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1.
Eur J Surg Oncol ; 40(11): 1467-73, 2014 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-25086990

RESUMEN

BACKGROUND: Complete cytoreductive surgery (CCRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) is on the verge of becoming the gold standard treatment for selected patients presenting peritoneal metastases (PM) of colorectal origin. PM is scored with the peritoneal cancer index (PCI), which is the main prognostic factor. However, small bowel (SB) involvement could exert an independent prognostic impact. AIM: To define an adequate cut-off for the PCI and to appraise whether SB involvement exerts an impact on this cut-off. PATIENTS AND METHODS: Patients (n = 139) treated with CCRS plus HIPEC were prospectively verified and retrospectively analyzed. One hundred presented with SB involvement of different extents and at different locations. RESULTS: All the patients with a PCI ≥ 15 exhibited SB involvement. Five-year overall survival was 48% when the PCI was <15 vs 12% when it was ≥ 15 (p < 0.0001. The multivariate analysis retained two prognostic factors: PCI ≥ 15 (p = 0.02, HR = 1.8), and the involvement of area 12 (lower ileum) (p = 0.001, HR = 3.1). When area 12 was invaded, it significantly worsened the prognosis: 5-year overall survival of patients with a PCI <15 and area 12 involved was 15%, close to that of patients with a PCI ≥ 15 (12%) and far lower than that of patients with a PCI <15 and no area 12 involvement (70%). CONCLUSION: A PCI greater than 15 appears to be a relative contraindication for treatment of colorectal PM with CCRS + HIPEC. Involvement of the lower ileum is also a negative prognostic factor to be taken into consideration.


Asunto(s)
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Carcinoma/terapia , Neoplasias Colorrectales/terapia , Neoplasias Duodenales/terapia , Neoplasias del Íleon/terapia , Intestino Delgado/cirugía , Neoplasias del Yeyuno/terapia , Neoplasias Peritoneales/terapia , Peritoneo/cirugía , Adulto , Camptotecina/administración & dosificación , Camptotecina/análogos & derivados , Carcinoma/patología , Carcinoma/secundario , Estudios de Cohortes , Neoplasias Colorrectales/patología , Supervivencia sin Enfermedad , Neoplasias Duodenales/patología , Neoplasias Duodenales/secundario , Femenino , Humanos , Hipertermia Inducida , Neoplasias del Íleon/patología , Neoplasias del Íleon/secundario , Infusiones Parenterales , Intestino Delgado/patología , Irinotecán , Neoplasias del Yeyuno/patología , Neoplasias del Yeyuno/secundario , Masculino , Metastasectomía , Persona de Mediana Edad , Compuestos Organoplatinos/administración & dosificación , Oxaliplatino , Selección de Paciente , Lavado Peritoneal , Neoplasias Peritoneales/patología , Neoplasias Peritoneales/secundario , Peritoneo/patología , Estudios Retrospectivos , Resultado del Tratamiento
2.
Support Care Cancer ; 11(9): 575-80, 2003 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-12783290

RESUMEN

GOALS: To describe an acute respiratory distress syndrome (ARDS) occurring after chemotherapy for non-seminomatous germ-cell tumors (NSGCT) with diffuse lung metastases, we conducted a retrospective study in a 15-bed intensive care unit (ICU) in a comprehensive cancer center. PATIENTS AND METHODS: During a 10-year period, 16 consecutive patients with diffuse lung metastases from a NSGCT were admitted to the ICU for respiratory distress and high-risk chemotherapy. MAIN RESULTS: Nine patients developed acute respiratory failure requiring mechanical ventilation (MV) within 3 days of the initiation of chemotherapy, while the respiratory status of the seven other patients improved. The evolution was independent of tumor marker levels and the type of chemotherapy regimen. The SAPS II score did not accurately describe the severity of this population. The only predictor of intubation was the initial PaO2/FiO2 ratio upon admission to the ICU. Six out of seven patients who did not require MV were discharged alive from the hospital, whereas all but one patient requiring MV died. Refractory hypoxemia and ventilator-associated pneumonia were the leading causes of death. CONCLUSIONS: Acute respiratory distress in patients with lung metastases from NSGCT is a rare cause of ARDS. Chemotherapy could be responsible for triggering the respiratory worsening. Patients with severe respiratory insufficiency (PaO2 <70 mmHg on room air) on admission to hospital should be promptly transferred to the ICU for the first chemotherapy course.


