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BACKGROUND AND PURPOSE: This study aimed to assess the predictive value of multimodal brain magnetic resonance imaging (MRI) on survival in a large cohort of patients with motor neuron disease (MND), in combination with clinical and cognitive features. METHODS: Two hundred MND patients were followed up prospectively for a median of 4.13 years. At baseline, subjects underwent neurological examination, cognitive assessment and brain MRI. Grey matter volumes of cortical and subcortical structures and diffusion tensor MRI metrics of white matter tracts were obtained. A multivariable Royston-Parmar survival model was created using clinical and cognitive variables. The increase of survival prediction accuracy provided by MRI variables was assessed. RESULTS: The multivariable clinical model included predominant upper or lower motor neuron presentations and diagnostic delay as significant prognostic predictors, reaching an area under the receiver operating characteristic curve (AUC) of a 4-year survival prediction of 0.79. The combined clinical and MRI model including selected grey matter fronto-temporal volumes and diffusion tensor MRI metrics of the corticospinal and extra-motor tracts reached an AUC of 0.89. Considering amyotrophic lateral sclerosis patients only, the clinical model including diagnostic delay and semantic fluency scores provided an AUC of 0.62, whereas the combined clinical and MRI model reached an AUC of 0.77. CONCLUSION: Our study demonstrated that brain MRI measures of motor and extra-motor structural damage, when combined with clinical and cognitive features, are useful predictors of survival in patients with MND, particularly when a diagnosis of amyotrophic lateral sclerosis is made.
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Imagen de Difusión Tensora , Sustancia Gris/diagnóstico por imagen , Enfermedad de la Neurona Motora/diagnóstico por imagen , Enfermedad de la Neurona Motora/mortalidad , Enfermedad de la Neurona Motora/fisiopatología , Anciano , Diagnóstico Tardío , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Modelos TeóricosRESUMEN
INTRODUCTION AND OBJECTIVES: Quantifying breathing effort in non-intubated patients is important but difficult. We aimed to develop two models to estimate it in patients treated with high-flow oxygen therapy. PATIENTS AND METHODS: We analyzed the data of 260 patients from previous studies who received high-flow oxygen therapy. Their breathing effort was measured as the maximal deflection of esophageal pressure (ΔPes). We developed a multivariable linear regression model to estimate ΔPes (in cmH2O) and a multivariable logistic regression model to predict the risk of ΔPes being >10 cmH2O. Candidate predictors included age, sex, diagnosis of the coronavirus disease 2019 (COVID-19), respiratory rate, heart rate, mean arterial pressure, the results of arterial blood gas analysis, including base excess concentration (BEa) and the ratio of arterial tension to the inspiratory fraction of oxygen (PaO2:FiO2), and the product term between COVID-19 and PaO2:FiO2. RESULTS: We found that ΔPes can be estimated from the presence or absence of COVID-19, BEa, respiratory rate, PaO2:FiO2, and the product term between COVID-19 and PaO2:FiO2. The adjusted R2 was 0.39. The risk of ΔPes being >10 cmH2O can be predicted from BEa, respiratory rate, and PaO2:FiO2. The area under the receiver operating characteristic curve was 0.79 (0.73-0.85). We called these two models BREF, where BREF stands for BReathing EFfort and the three common predictors: BEa (B), respiratory rate (RE), and PaO2:FiO2 (F). CONCLUSIONS: We developed two models to estimate the breathing effort of patients on high-flow oxygen therapy. Our initial findings are promising and suggest that these models merit further evaluation.
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Magnetic nanoparticles are being increasingly used in numerous biomedical applications for diagnosis and therapy. During the course of these applications nanoparticle biodegradation and body clearance may occur. In this context, a portable, non-invasive, non-destructive and contactless imaging device can be relevant to trace the nanoparticle distribution before and after the medical procedure. We present a method for in vivo imaging the nanoparticles based on the magnetic induction technique, and we show how to properly tune it for magnetic permeability tomography, maximizing the permeability selectivity. A tomograph prototype was designed and built to demonstrate the feasibility of the proposed method. It includes data collection, signal processing and image reconstruction. Useful selectivity and resolution are achieved on phantoms and animals, proving that the device can be used to monitor the presence of magnetic nanoparticles without requiring any particular sample preparation. By this way, we show that magnetic permeability tomography may become a powerful technique to assist medical procedures.
