Pancoast tumour: current therapeutic options.

BACKGROUND: Pancoast's syndrome is caused by malignant neoplasm of superior sulcus of the lung which produces destructive lesions of thoracic inlet and comes along with the involvement of brachial plexus and stellate ganglion. Computed tomography (CT) or magnetic resonance imaging (MRI) scans can detect early lesions otherwise missed by routine radiographs and can also define the local extent or metastatic progression of the disease. Protocols involving combinations of irradiation, chemotherapy, and surgery are currently being under investigation to determine the best management. AIMS: This work reviewed the current diagnostic and therapeutic approaches to Pancoast's tumors. DISCUSSION: Patients with lung superior sulcus carcinoma should be considered for surgery only after an appropriate diagnostic assessment. The perfect candidate for surgery should have a confined to the chest disease with T3N0M0 staging. Inoperable patient with severe pain after irradiation therapy may benefit from palliative surgical resection. Medical therapy plays only a secondary role in lung cancers, patients with disseminated lung cancer might require palliative treatment and medical management of paraneoplastic syndrome symptoms. Following surgery, radiation and chemotherapy may improve local and systemic control by addressing individual adverse findings. CONCLUSIONS: The cooperation of surgeons, clinicians and radiologists represents the gold standard today and a multidisciplinary approach is essential to achieve the best outcome possible. Further studies are advisable in order to define the best surgical approach and the real advantage of mini-invasive surgery by comparison with open surgery.

Ultrasound-guided port-a-cath positioning with the new one-shoot technique: thoracic complications.

OBJECTIVES: Port-a-cath catheterization is often required for those patients who need long-term therapies (malnutrition, neoplasm, renal failure, other severe diseases). The use of ports for a wide range of indications is not exempt from complications. Ultrasound-guided central venous catheterization (CVC) is a safe and fast technique for the introduction of the catheter inside a central vein. This retrospective study reports our experience with US-guided CVC in patient eligible for port-a-cath implantation. MATERIALS AND METHODS: From January 2007 to March 2017, 108 CVC (out of 770 procedures), were positioned using an ultrasound guide, with the new "one-shoot technique" (group 1) and the classic Seldinger technique (group 2). RESULTS: One-shoot techniques showed a reduced operative time, in comparison to Seldinger technique, with a negligible minor complication rate. No major complication were evidenced. CONCLUSIONS: CVC is a safe procedure, although not free from complications. Ultrasonography enhances safety of the procedure by decreasing puncture attempts and complications; it is helpful in patients with vascular anatomical variations, with no visualized or palpable landmarks or for patients with coagulation disorders.

[Laparoscopic rectopexy: our experience in the treatment of complete rectal prolapse]. / Rettopessi per via laparoscopica: nostra esperienza nel trattamento del prolasso rettale completo.

Surgical treatments of rectal prolapse still await a final arrangement. The aim of this work is to present Authors' experience with 12 female patients who underwent laparoscopic rectopexy. The patients, aged between 67 and 84 years, were suffering of a different degree of incontinence classified according to the Browing and Parks scale. Pneumoperitoneum was induced through the Veres needle end 5 trocars were placed. The technique used was the modified Orr-Loygue. One no death was observed and only two not serious intraoperative complications were registered, in both conversion to laparotomy was not necessary. Functional result as for incontinence has been really good (disappeared in 11 cases and improved in one). Whereas regarding the constipation, no improvement was observed in those in who in it was preexisting the operation, not appearing nevertheless, as on the contrary reported by other Authors, in those in whom it wasn't present before surgical treatment. The patients, all in follow-up (range between 10 and 36 months, average 25.08), still now experienced no relapse. In conclusion, on the base of Authors' experience, laparoscopic rectopexy is considered free of particular risks and excellent in the results even if, due to the slight number of series, any definitive judgement can be expressed.

[Two new cases of autonomous ectopic goiter]. / Deux nouveaux cas de goitre ectopique autonome.

We observed two cases of autonomous intrathoracic goiter in patients with no past history of thyroidectomy. After resection, the surgical specimens confirmed the non-malignant nature of the goiter. We discuss the literature on management of autonomous intrathoracic goiter.

The influence of HLA-matched sibling donor availability on treatment outcome for patients with AML: an analysis of the AML 8A study of the EORTC Leukaemia Cooperative Group and GIMEMA. European Organization for Research and Treatment of Cancer. Gruppo Italiano Malattie Ematologiche Maligne dell'Adulto.

