarias/epidemiología , Neoplasias Primarias Secundarias/etiología , Neoplasias Testiculares/complicaciones , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Antineoplásicos/efectos adversos , Niño , Terapia Combinada , Humanos , Masculino , Persona de Mediana Edad , Neoplasias Primarias Secundarias/mortalidad , Orquiectomía , Radioterapia , Análisis de Supervivencia , Neoplasias Testiculares/terapiaRESUMEN
Acute hemorrhage from esophageal varices due to portal hypertension is a frequent and serious complication of liver cirrhosis. Bacterial infection may be one of the factors influencing such hemorrhage. Endotoxins may increase portal tension and at the same time result in primary hemostasis disorder, thus becoming one of the causes of hemorrhage. The authors of the paper compared the incidence of bacterial infection in 53 patients with varicose hemorrhage due to portal hypertension with 62 patients with liver cirrhosis and portal hypertension without varicose hemorrhage. At least one pathogen was found in considerable 61.1% of the total of patients in the liver cirrhosis group, while the difference between the two groups was but insignificant. No statistically significant difference was found between the group of patients with hemorrhage and those without hemorrhage in terms of presence of bacterial infection in hemoculture, urine, throat, faeces and ascites, nor was there a difference in the etiology of the G+ bacteria, G- bacteria or fungi and yeast infectious agents in the hemoculture, urine, throat, faeces and ascites in either of the groups. No statistically significant difference was found in comparing the patients with a recurrence of hemorrhage (or with mortality) and with infection with those without recurrence of hemorrhage. Bacterial infection was more often found in patients with a recurrence of hemorrhage (75%) as compared with those without any recurrence (52%), and also in patients who died bacterial infection was proven more often than in those who survived (61.9% vs. 58.1%, respectively). There was no difference in morbidity or recurrence of hemorrhage between the patients treated with norfloxacin and ampicilin/sulbactam. No statistically significant difference was recorded between the 1st and 5th day in terms of decrease in bacterial infection. A significant difference was found in the urine etiological agent, where a significant increase in the share of fungal and yeast urine infection (p = 0.011) was recorded after the application of the therapy, as well as a drop in urine infection caused by the G- bacterial agent (p = 0.057).
Asunto(s)
Infecciones Bacterianas/complicaciones , Várices Esofágicas y Gástricas/microbiología , Hemorragia Gastrointestinal/microbiología , Femenino , Humanos , Hipertensión Portal/microbiología , Cirrosis Hepática/microbiología , Masculino , Persona de Mediana EdadRESUMEN
Contrast media-induced nephropathy (CMIN) is accompanied by high morbidity, lengthy hospitalization, and a higher mortality rate. In proportion to the rising number of diagnostic and interventional radiological procedures, the prevalence of this complication is also rising The study briefly tackles the currently known pathophysiological mechanisms that lead to CMIN and deals with various risk factors which increase the probability of development of contrast nephropathy. Among these factors are, in the first place, diabetes mellitus, a pre-existing renal illness and hypertension. In addition, the risk of developing CMIN significantly increases in patients on risky medication. In our study, this medication was a combination of ACE-inhibitors (ACEI) and furosemide. Even though none of the patients met the criteria defined for CMIN, radiocontrast examination showed a significant statistical decline in glomerular filtration (GFR) and a rise in proteinuria (PU) in the sub-group which used this combination of medication. The risk level of this medication especially in patients with pre-existing nephropathy is also underlined by the suggested dependency of the relative rise in the serum levels of creatinine in terms of its input value. It is necessary, as early as the radiocontrast examination is being done, to bare in mind the possibility of CMIN occurring and avoid it also through the modification of the risk factors which can be influenced, e.g. elimination of risky medication and in indicated cases, taking preventive measures.