RESUMEN
Transitional cell carcinoma of the bladder (TCC) represents nearly 90% of genitourinary malignancies and typically presents with locally invasive symptoms. Metastasis to the central nervous system (CNS) is uncommon occurring in <5% of patients. When present, metastatic lesions are typically solid, isolated and located in the cerebrum. We report a case of a patient with a history of TCC who presented with lethargy and ataxia and was found to have a solitary cystic cerebellar lesion consistent with metastatic disease. Unfortunately, the prognosis for patients with TCC and CNS metastases is poor. Treatment options include debulking surgery, whole brain radiation, stereotactic radiosurgery and chemotherapy. Unfortunately, treatment may not appreciably extend survival and care is often supportive in previously reported cases. Though uncommon, TCC can metastasise to the CNS and should be considered in the differential diagnosis of patients, particularly those who were treated with aggressive surgery or combination chemotherapy previously.
Asunto(s)
Carcinoma de Células Transicionales , Neoplasias Cerebelosas/secundario , Neoplasias de la Vejiga Urinaria , Anciano , Ataxia Cerebelosa/etiología , Neoplasias Cerebelosas/diagnóstico , Diagnóstico Diferencial , Resultado Fatal , Humanos , Letargia/etiología , Imagen por Resonancia Magnética , MasculinoRESUMEN
OBJECTIVES: To evaluate end-of-life care in a cohort of oncology patients in Olmsted County, Minnesota, USA, and compare differences between patients participating in clinical trials and those not in clinical trials. METHODS: A population-based cohort of subjects with active oncological disease who died between 2000 and 2002 was constructed retrospectively using institutional databases. Clinical trial participation and care during the last 2 months of life were analysed. RESULTS: A total of 395 eligible patients were identified. In the 2 months prior to death, 94 (24%) patients received chemotherapy, 232 (59%) were hospitalised, 249 (63%) were in hospice and 315 (80%) had a do not resuscitate (DNR) code status. Only 8 (2%) patients received cardiopulmonary resuscitation (CPR) and 26 (7%) patients participated in a clinical trial. Patients in clinical trials were more likely to receive chemotherapy (69.2% vs 20.6%; p<0.001), undergo intubation/mechanical ventilation (15.4% vs 5.4%; p=0.040) and less likely to have DNR code status (50.0% vs 81.8%; p<0.001) when compared with patients not in clinical trials. However, no differences in hospice enrolment, days in hospice, days in the hospital, CPR or location of death were noted. CONCLUSIONS: Although opportunities for improvement exist, high quality end-of-life care was found in this study of patients with active malignancy. A majority (over 60%) of patients enrolled in hospice prior to death, 80% had a DNR status and only 2% received CPR. Although clinical trial participants received more aggressive treatments during the last 2 months of life, they did not appear to have lower quality end-of-life care.
Asunto(s)
Ensayos Clínicos como Asunto/estadística & datos numéricos , Neoplasias/terapia , Cuidados Paliativos/estadística & datos numéricos , Nivel de Atención/estadística & datos numéricos , Cuidado Terminal/estadística & datos numéricos , Anciano , Reanimación Cardiopulmonar/estadística & datos numéricos , Estudios de Cohortes , Femenino , Cuidados Paliativos al Final de la Vida/normas , Cuidados Paliativos al Final de la Vida/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Humanos , Intubación Intratraqueal/estadística & datos numéricos , Tiempo de Internación , Masculino , Minnesota , Neoplasias/tratamiento farmacológico , Cuidados Paliativos/normas , Respiración Artificial/estadística & datos numéricos , Órdenes de Resucitación , Estudios Retrospectivos , Nivel de Atención/normas , Cuidado Terminal/normasRESUMEN
INTRODUCTION: Pulmonary arterial hypertension (PAH) is a progressive and ultimately fatal disease of the pulmonary circulation. There has never been an investigation of the end-of-life symptoms in patients with PAH. In this investigation, we surveyed surrogates of recent decedents with PAH. We evaluate their responses to better understand the end-of-life experience of patients with PAH. METHODS: The survey instrument includes demographic information and the Edmonton Symptoms Assessment Scale. Accredo Therapeutics mailed the survey to surrogates of recent decedents with PAH, and responses were anonymously returned to investigators at Virginia Commonwealth University and used in our descriptive analysis. RESULTS: Of 100 surveys distributed over 24 months (February 2009 to February 2011), we obtained 36 responses (response rate 36%). We found that most patient deaths (90%) were related to PAH, that the majority of patients died in the hospital (67%), with the majority of in-hospital deaths (83%) occurring in intensive care. Palliative care was infrequently involved in patients' care, and many surrogates were unaware of palliative care and hospice services available to the decedents. Patients died with a high symptom burden, especially dyspnea. CONCLUSION: In this cohort, patients with PAH usually died from their disease, often in the hospital setting with a high symptom burden. Further study will be needed to confirm the findings from this study and to better understand the forces leading to the trends uncovered in this investigation.