Successful surgical management of an extrahepatic biliary cystadenocarcinoma.

Extrahepatic bile duct cancer is an uncommon disease, and few cases are curable by surgery. We report a case of extrahepatic biliary cystadenocarcinoma (BCAC) associated with atrophy of the left hepatic lobe. A 54-year old male was admitted with painless obstructive jaundice and a hepatic palpable mass noticed one month before presentation. Liver functions tests were consistent with cholestatic damage and serum carbohydrate antigen 19.9 (CA 19-9) was increased before treatment. Magnetic resonance imaging (MRI) disclosed dilatation of the left hepatic bile duct with irregular wall thickening close to the hepatic confluence, and atrophy of left hepatic lobe. The patient was submitted to en bloc extended left hepatectomy with resection of caudate lobe, hilar lymphadenectomy, and suprapancreatic biliary tree resection. All surgical margins were grossly negative, and postoperative course was uneventful, except for a minor bile leak. The patient was discharged on the 15th postoperative day; he is alive without tumor recurrence one year after primary therapy. Although technically challenging, extended en bloc resection is feasible in adults with extrahepatic BCAC and can improve survival with acceptable and manageable morbidity.

Prognostic relevance of TTF-1 and MMP-9 expression in advanced lung adenocarcinoma.

BACKGROUND: The thyroid transcription factor-1 (TTF-1) is a tissue-specific transcription factor that could play an important role in cell differentiation and morphogenesis of lung tumors. Matrix metalloproteinase-9 (MMP-9) is a protease commonly expressed in non-small cell lung cancer, conferring angiogenic and metastatic potential. METHODS: We assessed TTF-1 and MMP-9 tumor expression by immunohistochemistry in 51 patients with lung adenocarcinoma, stage IIIB or IV, treated with platinum regimens. A bicategorical prognostic model was obtained using the Kaplan-Meier method, Cox regression, and conjunctive consolidation. RESULTS: The median expression of TTF-1 was 30.0% (range: 0-85.9%). All tumors expressed MMP-9 (median: 78.7%; range: 15.2-96.1%). Median survival was 41.6 weeks, with estimated 1- and 2-year survival rates of 45.0% and 22.0%, respectively. Poor performance status (Karnofsky scale) - hazards ratio (HR): 1.03, 95% confidence interval (CI): 1.01-1.06; low TTF-1 expression (<40%) - HR: 4.00, 95% CI: 1.75-9.09; and high MMP-9 expression (> or =80%) - HR: 2.82, 95% CI: 1.30-6.08 were independent prognostic factors. Patients could be stratified in three death risk groups according to markers expression: low risk (high TTF-1 and low MMP-9; median survival: 127.6 weeks), intermediate risk (low TTF-1 or high MMP-9; median survival: 39.0 weeks); and high risk (low TTF-1 and high MMP-9; median survival: 16.4 weeks). CONCLUSION: TTF-1 and MMP-9 tumor expression as detected by immunohistochemistry may allow identification of different, clinically meaningful, prognostic groups of advanced lung adenocarcinoma patients treated with platinum regimens.

Caracterização dos protocolos de terapia antineoplásica na rede de assistência ambulatorial para servidores do estado da Bahia, Brasil / Characterization of antineoplastic therapy protocols im ambulatory care facilities for public servants in the state of Bahia, Brazil

Este artigo descreve o perfil da terapia antineoplásica adotado na rede de prestadores de serviços credenciados pelo órgão do Estado da Bahia, responsável por prover assistência médica suplementar aos servidores públicos associados. Foram analisadas as terapias antineoplásicas em curso entre setembro de 2004 e maio de 2005, procurando conhecer o perfil da clientela e a consistência técnica dos tratamentos prescritos. No período, havia 833 beneficiários em tratamento oncológico, em nove serviços credenciados. A maioria da clientela era constituída por mulheres (65,5por cento) e residentes em Salvador (68,1por cento). Câncer de mama nas mulheres e câncer de próstata foram os principais tipos de câncer encontrados. Comparado às mulheres, o diagnóstico do câncer entre homens deu-se em idades e estágios clínicos mais avançados. Os especialistas credenciados adotavam, preferencialmente, condutas terapêuticas embasadas em evidências científicas. Os autores discutem as implicações de protocolos assistenciais para o controle de custos com terapia antineoplásica.

Inflammatory pseudotumor: A diagnostic dilemma.