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BACKGROUND: No reliable indicators of the transition to the progressive course in multiple sclerosis (MS) have been identified so far. The main clinical feature of the progressive phase of MS is usually impairment of walking. Magnetic resonance imaging and optical coherence tomography have emerged recently as promising tools to assess increasing neurodegeneration and axonal loss in disease progression in MS. RESULTS: We report a case of progressive visual impairment as the dominant symptom in the transition to secondary progressive MS. CONCLUSIONS: Impairment of vision, together with walking and cognition, should be considered to better define the transition from relapsing/remitting to secondary-progressive MS.
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Esclerosis Múltiple Crónica Progresiva/diagnóstico , Esclerosis Múltiple Crónica Progresiva/fisiopatología , Trastornos de la Visión/diagnóstico , Trastornos de la Visión/fisiopatología , Encéfalo/diagnóstico por imagen , Progresión de la Enfermedad , Femenino , Humanos , Esclerosis Múltiple Crónica Progresiva/terapia , Trastornos de la Visión/etiología , Adulto JovenRESUMEN
Magnetic hyperthermia is an oncological therapy where magnetic nanostructures, under a radiofrequency field, act as heat transducers increasing tumour temperature and killing cancerous cells. Nanostructure heating efficiency depends both on the field conditions and on the nanostructure properties and mobility inside the tumour. Such nanostructures are often incorrectly bench-marketed in the colloidal state and using field settings far off from the recommended therapeutic values. Here, we prepared nanoclusters composed of iron oxide magnetite nanoparticles crystallographically aligned and their specific absorption rate (SAR) values were calorimetrically determined in physiological fluids, agarose-gel-phantoms and ex vivo tumours extracted from mice challenged with B16-F0 melanoma cells. A portable, multipurpose applicator using medical field settings; 100 kHz and 9.3 kA m-1, was developed and the results were fully analysed in terms of nanoclusters' structural and magnetic properties. A careful evaluation of the nanoclusters' heating capacity in the three milieus clearly indicates that the SAR values of fluid suspensions or agarose-gel-phantoms are not adequate to predict the real tissue temperature increase or the dosage needed to heat a tumour. Our results show that besides nanostructure mobility, perfusion and local thermoregulation, the nanostructure distribution inside the tumour plays a key role in effective heating. A suppression of the magnetic material effective heating efficiency appears in tumour tissue. In fact, dosage had to be increased considerably, from the SAR values predicted from fluid or agarose, to achieve the desired temperature increase. These results represent an important contribution towards the design of more efficient nanostructures and towards the clinical translation of hyperthermia.
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Óxido Ferrosoférrico/química , Hipertermia Inducida , Melanoma Experimental/terapia , Nanopartículas/química , Sefarosa/química , Animales , Línea Celular Tumoral , Supervivencia Celular/efectos de los fármacos , Coloides/química , Microscopía por Crioelectrón , Femenino , Magnetismo , Melanoma Experimental/diagnóstico , Melanoma Experimental/diagnóstico por imagen , Ratones , Ratones Endogámicos C57BL , Método de Montecarlo , Nanopartículas/metabolismo , Nanopartículas/toxicidad , Fantasmas de Imagen , TemperaturaRESUMEN
The semaphorin family of guidance molecules plays a role in many aspects of neural development, and more recently semaphorins have been implicated to contribute to the failure of injured CNS neurons to regenerate. While semaphorin expression patterns after neural injury are partially understood, little is known about the expression of their signal transducing transmembrane receptors, the plexins. Therefore, in this study, we compared the expression patterns of all class A plexins (Plxn-A1, A2, A3, A4) in mouse CNS (rubrospinal) and peripheral nervous system (PNS)-projecting (facial) motoneurons for up to two weeks following axonal injury. Using in situ hybridization, immunohistochemistry, and Western blot analysis, in rubrospinal neurons, Plxn-A1 mRNA and protein and Plxn-A4 expression did not change as a result of injury while Plxn-A2 mRNA increased and Plxn-A3 mRNA was undetectable. In facial motoneurons, Plxn-A1, -A3 and -A4 mRNA expression increased, Plxn-A2 mRNA decreased while Plxn-A1 protein expression did not change following injury. We demonstrate that with the exception of the absence of Plxn-A3 mRNA in rubrospinal neurons, both injured rubrospinal (CNS) and facial (PNS) neurons maintain expression of all plexin A family members tested. Hence, there are distinct expression patterns of the individual plexin-A family members suggesting that regenerating rubrospinal and facial motoneurons have a differential ability to transduce semaphorin signals.