Asunto(s)
Protocolos de Quimioterapia Combinada Antineoplásica/efectos adversos , Germinoma/tratamiento farmacológico , Germinoma/secundario , Neoplasias Pulmonares/tratamiento farmacológico , Neoplasias Pulmonares/secundario , Síndrome de Dificultad Respiratoria/inducido químicamente , Adulto , Femenino , Humanos , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Respiración Artificial , Síndrome de Dificultad Respiratoria/terapia , Estudios Retrospectivos , Factores de Tiempo
4.
Bull Cancer ; 87(9): 665-70, 2000 Sep.
Artículo en Francés | MEDLINE | ID: mdl-11038416

RESUMEN

Peritoneal carcinomatosis represents the terminal stage of adenocarcinomas of the gastrointestinal tract. A new treatment combining cytoreductive surgery and intraperitoneal chemotherapy-hyperthermia has been used with encouraging results. The purpose of this study was to report the complications associated with this treatment. Fourty procedures were carry out in 37 patients. Death occurred in 3 patients. Major medical complications were 13 pulmonary infections, 11 acute renal failure (with only 3 who needed dialysis) and 10 patients with neutropenia grade 3 and 4 toxicity. Intra-abdominal complications occurred in 16 patients (there were 11 anastomotic leak and/or bowel perforation, and 12 intra-abdominal infections). Some complications like secretory diarrhea or tubulopathia which were related to these treatment need further investigations. Six procedures were without any complications, 6 presented minor ones and 22 major complications. Adverse effects were relatively important with this new treatment strategy. This was maybe due to a learning process; there is no death and only one anastomotic leak in our last study including 30 patients with cytoreductive surgery and intraperitoneal chemotherapy-hyperthermia.


Asunto(s)
Protocolos de Quimioterapia Combinada Antineoplásica/efectos adversos , Carcinoma/tratamiento farmacológico , Carcinoma/cirugía , Hipertermia Inducida/efectos adversos , Neoplasias Peritoneales/tratamiento farmacológico , Neoplasias Peritoneales/cirugía , Complicaciones Posoperatorias , Adolescente , Adulto , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Terapia Combinada , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad
5.
Intensive Care Med ; 26(12): 1837-42, 2000 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-11271093

RESUMEN

OBJECTIVE: To verify the accuracy of totally implanted ports, tunnelled central venous catheters (CVC), widely used in cancer patients, and multi-lumen catheters, used in intensive care units (ICUs), in measuring central venous pressure (CVP), using right atrial pressure (RAP) measured in a Swan-Ganz catheter as the reference standard. DESIGN: A prospective study, over a 10-month period. SETTING: A medical-surgical ICU in a comprehensive cancer centre. PATIENTS AND PARTICIPANTS: Patients who had both (1) a Swan-Ganz catheter and (2) either a tunnelled catheter, a single or a multi-lumen catheter, or a totally implanted port. INTERVENTIONS: RAP and CVP were measured simultaneously in each patient. MEASUREMENTS AND RESULTS: Fifty-six pairs of RAP-CVP measurements were performed in 35 patients: 6 tunnelled catheters, 6 non-tunnelled single-lumen catheters, 26 multiple-lumen catheters and 18 totally implanted ports were studied. RAP measured in the Swan-Ganz catheter and CVP measured in the CVC were strongly correlated (r = 0.94, p < 0.01), whatever the type of catheter studied. The mean difference between RAP and CVP was -0.39 +/- 1.73 (SD) mmHg. In 51 cases (91%), the difference was within the limits of agreement (-3.78 to 3.00 mmHg, Bland and Altman method). For the five cases with a difference of 4 mmHg (three totally implanted ports, one double- and one triple-lumen catheter), CVP was greater than RAP. CONCLUSIONS: CVP can be accurately measured in totally implanted ports, tunnelled or non-tunnelled single-lumen and multiple-lumen catheters. When the difference exceeds the limit of agreement, the discrepancy between the two measurements has limited significance in most cases.