Inflammatory pseudotumor (IP) is a disorder that constitutes a differential diagnosis of a series of clinical conditions due to a large spectrum of manifestations in presentation since it can involve any organ of the human body. Its basic characteristic is the appearance of inflammatory masses whose symptoms depend on their location. We describe two cases of IP that clearly illustrate this diversity of presentation and we review the diagnostic and therapeutic strategies for such a condition.

Lung cancer symptoms and pulse oximetry in the prognostic assessment of patients with lung cancer.

BACKGROUND: Medical oncologists continue to use performance status as a proxy for quality of life (QOL) measures, as completion of QOL instruments is perceived as time consuming, may measure aspects of QOL not affected by cancer therapy, and interpretation may be unclear. The pulse oximeter is widely used in clinical practice to predict cardiopulmonary morbidity after lung resection in cancer patients, but little is known on its role outside the surgical setting. We evaluated whether the Lung Cancer Symptom Scale and pulse oximetry may contribute to the evaluation of lung cancer patients who received standard anticancer therapy. METHODS: We enrolled forty-one consecutive, newly diagnosed, patients with locally advanced or metastatic lung cancer in this study. We developed a survival model with the variables gender, age, histology, clinical stage, Karnofsky performance status, wasting, LCSS symptom scores, average symptom burden index, and pulse oximetry (SpO2). RESULTS: Patient and observer-rated scores were correlated, except for the fatigue subscale. The median SpO2 was 95% (range: 86 to 98), was unrelated to symptom scores, and was weakly correlated with observer cough scores. In a multivariate survival model, SpO2 > 90% and patient scores on the LCSS appetite and fatigue subscales were independent predictors of survival. CONCLUSION: LCSS fatigue and appetite rating, and pulse oximetry should be studied further as prognostic factors in lung cancer patients.

Chemotherapy with cisplatin and vinorelbine for elderly patients with locally advanced or metastatic non-small-cell lung cancer (NSCLC).

BACKGROUND: Although modest improvements in the survival of patients with non-small cell lung cancer (NSCLC) can be achieved with cisplatin-based chemotherapy (CT), its value is disputed in the geriatric setting. In this study, we evaluate the feasibility of vinorelbine/cisplatin CT for elderly NSCLC patients. METHODS: In this pilot phase I/II trial, all patients received CT with vinorelbine 25 mg/m2, on day 1 and 8, and cisplatin on day 1, in 28 days-cycles. After stratification for age (up to 75 years), younger patients were sequentially allocated to moderate cisplatin doses (80 mg/m2 or 90 mg/m2), and older patients were allocated to lower cisplatin doses (60 mg/m2 or 70 mg/m2). We recruited patients aged over 70 years with newly diagnosed NSCLC, clinical stage III or IV, Karnofsky performance status >or= 70%, normal serum creatinine, peripheral neuropathy

Pilot trial of concomitant chemotherapy with paclitaxel and split-course radiotherapy for very advanced squamous cell carcinoma of head and neck.

PURPOSE: The combination of chemotherapy and irradiation is considered the standard of care for the treatment of advanced squamous cell carcinoma of head and neck (SCCHN). Paclitaxel has shown a single-agent activity in SCCHN. Besides, this drug is a promising radiosensitizer for some human solid tumors. This is a phase II trial to evaluate the feasibility, efficacy, and toxicity of paclitaxel administered concurrently with split-course radiotherapy in advanced unresectable SCCHN. Methods and Materials Thirty-one patients with advanced SCCHN were enrolled in this trial. Radiotherapy consisted of 66 to 70 Gy delivered over 8 to 10 weeks to the primary tumor and lymphatic drainage, with a fractionation scheme of 1.8 to 2 Gy/field/d. After the initial five patients were treated, a 1-week treatment break was introduced. Paclitaxel was administered weekly in a 1-hour intravenous infusion at a projected dosage of 45 mg/m(2)/wk. RESULTS: The complete and partial response rates, based on a 4-week postradiation evaluation were 43.3% and 40%, respectively, with an overall response rate of 83.3%. Median survival was 49.4 weeks, and 1-year survival was 48%. Freedom from local progression was 65.6% at 1 year. Thirty-six percent and 20% of the patients are alive and disease free at 1 and 2 years, respectively. Grade 3/4 of acute toxicity consisted mostly of mucositis, cutaneous reaction, and weight loss. CONCLUSIONS: Paclitaxel concurrent with radiotherapy seems to be active in squamous cell carcinoma of the head and neck. In the regimen selected for this trial, toxicity was significant and led to a prolongation of treatment time.