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Nervio Facial/metabolismo , Neuronas Motoras/metabolismo , Regeneración Nerviosa/fisiología , Proteínas del Tejido Nervioso/metabolismo , Vías Nerviosas/metabolismo , Receptores de Superficie Celular/metabolismo , Núcleo Rojo/metabolismo , Animales , Axotomía , Sistema Nervioso Central/metabolismo , Sistema Nervioso Central/fisiopatología , Nervio Facial/fisiopatología , Regulación de la Expresión Génica/fisiología , Masculino , Ratones , Proteínas del Tejido Nervioso/genética , Vías Nerviosas/fisiopatología , Sistema Nervioso Periférico/metabolismo , Sistema Nervioso Periférico/fisiopatología , ARN Mensajero/metabolismo , Receptores de Superficie Celular/genética , Núcleo Rojo/fisiopatología , Semaforinas/metabolismo , Transducción de Señal/fisiología , Regulación hacia Arriba/fisiologíaRESUMEN
A three op-amps instrumentation amplifier (I.A) with active dc suppression is presented. dc suppression is achieved by means of a controlled floating source at the input stage, to compensate electrode and op-amps offset voltages. This isolated floating source is built around an optical-isolated device using a general-purpose optocoupler, working as a photovoltaic generator. The proposed circuit has many interesting characteristics regarding simplicity and cost, while preserving common mode rejection ratio (CMRR) and high input impedance characteristics of the classic three op-amps I.A. As an example, a biopotential amplifier with a gain of 80 dB, a lower cutoff frequency of 0.1 Hz, and a dc input range of +/- 8 mV was built and tested. Using general-purpose op-amps, a CMRR of 105 was achieved without trimmings.
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Amplificadores Electrónicos , Fuentes de Energía Bioeléctrica , Impedancia Eléctrica , Instalación Eléctrica/instrumentación , Óptica y Fotónica , Procesamiento de Señales Asistido por Computador , Potenciales de Acción , ArtefactosRESUMEN
Biopotential measurements are very sensitive to electromagnetic interference (EMI). EMI gets into the acquisition system by many ways, both as differential and common mode signals, driven-right-leg circuits (DRL) are widely used to reduce common mode interference. This paper reports an improvement on the classic DRL. The proposed circuit uses a transconductance amplifier to drive the patient's body. This configuration has some interesting properties, which provide an extended bandwidth for high-frequency EMI rejection (such as fluorescent lights interference). The improvement is around 20 dB for frequencies of few kilohertz and the circuit is easy to compensate for stability. A comparative analysis against a typical DRL is presented, the results obtained have been experimentally tested.
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Electricidad , Radiación , Conductividad Eléctrica , Electrofisiología , Humanos , Modelos TeóricosRESUMEN
Muscle fibre conduction velocity is an important measurement in electrophysiology, both in the research laboratory and in clinical practice. It is usually measured by placing electrodes spaced at known distances and estimating the transit time of the action potential. The problem, common to all methods, is the estimation of this time delay. Several measurement procedures, in the time and frequency domains, have been proposed. Time-domain strategies usually require two acquisition channels, whereas some frequency-domain methods can be implemented using a single one. The method described operates in the time domain, making use of the autocorrelation function of the difference signal obtained from two needle electrodes and only one acquisition channel. Experimental results were obtained from the electromyogram of two biceps muscles (two adult male subjects, nine records each) under voluntary contraction, yielding an average of 3.58 m s(-1) (SD=0.04 m s(-1)) and 3.37m s(-1) (SD=0.03 m s(-1)), respectively. Several tests showed that the proposed method works properly with electromyogram records as short as 0.3 s.