Asunto(s)
Cateterismo Venoso Central/instrumentación , Catéteres de Permanencia/normas , Presión Venosa Central , Anciano , Sesgo , Instituciones Oncológicas , Cateterismo de Swan-Ganz , Catéteres de Permanencia/clasificación , Diseño de Equipo , Femenino , Humanos , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Neoplasias/terapia , Estudios Prospectivos , Factores de Tiempo
6.
Chest ; 115(6): 1641-5, 1999 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-10378562

RESUMEN

STUDY OBJECTIVES: Quantitative culture of protected samples of lower respiratory tract secretions obtained by a fiberoptic protected specimen brush (PSB) is widely accepted for the diagnosis of ventilator-associated pneumonia (VAP), but this diagnostic procedure is time consuming, expensive, and may give rise to iatrogenic complications, especially in cancer patients who often present with thrombocytopenia. The plugged telescoping catheter (PTC) could be a satisfactory alternative to the PSB in this setting. The aim of the present study was to evaluate the interest of the PTC to diagnose VAP in ventilated cancer patients. DESIGN: A prospective observational study. SETTING: A 15-bed medical-surgical ICU in a comprehensive cancer center. PATIENTS AND INTERVENTIONS: Over a 9-month period, 42 patients suspected of having bacterial VAP during mechanical ventilation underwent 69 bronchial samplings: a blinded PTC and a fiberoptic PSB were performed successively in each case. A positive culture for both sampling procedures was defined as the recovery of > or = 10(3) cfu/mL of at least one potential pathogen. The PSB result was taken as the reference standard. MEASUREMENTS AND RESULTS: The overall agreement between the techniques was 87% (60/69). PTC had a sensitivity of 67%, a specificity of 93%, a positive predictive value of 71%, and a negative predictive value of 91%. CONCLUSIONS: We conclude that the accuracy of the blinded PTC compares well with that of the PSB for the diagnosis of VAP in cancer patients. The sensitivity of the PTC observed herein, which is slightly lower than that described in previous studies, may be due to the blinded nature of the method: the indications for initial or secondary coupling with a directed sampling method in patients with suspicion of localized pneumonia remain to be determined.


Asunto(s)
Bacterias/aislamiento & purificación , Broncoscopía , Infección Hospitalaria/diagnóstico , Neoplasias/terapia , Neumonía Bacteriana/diagnóstico , Respiración Artificial/efectos adversos , Manejo de Especímenes/instrumentación , Infección Hospitalaria/etiología , Contaminación de Equipos , Femenino , Tecnología de Fibra Óptica , Humanos , Intubación Intratraqueal/efectos adversos , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Neumonía Bacteriana/etiología , Estudios Prospectivos , Sensibilidad y Especificidad
7.
Leuk Lymphoma ; 29(1-2): 205-9, 1998 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-9638991

RESUMEN

We describe the case of a 35-year old male who developed acute renal failure following high dose methotrexate therapy for Burkitt's non Hodgkin lymphoma. Serum methotrexate levels reached 37 micromol/l, and remained higher than 1 micromol/l for more than a week. Folinic acid rescue was intensified to 200-400 mg intravenously every 4 hours. As methotrexate binds markedly to proteins, plasma exchange was initially chosen, 4 sessions being performed from day 2 to day 4. The methotrexate pharmacokinetic profile was not significantly modified during plasma exchange, and serum drug level was 3 micromol/l. Continuous veno-venous hemodiafiltration was therefore performed from day 5 to day 10. This procedure also seemed ineffective, with evidence of low ultrafiltrate clearance. No extrarenal toxicity was observed in our patient. Thus, conventional extrarenal procedures appear to have a limited role in the setting of overexposure to methotrexate. The use of very high doses of folinic acid in our case probably played a major role in the eventual favorable outcome.


