RESUMO

Patients with unresectable metastatic colorectal cancer live for a median of three years when treated with standard therapies. While the evidence guiding cancer-directed treatment of this disease comes from phase III trials that have mostly enrolled patients with good performance status, some patients present with poor clinical conditions. The best treatment for these patients remains to be determined. We performed a systematic review of the treatment outcomes of patients with metastatic colorectal cancer and poor performance status, defined as Eastern Cooperative Oncology Group performance status ≥2. Eligible articles were prospective or retrospective studies or case reports published in English, Portuguese or Spanish. We searched PubMed, EMBASE, LILACS and the Cochrane Library from onset until October 2017 using specific keywords for each search. We found a total of 18 publications, mostly case reports and retrospective studies (14 articles). One was an uncontrolled prospective trial, two were observational studies and one was an individual patient meta-analysis. Although some studies suggested benefits in terms of symptomatic response with standard chemotherapy, with good safety profiles when dose-reduced regimens were administered, a true survival gain could not be demonstrated. The scientific evidence for treating metastatic colorectal cancer patients with poor performance status is scarce, and more studies evaluating treatment for this population are necessary since this condition is not uncommon in clinical practice, particularly in the public healthcare system and developing countries and among destitute populations.

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PURPOSE: Although patients with incurable disease and Eastern Cooperative Oncology Group performance status (ECOG-PS ≥ 2) are underrepresented in clinical trials, they are frequently offered palliative chemotherapy (pCT) in daily clinical practice in order to improve symptoms and quality of life. In this case-control retrospective analysis, our goal was to identify factors associated with poorer survival and lack of benefit of pCT in this population. PATIENTS AND METHODS: We evaluated 2,514 patients who died between August 2011 and July 2012 in an academic cancer care institution and its hospice. A total of 301 patients with solid tumours and ECOG-PS ≥ 2 at prescription of pCT were selected for this case-control retrospective analysis. Cases were defined as patients who survived less than 90 days after the first cycle of first line pCT, and controls were those who had a longer survival. RESULTS: 142 cases and 159 controls were included. Cases were more likely to experience grade ≥ 3 toxicity (43% versus 28%; p = 0.005), die of toxicity (16% versus 6%; p < 0.001) and not be offered best supportive care (BSC) only (47% versus 71%; p < 0.001). Median overall survival was 204 among controls and 34 days in cases (hazard ratio = 0.177; 95%, confidence interval = 0.015-0.033, p < 0.001). Logistic regression analysis identified ECOG-PS > 2 (odds ratio (OR) = 2.3, p = 0.044) and serum creatinine (sCr) > 1 mg/dL (OR = 11.2, p < 0.001) as independent predictors of 90-day mortality. CONCLUSIONS: The independent predictors of short survival (less than 3 months) after initiation of pCT in this population were ECOG-PS > 2 and elevated sCr. Therefore, patient selection is crucial, as pCT may be deleterious in ECOG-PS ≥ 2 pts.

RESUMO

Patients with unresectable metastatic colorectal cancer live for a median of three years when treated with standard therapies. While the evidence guiding cancer-directed treatment of this disease comes from phase III trials that have mostly enrolled patients with good performance status, some patients present with poor clinical conditions. The best treatment for these patients remains to be determined. We performed a systematic review of the treatment outcomes of patients with metastatic colorectal cancer and poor performance status, defined as Eastern Cooperative Oncology Group performance status ≥2. Eligible articles were prospective or retrospective studies or case reports published in English, Portuguese or Spanish. We searched PubMed, EMBASE, LILACS and the Cochrane Library from onset until October 2017 using specific keywords for each search. We found a total of 18 publications, mostly case reports and retrospective studies (14 articles). One was an uncontrolled prospective trial, two were observational studies and one was an individual patient meta-analysis. Although some studies suggested benefits in terms of symptomatic response with standard chemotherapy, with good safety profiles when dose-reduced regimens were administered, a true survival gain could not be demonstrated. The scientific evidence for treating metastatic colorectal cancer patients with poor performance status is scarce, and more studies evaluating treatment for this population are necessary since this condition is not uncommon in clinical practice, particularly in the public healthcare system and developing countries and among destitute populations.