Factores de riesgo de mortalidad en personas mayores de 65 años internadas en un hospital universitario, Sao Paulo, Brasil / Mortality risk factors for persons over age 65 hospitalized in a university hospital in Sao Paulo, Brazil

Diversos estudios muestran que la edad en sí no es un factor independiente predictor de la supervivencia de las personas mayores gravemente enfermas, pero el grupo mayor de 65 años de edad no suele tener acceso a los recursos diagnósticos y terapéuticos más complejos. Con el continuo envejecimiento de la población se hace cada vez más importante poder determinar los factores de riesgo de mortalidad que afectan a las posibilidades de supervivencia de la gente mayor hospitalizada, especialmente en condiciones de urgencia. El objetivo de este trabajo fue analizar los factores de riesgo asociados con la mortalidad de personas mayores de 65 años internadas en el Servicio de Urgencia del hospital Santa Casa de Sao Paulo, institución académica de nivel terciario. El estudio se basó en un análisis por regresión logística no condicional de los datos personales recogidos en el hospital en las historias clínicas respectivas y otros documentos pertenecientes a los pacientes hospitalizados durante el período de julio de 1993 a marzo de 1994, inclusive. Durante dicho período se hospitalizó a 599 pacientes - 326 hombres (54,4 por cien) y 273 mujeres (45,6 por cien) - con una mediana de edad de 73,3 años. Las razones principales de internamiento fueron neumonía (14,4 por cien), enfermedad cerebrovascular (11,5 por cien) e insuficiencia cardíaca (8,2 por cien). El total de defunciones ascendió a 160. Los pacientes que fallecieron tuvieron una estadía mediana en el hospital de 4 días (intervalo de 1 a 72), semejante a la de los que sobrevivieron (3 días; intervalo de 0 a 35 días; P= 0,29). Según el análisis multivariado, independientemente del sexo, la edad, la raza, la observancia del tratamiento, el diagnóstico inicial y otros estados patológicos presentes, la hipertensión arterial (razón de posibilidades, RP u odds ratio en inglés=0,39, IC95 por cien: 0,23 a 0,68), la enfermedad pulmonar obstructiva crónica (RP=0,45; IC95 por cien:0,22 a 0,95) y la diabetes mellitus (RP=0,50; IC95 por cien: 0,27 a 0,91) fueron factores predictores de supervivencia, mientras que la presencia de infecciones extrapulmonares (RP=2,34; IC95 por cien: 1,13a 4,86) y el número de enfermedades preexistentes - una (RP=2,78; IC95 por cien: 1,56 a 4,96), dos (RP=4,56; IC95 por cien: 2,28 a 9,15) y más de dos (RP=15,88; IC95 por cien: 6,49 a 38,85) - fueron factores de pronóstico independientes, indicadores de fallecimiento durante la hospitalización. Se concluye que el mejoramiento del diagnóstico y el tratamiento de las infecciones puede reducir la mortalidad de las personas de edad avanzada ingresadas en los servicios de urgencia. La multiplicidad de enfermedades, no la edad, fue el factor que aumentó el riesgo de muerte en este grupo de pacientes. No puede justificarse restringir el acceso de los pacientes geriátricos a los mejores recursos de diagnóstico y terapéutica, solo por la edad, si dichos recursos pueden resultar en mayor supervivencia, prevención de discapacidades o una mejor calidad de vida

