RESUMO
Pretransplant malignancy unrelated to hepatocellular carcinoma is a challenging condition in liver transplantation. Standard of care requires the completion of treatments and a disease-free period before the transplant. However, in the setting of a fulminant hepatic failure, these steps cannot be achieved. A 46-year-old woman with a recent diagnosis of stage 2 breast cancer presented to our center with a fulminant hepatic failure of unknown origin. Because of the rapid worsening of her clinical status, she was listed as eligible for transplant after a multidisciplinary evaluation. Because of a shortage of available donors, a deceased donor ABO-incompatible liver transplant with a synchronous mastectomy and first-level axillary lymphadenectomy was performed. To prevent antibody-mediated rejection, a triple immunosuppression therapy and a postoperative therapeutic plasmapheresis were performed. The patient remains without cancer recurrence at 18 months of follow-up. Recent studies have shown that cancer recurrence in recipients with pretransplant malignancy is considerably lower than suggested in previously published studies. However,this data is not sufficient to establish evidence-based guidelines on the indications and timing of transplant. In selected cases, the presence of a pretransplant malignancy does notrepresent a contraindication for a rescue liver transplant. Further studies are needed to stratify the risk and to help clinicians to choose the best strategy in an urgent context such as this.
Assuntos
Neoplasias da Mama , Falência Hepática Aguda , Neoplasias Hepáticas , Transplante de Fígado , Humanos , Feminino , Pessoa de Meia-Idade , Transplante de Fígado/efeitos adversos , Neoplasias da Mama/cirurgia , Incompatibilidade de Grupos Sanguíneos , Mastectomia , Recidiva Local de Neoplasia , Neoplasias Hepáticas/cirurgia , Falência Hepática Aguda/diagnóstico , Falência Hepática Aguda/etiologia , Falência Hepática Aguda/cirurgia , Sistema ABO de Grupos Sanguíneos , Rejeição de Enxerto/etiologia , Doadores VivosRESUMO
Neurological complications (NCs) can frequently and significantly affect morbidity and mortality of liver transplant (LT) recipients. We analysed incidence, risk factors, outcome and impact of the immunosuppressive therapy on NC development after LT. We analysed 478 LT in 440 patients, and 93 (19.5%) were followed by NCs. The average LOS was longer in patients experiencing NCs. The 1-, 3- and 5-year graft survival and patient survival were similar in patients with or without a NC. Multivariate analysis showed the following as independent risk factors for NC: a MELD score ≥20 (OR = 1.934, CI = 1.186-3.153) and an immunosuppressive regimen based on calcineurin inhibitors (CNIs) (OR = 1.669, CI = 1.009-2.760). Among patients receiving an everolimus-based immunosuppression, the 7.1% developed NCs, vs. the 16.9% in those receiving a CNI (P = 0.039). There was a 1-, 3- and 5-year NC-free survival of 81.7%, 81.1% and 77.7% in patients receiving a CNI-based regimen and 95.1%, 93.6% and 92.7% in those not receiving a CNI-based regimen (P < 0.001). In patients undergoing a LT and presenting with nonmodifiable risk factors for developing NCs, an immunosuppressive regimen based on CNIs is likely to result in a higher rate of NCs compared to mTOR inhibitors.
Assuntos
Inibidores de Calcineurina/efeitos adversos , Everolimo/efeitos adversos , Terapia de Imunossupressão/efeitos adversos , Imunossupressores/efeitos adversos , Transplante de Fígado , Doenças do Sistema Nervoso/imunologia , Complicações Pós-Operatórias/imunologia , Adulto , Idoso , Quimioterapia Combinada , Feminino , Seguimentos , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Doenças do Sistema Nervoso/epidemiologia , Doenças do Sistema Nervoso/etiologia , Avaliação de Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/epidemiologia , Prevalência , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: Intracranial germ cell tumors (GCTs) represent less than 5% of pediatric brain tumors. Neurosurgical treatment remains essential in the management of patients with intracranial nongerminomatous GCT. CASE DESCRIPTION: A 12-year-old girl presented with clinical features of neurohypophyseal dysfunction and rapidly progressive visual worsening. Magnetic resonance imaging (MRI) showed a lesion arising from the sella with a significant suprasellar component, compressing the optic chiasm and extending into the third ventricle. The tumor was removed via an endoscopic endonasal transtuberculum-transplanum approach and the histology revealed a mixed germinoma. In the postoperative course, a conspicuous improvement of visual function was observed; an early postoperative MRI showed near-total removal of the lesion. The patient was referred to pediatric oncologist for the adjunctive chemotherapy and radiotherapy. CONCLUSIONS: The management of primary intracranial sellar and suprasellar germinomas still remains controversial. With this report we highlighted another possible surgical option among therapeutic strategies for these highly malignant tumors.
RESUMO
INTRODUCTION: Pre-injury antithrombotic therapy might influence the outcome of subjects with head injuries and positive computed tomography (CT) scans. We aimed to determine the potential risk of pre-injury antiplatelet drug use on short- and long-term outcome of head injured subjects admitted to emergency departments (EDs) in Italy for extended observation. METHODS: A total of 1,558 adult subjects with mild, moderate and severe head injury admitted to Italian EDs were studied. In multivariable logistic regression analyses, the short-term outcome was assessed by an evaluation of head CT scan at 6 to 24 hours after trauma and the long-term outcome by the Glasgow outcome scale (GOS) at six months. RESULTS: Head CT scan comparisons showed that 201 subjects (12.9%) worsened. The risk of worsening was increased two fold by the use of antiplatelet drugs (106, 19.7% treated versus 95, 9.3% untreated; relative risk (RR) 2.09, 95% CI 1.63 to 2.71). The risk was particularly high in subjects on clopidogrel (RR 5.76, 95% CI 3.88 to 8.54), independent of the association with aspirin. By logistic regression, 5 of 14 items were independently associated with worsening (Glasgow coma scale (GCS), Marshall category, antiplatelet therapy, intraventricular hemorrhage, number of lesions). After six months, only 4 of 14 items were predictors of unfavorable outcome (GOS 1 to 3) (GCS score, Marshall category, age in decades, intracerebral hemorrhage/contusion). The risk increased by 50% in the group treated with antiplatelet therapy (RR 1.58, 95% CI 1.28 to 1.95; P<0.001). CONCLUSIONS: Antithrombotic therapy (in particular clopidogrel) is a risk factor for both short-term and long-term unfavorable outcome in subjects with head injury, increasing the risk of progression and death, permanent vegetative state and severe disability.