Asunto(s)
Lesión Renal Aguda/terapia , Antídotos/uso terapéutico , Leucovorina/uso terapéutico , Metotrexato/efectos adversos , Lesión Renal Aguda/inducido químicamente , Lesión Renal Aguda/metabolismo , Adulto , Linfoma de Burkitt/complicaciones , Linfoma de Burkitt/tratamiento farmacológico , Linfoma de Burkitt/metabolismo , Relación Dosis-Respuesta a Droga , Humanos , Masculino , Metotrexato/farmacocinética
8.
Crit Care Med ; 26(3): 488-93, 1998 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-9504577

RESUMEN

OBJECTIVES: To use three severity of illness scores to estimate the probability of hospital mortality among patients with cancer and neutropenia; to compare the performance of these scores, calculated at admission to an intensive care unit (ICU); and to test the improvement in estimation obtained by taking into account the first 72-hr period. DESIGN: Collection of data for every neutropenic patient hospitalized in the ICU during a 4-yr period. SETTING: A comprehensive cancer center. PATIENTS: Ninety-four patients were neutropenic at ICU admission. Their vital status was measured at hospital discharge. MEASUREMENTS AND MAIN RESULTS: The new Simplified Acute Physiology Score (SAPS) II improved the estimation of hospital mortality compared with the original SAPS score. Using a simple score based on the number of acute organ system failures (OSFs) to classify the patients, good discrimination between survivors and nonsurvivors was observed (area under the receiver operating characteristic curves, 79 +/- 5 [SD] %). The relationship between successive scores and outcome was explored using recursive partitioning. Patients were first classified according to their OSF value on the first day of hospitalization in the ICU with a cutoff of two organ failures, and classification was then improved by taking into account the OSF score on the third day. CONCLUSIONS: For cancer patients hospitalized in an ICU for a neutropenic episode, the severity of illness and the risk of death can be accurately assessed by the SAPS II score and the number of acute organ failures at admission. The OSF values on the first and third days of hospitalization both provided information, allowing the classification of patients into groups with different probabilities of hospital mortality.


Asunto(s)
Neoplasias/mortalidad , Neutropenia/complicaciones , Índice de Severidad de la Enfermedad , APACHE , Adolescente , Adulto , Anciano , Niño , Humanos , Unidades de Cuidados Intensivos , Persona de Mediana Edad , Neoplasias/complicaciones , Valor Predictivo de las Pruebas , Curva ROC , Factores de Riesgo , Tasa de Supervivencia
9.
Eur J Cancer ; 33(7): 1031-7, 1997 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-9376183

RESUMEN

The admission of neutropenic patients to an intensive care unit (ICU) is still controversial, especially if mechanical ventilation is required. To avoid useless stays in ICU, the evaluation of the respective role of the underlying malignancy and acute organ failures might be useful for better definition of the categories of patients who could benefit from aggressive ICU support. For this purpose, we carried out a retrospective study of the charts of 107 consecutive neutropenic patients admitted to an ICU in a comprehensive cancer centre over a four-year period. The following characteristics were recorded within 24 h of admission: patient data, characteristics of neutropenia and the underlying malignancy, the type and number of organ system failures (OSFs) and simplified acute physiological scores (SAPS and SAPS II). The impact of each variable on outcome in the ICU was studied by univariate and multivariate (logistic regression) analysis. 59 patients died in the ICU (mortality rate: 55%). Patients with a haematological malignancy (n = 57, 53%) were more likely to experience respiratory failure, an underlying malignancy deemed rapidly fatal, and to have longer lasting neutropenia than patients with a solid tumour (n = 50, 47%). However, the mortality rate did not differ in the two groups (haematological malignancy 61% versus solid tumour 48%, p = 0.16). Respiratory and cardiovascular organ failure (p < 0.001 for both) correlated with mortality in the ICU. In the multiple logistic regression model, only the number of organ system failures and respiratory failure remained predictive of ICU mortality. In conclusion, the characteristics of the underlying malignancy are not relevant when deciding whether or not neutropenic patients should be admitted to an ICU. The main risk factors for death in an ICU are the number of organ failures on admission, and among them the presence of respiratory failure.


Asunto(s)
Cuidados Críticos , Neoplasias/complicaciones , Neutropenia/mortalidad , Adulto , Antineoplásicos/efectos adversos , Femenino , Humanos , Modelos Logísticos , Masculino , Insuficiencia Multiorgánica/complicaciones , Análisis Multivariante , Neoplasias/mortalidad , Neutropenia/inducido químicamente , Neutropenia/complicaciones , Neutropenia/terapia , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Análisis de Supervivencia , Resultado del Tratamiento
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