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Electromiografía/métodos , Fibras Musculares Esqueléticas/fisiología , Conducción Nerviosa , Potenciales de Acción , Adulto , Humanos , Masculino , Procesamiento de Señales Asistido por ComputadorRESUMEN
A biopotential amplifier for single supply operation is presented. It uses a Driven Right Leg Circuit (DRL) to drive the patient's body to a DC common mode voltage, centering biopotential signals with respect to the amplifier's input voltage range. This scheme ensures proper range operation when a single power supply is used. The circuit described is especially suited for low consumption, battery-powered applications, requiring a single battery and avoiding switching voltage inverters to achieve dual supplies. The generic circuit is described and, as an example, a biopotential amplifier with a gain of 60 dB and a DC input range of +/-200 mV was implemented using low power operational amplifiers. A Common Mode Rejection Ratio (CMRR) of 126 dB at 50 Hz was achieved without trimming.
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Amplificadores Electrónicos , Procesamiento de Señales Asistido por Computador/instrumentación , Impedancia Eléctrica , Suministros de Energía Eléctrica , Electrocardiografía , Diseño de EquipoRESUMEN
A fluorocarbonate emulsion was infused into 30 rabbits after the removal of varying amounts of blood. Parameters relating to the transport of respiratory gases and the fundamental features of the macrocirculation were monitored. The animals were sacrificed after 6 or 24 hr and the histological changes in the main parenchymas were assessed. The material injected displayed low toxicity, a good ability to act as a vehicle for oxygen and carbon dioxide, and no tendency to alter the macrocirculation. Numerous problems remain, however, with regard to the stability of fluorocarbonates over the course of time and the effect of their uptake by tissues.
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Sustitutos Sanguíneos/metabolismo , Butilaminas/metabolismo , Fluorocarburos/metabolismo , Hígado/metabolismo , Animales , Masculino , Conejos , Distribución TisularRESUMEN
Fluorocarbonates are organic compounds capable of carrying oxygen and surrendering it to tissues by means of biological sound modalities. Experimentation of an emulsion consisting of perfluorotripropylamine and perfluorodecaline (Fluosol DA 20%) as a blood substitute is reported. Acute (Ht less than 1%) and chronic morphological (Ht = 15%) studies were performed on rats, and a semi-acute biochemical and morphological protocol (Ht = 21%) was experimented in pigs. The first signs of altered cerebral electrical activity occurred at Ht = 2% in the acute experiments, and death due to respiratory arrest took pace at Ht = 0.5%. In the semiacute and chronic experiments, widespread infiltration of fluorocarbonic micelles was noted on histological and electron microscope lung and liver preparations.
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Sustitutos Sanguíneos , Fluorocarburos/farmacología , Equilibrio Ácido-Base/efectos de los fármacos , Animales , Transporte Biológico , Glucemia/análisis , Presión Sanguínea/efectos de los fármacos , Intoxicación por Monóxido de Carbono/terapia , Presión Venosa Central/efectos de los fármacos , Diuresis/efectos de los fármacos , Combinación de Medicamentos/farmacología , Electrocardiografía , Electroencefalografía , Electromiografía , Emulsiones , Fluorocarburos/metabolismo , Gelatina/farmacología , Frecuencia Cardíaca/efectos de los fármacos , Hematócrito , Hemodilución , Hemorragia/terapia , Derivados de Hidroxietil Almidón , Hígado/efectos de los fármacos , Sistema Mononuclear Fagocítico/efectos de los fármacos , Consumo de Oxígeno , Tiempo de Protrombina , Ratas , Conservación de Tejido , TrasplanteRESUMEN
Certain fluorinated carbonate compounds can carry O2 and CO2 in a physiological manner. This faculty was exploited in the elaboration of an experimental intra-alveolar oxygenating washing protocol employing such compounds as intrapulmonary oxygenating liquids conveyed by transtracheal flooding of the alveoli in 20 rabbits. AP, PaP, CVP and EP were monitored in accordance with a 35' protocol, during which the positive oxygenation and negative emptying phases of the washing process were repeated at an average 2 cycles/min. A respiratory exchange capable of keeping all the animals alive until the recommencement of spontaneous ventilation was noted, along with only slight changes in lung structure. Once an in-depth study is made of certain fundamental phenomena related to structure and lung function, it is felt that this washing method can be used clinically for the treatment of hypoxaemic situations in which normal alveocapillary exchange is impeded by extraneous material, as in desquamative interstitial pneumonia, pulmonary alveolar proteinosis, etc.