Various studies show that age in itself is not an independent predictive factor for the survival of critically ill older persons. In spite of that fact, people over 65 tend not to have access to the most-sophisticated diagnostic and therapeutic resources. With the continued aging of the population, it is increasingly important to be able to determine the mortality risk factors that affect the survival possibilities of hospitalized older people, especially in emergency situations. The objective of this study was to analyze the risk factors related to mortality among people over 65 admitted to the emergency service of the Santa Casa Hospital of São Paulo, a third-level academic institution. The study was based on a nonconditional logistic regression analysis of personal data in the clinical histories and other documents of the hospitalized patients. From July 1993 through March 1994, 599 patients over 65 were hospitalized. They included 326 men (54.4%) and 273 women (45.6%), with a median age of 73.3 years. The primary reasons for admission were pneumonia (14.4%), cerebrovascular disease (11.5%), and congestive heart failure (8.2%). There were 160 deaths among the group. Those who died had a median stay in the hospital of 4 days (range, 1 to 72), which was similar to that of those who survived (median, 3 days; range, 0 to 35 days; P = 0.29). According to multivariate analysis, factors predictive of survival were hypertension (odds ratio = 0.39; 95% CI: 0.23 to 0.68), chronic obstructive pulmonary disease (OR = 0.45; 95% CI: 0.22 to 0.95), and diabetes mellitus (OR = 0.50; 95% CI: 0.27 to 0.91). This was true regardless of sex, age, race, compliance with treatment, initial diagnosis, and other pathological conditions present. On the other hand, two factors were predictive of mortality during hospitalization. They were the presence of extrapulmonary infections (OR =2.34; 95% CI: 1.13 to 4.86) and the number of preexisting illnesses: one (OR = 2.78; 95% CI: 1.56 to 4.96), two (OR = 4.56; 95% CI: 2.28 to 9.15), and three or more (OR = 15.88; 95% CI: 6.49 to 38.85). This study shows that improving the diagnosis and treatment of infections can reduce mortality of elderly persons admitted to emergency services. Rather than age, the multiplicity of diseases was the factor that increased the risk of death among these patients. There is no justification for using age alone to limit the access that older patients have to better diagnosis and treatment resources, if these resources can result in better survival rates, fewer disabilities, or a better quality of life

Perfil clínico de pacientes com síndrome da veia cava superior por câncer de pulmäo / Clinical features of patients ith superior vena cava syndrome and lung cancer

A principal causa da obstruçäo da veia cava superior é o carcinoma broncogênico. Neste estudo decritivo säo apresentadas as características clínicas de 136 doentes que apresentaram síndrome da veia cava superior (SVCS) à época do diagnóstico do carcinoma broncogênico. A idade dos doentes variou de 24 a 78 anos (mediana de 58). Havia 108 (77,7 por cento) homens e 123 (88, 5 por cento) fumantes. Queixas comuns foram tosse (92,8 por cento), dispnéia (85,26 por cento), dor torácica (72,7 por cento), sibilância (50, 4 por cento) e hemoptise (50, 4 por cento): 34 (24,5 por cento) apresentavam capacidade de desempenho (CD) de 0 ou 1;73 (52,5 por cento) com CD grau 2 e 32 (23,0 por cento) CD igual a 3 ou 4. Havia 56 casos (40,3 por cento) de carcinoma broncogênico de pequenas células (CBPC) e 83 (59,7 por cento) de outros tipos histológicos (CBOTH); estes grupos näo diferiam quanto a idade, sexo, tabagismo, sintomas ou capacidade de desempenho. O tempo médio de sobrevida foi de 26,0 semanas (IC a 95 por cento: 23,7 - 28,2) para os casos de CBPC e 18,7 semanas (IC a 95 por cento: 17,1 - 20,3) para os CBOTH (logrand X²=2,81 pd=+0,093. Independente da idade, capacidade de desempenho, estadiamento clínico ou tipo histológico, apresentaram maior sobrevida os doentes que receram tratamento específico para a doença neoplásica

Aspectos psicossociais e sexuais de gestantes adolescentes em Belém-Pará / Psychosocial and sexual aspects of pregnant adolescents at Belém-Pará

A gravidez na adolescência determina com muita frequência consequências psicossociais para as gestantes adolescentes. Foram avaliados alguns aspectos pessoais-sociais e sexuais de 120 gestantes, na faixa etária de 12 a 18 anos, atendidas no Serviço de Pré-Natal de Risco da Secretaria de Saúde do Estado, durante a primeira consulta do pré-natal e independentemente da idade gestacional, de 10/1991 a 04/1992, Belém-Pará. Os resultados demonstraram que a menarca ocorreu em maior frequência entre 12 e 13 anos (mediana 12,2 anos); 50,9 por cento da iniciaçäo sexual se deu com até 14 anos e 56,6 por cento das gestantes avaliadas encontravam-se na faixa etária de até 16 anos. A maioria (98,4 por cento) das adolescentes iniciaram vida sexual com namorados; 72,5 por cento por desejo próprio e 67,5 por cento com até um ano de namoro, sendo esta atitude mais frequente (79,4 por cento) entre aquelas mais jovens (12-16 anos). A principal fonte de informaçäo sobre sexualidade referida pelas adolescentes foram os colegas (65,1 por cento) e, quanto ao conhecimento e uso da contracepçäo, 55,9 por cento conheciam algum método, entretanto, apenas 13,3 por cento faziam uso. Do total das adolescentes, 96,7 por cento eram dependentes da família e 30,3 por cento e 32,1 por cento, respectivamente, referiram ter abandonado a escola antes ou durante a gestaçäo. As adolescentes, principalmente as mais jovens, demonstraram pouco conhecimento e uso da contracepçäo; desinformaçäo nas questöes da sexualidade e altos índices de iniciaçäo sexual precoce, fatores estes que podem ter contribuído para a ocorrência de gravidez precoce entre as adolescentes .