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Treatment of adult osteosarcoma (AOS) includes perioperative chemotherapy and surgery. Standard chemotherapy consists of cisplatin (CP) and doxorubicin (DOX). Although considered the standard of care for pediatric patients, high-dose methotrexate (HDM) remains controversial in adults. We aimed to evaluate the role of HDM in AOS treated with curative intent. This study included patients with AOS who received perioperative chemotherapy with DOX and CP (group 1; N=16) and DOX, CP, and HDM (group 2; N=10). The primary endpoint was grade 3 or superior toxicities. The secondary endpoints included overall survival (OS) and disease-free survival. Despite lower average age (35.0±12.1 vs. 18.9±2.1 years), group 2 presented more grade 3-4 thrombocytopenia (0 vs 50%) and mucositis (0 vs 40%), whereas group 1 presented more grade 3-4 neutropenia (43.75 vs 40%). No grade 3-4 renal toxicities occurred. Two grade 5 toxicities occurred in group 2, both after the first HDM cycle. Disease-free survival (4.38±0.61 vs. 2.3±0.54 years, P=0.228) and OS (4.70±0.56 vs 2.52±0.57 years, P=0.107) were not statistically different, but presented a trend toward better outcomes in group 1. The 4-year OS was 65.6 and 32.8% for groups 1 and 2, respectively. In conclusion, HDM was associated with greater severe and lethal toxicity when added to CP and DOX in AOS. Also, it does not seem to impact on treatment efficacy. These data do not support the use of HDM for the perioperative treatment of AOS.

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Esta revisão é dedicada às principais questões relativas às alterações do segmento ST durante o infarto agudo do miocárdio (IAM), que podem ser estimadas a partir de eletrocardiograma (ECG). São discutidos o diagnóstico, o prognóstico, o tratamento e as desvantagens associadas a esta metodologia. Por fim, as principais avaliações quantitativas do IAM com base nas modificações do ECG são comparadas e discutidas no contexto dos sistemas de telemedicina.

This review focuses on the major issues regarding ST segment abnormalities during acute myocardial infarction (AMI), which may be estimated from electrocardiogram (ECG) tests. Diagnosis, prognosis, treatment and the drawbacks associated to this methodology are discussed. Finally, the major AMI quantitative assessments based on ECG deviations are compared and discussed in the context of telemedicine systems.

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Teratomas are the most commonly diagnosed germ cell tumors and occur primarily in testes and ovaries. Platinum-based therapy followed by surgical resection of the residual lesion is generally the recommended treatment. In contrast, immature uterine teratomas are rare, with few cases reported in the literature. Moreover, there is no standard treatment for these tumors. Non-puerperal uterine inversion is also rare in women younger than 45 years of age, and neoplastic lesions are responsible for this condition. Here, we report a case of an immature uterine teratoma associated with uterine inversion. The patient underwent surgery followed by adjuvant chemotherapy and continues to be monitored.

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OBJECTIVE: Evaluate correlations between variations in eletrocardiogram (ECG) recordings and acute myocardial infarction. METHODS: Use of a low-cost software to digitalize printed and/or ".pdf" file format ECG recordings. Calculation of ST-segment area and amplitudes of the J and Y points. RESULTS: The amplitude of the Y point holds maximum correlation with troponin concentration. ST-segment elevation is not a good statistical indicator of myocardial infarction severity. There is a strong negative correlation between the amplitude of the J point and the amount of magnesium ions, but no statistical correlation with sodium or calcium ions. Neither method for calculating the ST-segment area (pixel counts and interpolation) indicated any significant differences in the results. CONCLUSION: The software used proved to be functional and cost-effective. Y point amplitude is a sensitive marker of myocardial infarction, and is also a calculation method both simpler to use and less subject to error than the calculation of the ST-segment elevation area.

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OBJETIVO: Avaliar correlações entre as variações do eletrocar¡diograma (ECG) e o infarto agudo do miocárdio. MÉTODOS: Uso de software de baixo custo para digitalização de ECG impressos e/ou em formato "pdf". Cálculo de área do segmento ST e das amplitudes dos pontos J e Y RESULTADOS: A amplitude do ponto Y possui máxima correlação com a concentração da enzima troponina. O supradesnivelamento do segmento ST não se constitui bom indicador estatístico da gravidade do infarto. Existe uma forte correlação negativa entre a amplitude do ponto J e a quantidade de íons magnésio, mas nenhuma correlação estatística com os íons sódio ou cálcio. Os dois métodos de cálculo da área do segmento ST (contagem de pixels e interpolação) não mostraram diferenças significativas nos resultados. CONCLUSÃO: O software utilizado mostrou-se viável do ponto de vista econômico e funcional. A amplitude do ponto Y é um marcador sensível à ocorrência do infarto, tendo cálculo mais simples e menos sujeito a erros do que o cálculo da área de supradesnivelamento do segmento ST.

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