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Fluorocarburos/uso terapéutico , Enfermedades Pulmonares/terapia , Alveolos Pulmonares , Irrigación Terapéutica , Animales , ConejosRESUMEN
Although therapeutic thinking and practice have entered their second century, most practitioners remain largely uncertain as to what data to trust, including "what works" and, "why it works." If anything, practitioners' reliance on ever-increasing numbers of theoretical models and either vague or contradictory research findings as primary guidelines to their practice has added to the confusion. What can the practitioner trust? This paper puts forward the "dangerous proposal" that it is of primary value for clinical professionals to place their trust on an often overlooked variable: the clients' statements about their therapy and their relationship to and with their therapist. It is argued that through the clarification of this variable will emerge a better understanding of the nonspecific variables of the therapeutic relationship itself and, as significantly, of the encompassing interrelational realms of discourse evident in all therapeutic models.
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Relaciones Profesional-Paciente , Psicoterapia/normas , Humanos , Competencia Profesional , Teoría PsicológicaRESUMEN
Between 1978 and 1994, 55 patients (53 men and 2 women) with a mean age of 62 years underwent an extended lobectomy to the main bronchus, with bronchial re-anastomosis, for bronchogenic tumours located around the lobar orifice. There were 32 upper sleeve lobectomies (58%) with a wedge resection of carina in one instance, 7 lower mono/bilobectomies with an upper lobe "turn up" re-anastomosis (13%) and 16 upper wedge lobectomies (29%). Squamous cell carcinoma was predominant (32 patients, 58%), while the adenocarcinoma was present in 16%, adenosquamous in 5%, microcitoma in 9%, carcinoid in 4% and a well differentiated neuro-endocrine carcinoma in 2%. The indication for the bronchoplastic procedure was judged to be when the FEV, value was about -25% of the normal; in a few patients still in good respiratory condition, an elective indication was also admitted. Postoperative staging was: Stage 0 in 1 patient, Stage I in 7 patients; Stage II in 10 patients; Stage III A in 31 patients; Stage III B in 5 patients and Stage IV in 1 patient. Follow-up was completed with a mean extension of 40 months (range 3 months-16 years). There was no operative mortality in Stages I and II as well as in Stages III B and IV, while it was 9% in Stage III A patients. Survival rates according to the stage were as following: 66% 5 and 10 year for Stage I disease; 56% 5 year and 45% 10 year for Stage II disease; 7% 4 year for Stage III A. None of 5 patients belonging to Stage III B has survived for more than 18 months (mean 7). Some single survivals are mentioned because of their special clinical features. Besides stressing the absolute value of survival rates obtained in Stage I and II disease, the Author also point out the clinical role of these advanced surgical techniques in improving both the survival length and the quality of life, when applied for the treatment of more advanced Stage III A.