Evoluçäo do estado nutricional de menores de 5 anos em aldeias indígenas da tribo Parakanä, na Amazônia Oriental Brasileira (1989-1991) / Nutritional status of Parakanä Indian - children from birth through 5 years of age, eastern Amazonia, Brazil

Foi estudada a recente evoluçäo do estado nutricional de menores de 5 anos nas aldeias Parakanä, Maroxewara e Paranatinga. Dados antropométricos (peso, altura) foram obtidos em três estudos transversais para avaliaçäo da prevalência de desnutriçäo e acompanhamento da evoluçäo nutricional pelo incremento médio do índice peso/idade de 70 crianças (87,5 por cento dos menores existentes). A desnutriçäo nas aldeias foi proporcional ao tempo de contato com nossa cultura e atribuível a fatores socioculturais relatados. Na Paranatinga, os valores médios dos indicadores antropométricos - peso/idade, altura/idade e peso/altura - foram os menores, principalmente nas crianças entre o sexto e o 24§ mês. Reduziu-se em 76,1 por cento a prevalência de desnutriçäo global no grupo estudado, näo havendo mais casos de desnutriçäo aguda na última avaliaçäo. O incremento do indicador peso/idade foi proporcional à severidade do caso, näo havendo diferença significante entre as aldeias. Medidas de natureza preventiva adotadas foram eficazes em reduzir a prevalência de desnutriçäo infantil entre os Parakanä

Estabelecimento do perfil epidemiologico das populacoes da faixa de fronteira da Amazonia Legal: diretrizes gerais e estrategias de acao / Establishment of the epidemiological profile of the populations of the band of frontier of the Legal Amazonian: general directives and strategics of the actions

Foi apresentado o roteiro para coleta de dados secundarios empregado pelo NMT/UFPA no estabelecimento do perfil epidemiologico dos municipios de Vilhena/RO, Costa-Marques/RO, Guajara-Mirim/RO, Oiapoque/AP, Almeirim/PA, Obidos/PA e Oriximina/PA; discutiu-se o enquadramento destes estudos dentro de um modelo de intervencao local sobre questoes de saude, baseado no conceito de risco

Estudo clínico-laboratorial de doenças sexualmente transmissíveis entre os índios Parakanä / Clinical-laboratory study of sexualy transmissible diseases betwen the Parakanä indians

O atendimento à comunidade das aldeias Maroxewara e Paranatinga na Area Indígena Parakanä foi dirigido às mulheres e efetuado de forma sistemática; registrou-se idade, sexo, cônjuge, práticas sexuais e história tocoginecológica; procedeu-se a um exame físico e ginecológico e, em seguida, coleta de secreçäo vaginal para bacterioscopia (método de Gram) e de material para colpocitologia oncótica (método de Papanicolaou). Para os parceiros foi efetuada avaliaçäo urológica através de inspeçäo. O encaminhamento às consultas se deu de forma espontânea, sendo a motivaçäo devida à preparaçäo anterior feita pela equipe de educaçäo que atua nas aldeias. Após os resultados clínico-laboratoriais instituiu-se orientaçäo e terapêutica adequadas. Dos 71 exames laboratoriais realizados (83.5 por cento), observou-se pelo método de Gram flora Doderlein (46.5 por cento), flora bacilar Gram negativa (25.4 por cento), flora cocácea Gram positiva (43.7 por cento) e "clue cels" (33.8 por cento). Na colpocitologia, o achado mais comum foi de inflamaçäo (91.5 por cento), sendo que destes 36.9 por cento eram inespecíficas; dos casos de inflamaçäo específica, em 63.4 por cento foi diagnosticado infecçäo por Gardenerella vaginalis, em 34.1 por cento sugestivo de infecçäo por Papilomavírus (HPV), em 7.3 por cento infecçäo por Trichomonas vaginalis e, em 4.9 por cento, presença de candida sp. Houve ainda um caso de suspeita de infecçäo por HPV associado à NIC I