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Neoplasias Pulmonares/cirugía , Pulmón/cirugía , Adulto , Anciano , Femenino , Estudios de Seguimiento , Humanos , Neoplasias Pulmonares/patología , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Análisis de SupervivenciaRESUMEN
The TNM System as originally proposed by Denoix in 1946, provides a consistent, reproducible description of the anatomic extent of disease in cancer patients at a specific time in the life history of the cancer. C.F. Mountain first adapted this classification to lung cancer in 1973 on behalf of AJCC. In 1986 he presented the "New Intl. Staging System for Lung Cancers" mainly based on a 13 yr experience of the previous one, which was accepted world-wide through a round of international consensus meetings held in 1985. Clinical Staging is the best estimate of disease extent made prior to the institution of any therapy; Surgical-pathological Staging is the classification of disease extent as determined from pathological examination of resected specimens. Accordingly, once the diagnosis is made, it is necessary to stage accurately the tumour determining the size and location of the tumour (T status), the presence or absence of lymphnode involvement (N status), and whether the tumour is metastatic to distant sites (M status). Moreover the uniform staging criteria for lung cancer will assure for each patient the better selection of treatment, the evaluation of operability, the need for adjuvant therapy, as well as the estimation of prognosis. Equally important is the resultant ability to compare the outcome of treatment protocols from different centres. More recently C.F. Mountain has added to the Staging System a new standard logic or "convention" for classifying infrequently observed presentations of lung cancer with which the standard rules of Staging System itself don't fit. These conventions are based on empiric expectation for treatment selection and survival that are similar to those for the Staging definitions, which are based on actuarialsurvival data. Many different types of tumour such as multiple masses, synchronous multiple primitives, discontinuous tumour foci in visceral or parietal pleura as well neoplastic involvement of various mediastinal structures, could be now staged with a major benefit for their treatment protocols. In conclusion the Staging System represents today a standard clinical methodology which basically helps in a better clinical approach to lung cancer even if it cannot fully cover and consider all the innumerable manifestations of the tumor. Therefore, if it is true that in the near future the new molecular predictors of prognosis are expected to measure more deeply the extent of disease, for the present time the International Staging System still continues to act as the best common method for measuring prognosis.
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Neoplasias Pulmonares/patología , Estadificación de Neoplasias , Humanos , Pulmón/patología , Neoplasias Pulmonares/cirugía , Invasividad Neoplásica , Neoplasias Primarias Múltiples/patología , PronósticoRESUMEN
The complete resection for NSCLC is analyzed through the study of a series of retrospective surgical reports upon the incomplete resection, due to a microscopic residual tumor at the resection margin. Following Shields' statement in 1974, the incomplete resection represents, in fact, the basic study protocol for the local recurrence following the resection of primary NSCLC. First of all, the obligation for a careful intraoperative pathologic assessment upon the resection margins, clearly emerges from this study. Secondly, two main aspects featuring the incomplete resection have also been pointed out. The first is represented by the historical microscopic residual tumor at the bronchial resection margin, while the second, more recently recognized, is represented by the critical resection margin within the involved ipsilateral mediastinal lymphatic area. The analysis of such different figures leads to different considerations when dealing with the basic matter of the local-regional completeness of resection and the oncological result in terms of cure. In fact, while the problem of the bronchial remnant appears amenable to further improvement by activating the surgical attention, the second, instead, is to be considered unmodifiable by the surgery alone. It basically depends on the extended microvascularity of the large lymphatic mediastinal network which appears to be the crucial factor of risk for such a "lymphatic" resection margin. In conclusion, the matter of complete resection is still open to further research provided that the design is strictly prospective. As a matter of fact, so far the expectation for cure in any apparently completely resected NSCLC is ruled by other well-known factors of prognosis which do not consider the quality of the resected margin at all.
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Carcinoma de Pulmón de Células no Pequeñas/cirugía , Neoplasias Pulmonares/cirugía , Neumonectomía/métodos , HumanosRESUMEN
Such a novel surgical project is supported by a large basic knowledge on molecular biology of solid tumours progression as well as the already assessed clinical experience in the parallel field of surgery for lung, brain and liver metastases. While pathology and the clinical work up have for a long time pointed out the steady rate of adrenal metastatic involvement from lung cancer (from 25 to 28% of all cases at the autopsy and, on clinical grounds, the most important site of extrapulmonary tumour spread just after the first one represented by the mediastinal lymphatic groups), the surgical approach to the problem is still very limited and the few operated cases previously reported in world literature (summing up to a total of 21) are not truly homogeneous and even largely scattered in time. The Authors report on their personal contribution in this field with four consecutive cases who underwent surgery during the last five years. The most important clinical features together with the initial remarkable result obtained in one patient who is still free of disease more than 3 years after the sequential radical resection of the primary lung tumour and the metastatic ipsilateral adrenal gland, are presented. In the light of this preliminary positive experience, the Authors are planning a sound clinical research based on the combined resection of those NSC Lung Cancers which appear surgically resectable but already included in an unresectable Stage IV Disease only because of the contemporary adrenal metastases (M1). An adjuvant chemotherapy in usually added.
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Neoplasias de las Glándulas Suprarrenales/secundario , Neoplasias de las Glándulas Suprarrenales/cirugía , Adrenalectomía , Carcinoma de Pulmón de Células no Pequeñas/secundario , Carcinoma de Pulmón de Células no Pequeñas/cirugía , Neoplasias Pulmonares , Neoplasias de las Glándulas Suprarrenales/mortalidad , Carcinoma de Pulmón de Células no Pequeñas/mortalidad , Femenino , Humanos , Neoplasias Pulmonares/mortalidad , Neoplasias Pulmonares/cirugía , Masculino , Neumonectomía , Factores de TiempoRESUMEN
Preceded by an international overview on the surgical approach to the peripheral higher stage NSCLC, the cumulative clinical experience from ten Italian University Departments and Teaching Hospitals, is analyzed in the light of the corresponding international contributions. Accordingly, the clinical records of 470 patients affected by such Stage III tumors and surgically treated, were collected and retrospectively reviewed. 43 out of 120 patients belonging to the group of apical invasive Pancoast's tumour underwent an en-bloc chest-wall resection, while an extrapleural dissection was performed in the remaining 77. Combined segmentectomy was prevalent (54%), while lobectomy/bilobectomy was performed in 38%, wedge resection in 5% and pneumonectomy in 3% of all cases respectively. Preoperative high-voltage radiation was given in 70% of them; while adjuvant RT was requested in 17% of cases, mainly because of N1-2 status. Actuarial 5-year survival was 14% with a range of 0% in N2 cases to 21% in NO-1 ones. When considering surgical modes, the en-bloc chest-wall resection had a 5-year survival of 20% while the more limited extrapleural dissection yield only a 9% survival. Compared with the international experience the 14% 5-year survival is standing at the bottom of the scale. On the other hand, 350 patients belong to the other two main groups of peripheral tumors taken in consideration: the ones which, even apical, are yet lying anteriorly far enough from the costo-vertebral angle (apical non Pancoast tumor), and the other ones which are lower placed along the thoracic cage. The majority of these patients (213) were treated by an extrapleural dissection, while the remaining minority (123) received an en-bloc chest-wall resection with 1-2 ribs resected in 46%, 3 ribs in 38% and 4 ribs or more in 16%, respectively. Combined lobectomy/bilobectomy was prevalent (64%), while pneumonectomy was performed in 16%, more limited resections in 16% and exploration alone in 4% respectively. 5-year survival was 18% ranging from 0% in N2 patients to 23% in the NO-1 ones. The extrapleural dissection had a 5-year survival rate of 24.5%, while the en-bloc chest-wall resection yield a lower rate of 15.6%. This overall survival can be indeed considered nearer the international one, even if both surgical approach and the related 5-year survival rates are in full discordance with the compared international references.
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Neoplasias Pulmonares/cirugía , Humanos , Italia , Neoplasias Pulmonares/mortalidad , Neoplasias Pulmonares/patología , Estadificación de Neoplasias , Tasa de SupervivenciaRESUMEN
The rationale of the Staging System of Lung Cancer is discussed from his presentation (Mountain, 1985) to the recent revision and proposals of new classifications. Survival rates offered a strong statistical support to the latest revision in 1997. Stage Group have become 7 out of Stage 0 (Tis). In the New Lymph Node Map, station 4 is confirmed as mediastinal (N2). The improved definition of Stage Grouping requires a golden standard of staging and a worldwide consensus on the surgical approach to mediastinal lymphadenectomy. IASLC, the International Association for the Study of Lung Cancer, is now moving to collect a new largest database with the aim to offer the next expected Revision.