To determine whether patients with a HLA-identical sibling donor have a better outcome than patients without a donor, an analysis on the basis of intention-to-treat principles was performed within the framework of the EORTC-GIMEMA randomized phase III AML 8A trial. Patients in complete remission (CR) received one intensive consolidation course. Patients with a histocompatible sibling donor were then allocated allogeneic bone marrow transplantation (alloBMT), the patients without a donor were randomized between autologous BMT (ABMT) and a second intensive consolidation (IC2). 831 patients <46 years old and alive >8 weeks from diagnosis were included. HLA typing was performed in 672 patients. AlloBMT was performed during CR1 in 180 (61%) out of 295 patients with a donor. Another 38 patients were allografted: five in resistant disease, 14 during relapse and 19 in CR2. ABMT was performed in 130 (34%) out of 377 patients without a donor in CR1, in six (2%) patients during relapse and in 38 (10%) patients during CR2. The disease-free survival (DFS) from CR for patients with a donor was significantly longer than for patients without a donor (46% v 33% at 6 years; P=0.01, RR 0.78, 95% confidence interval 0.63-0.96). The overall survival from diagnosis for patients with a donor was longer, but not statistically significant, than for patients without a donor (48% v 40% at 6 years; logrank P=0.24). When patients were stratified according to prognostic risk groups, the same trend in favour of patients with a donor was seen for survival duration and the DFS remained significantly longer for this group of patients.

[Videolaparoscopic treatment of paraesophageal hiatal hernia]. / Traitement vidéolaparoscopique des hernies hiatales par roulement.

STUDY AIM: The aim of this prospective study was to report the results of videolaparoscopic repair in a series of ten patients with paraesophageal hernia. PATIENTS AND METHODS: From January 1982 to September 1998, ten patients (three men and seven women, mean age: 68 years [range: 42-87]) were operated on for paraesophageal hernia. An intrathoracic gastric volvulus was present in four patients, a severe anemia in four and two were asymptomatic. All interventions were performed laparoscopically and included sac resection, crura closure and realization of a posterior gastric valve on 270 degrees. RESULTS: There was one irruption of gastric juice in the bronchial tree at the beginning of the anesthesia which required assisted ventilation for 3 days. The mean follow-up was 17.5 months (range: 3-50). There was no postoperative diarrhea and no gas bloat syndrome. Eight patients complained of postoperative dysphagia which disappeared within 6 weeks, except in one patient with esophageal motility disorder postoperatively discovered. None of the patients had postoperative gastroesophageal reflux. A chest X-ray performed after 1 year detected no hernia recurrence in seven patients. There was no recurrent anemia after 6 months. CONCLUSION: The videolaparoscopic repair of paraesophageal hernias is feasible without any technical difficulties even in aged patients with precarious physical conditions. The results are good with a mean follow-up of 17.5 months.

Treatment of normal donors with rhG-CSF 16 micrograms/kg for mobilization of peripheral blood stem cells and their apheretic collection for allogeneic transplantation.

BACKGROUND: Utilization of peripheral blood stem cells (PBSC) in allogeneic transplantation requires a method for their mobilization and collection that is not inconvenient for the donor. METHODS: We administered rhG-CSF (filgrastim) 16 micrograms/kg subcutaneously for 4 days in five normal subjects (age 18-31, M = 3, F = 2), previously selected as HLA-identical donors of siblings with leukemia. All the donors gave written informed consent. On days 4 and 5 (in one donor on day 6 too), 10:l leukapheretic collection was performed with a CS-3000 (Baxter) or an AS-104 (Fresenius) cell separator through the antecubital vein. RESULTS: The WBC count reached a median peak of 57.0 x 10(9)/L on day 5. The peripheral blood CFU-GM peaked to a median level of 8908/mL on day 5 with a median increase over baseline values of 39.1 times. The CD34+ cells peaked to (median) 147.0 x 10(6)/L on day 4 with a median increase of 65.3 times. A lesser enrichment was recorded for BFU-E (median increase 12.7 times) and CFU-GEMM (median increase 15.2 times). Even CD3+ and CD56+CD3- cells increased (median 1.7 and 1.5 times, respectively). A median of 771 x 10(8) MNC (range 672-1378), 116.4 x 10(6) CFU-GM (range 47.7-145.1) and 754 x 10(6) CD34+ cells (range 477-2599) were apheretically collected. Concerning side effects, mild to moderate back pain and general minor discomfort were reported by all donors. The platelet level regularly but transiently decreased after completion of the apheretic procedures with a median nadir of 69 x 10(9)/L (range 43-126) on (median) day 7, but in no case did thrombocytopenia cause bleeding. The thrombocytopenia was more pronounced with the CS-3000 than the AS-104 apparatus. CONCLUSIONS: rhG-CSF 16 micrograms/kg x 4 days is an efficient schedule for PBSC mobilization in healthy donors, but lower doses and even a single apheresis procedure might prove similarly adequate.

Engraftment kinetics and long-term stability of hematopoiesis following autografting of peripheral blood stem cells.

BACKGROUND: We analyzed short-term and sustained hematopoietic reconstitution after high-dose therapy with peripheral blood stem cell (PBSC) support in patients with various malignant disorders. METHODS: Fifty-six patients, all with malignant hematologic disorders, were autografted between 1989 and 1994 using PBSC (47 pts) or PBSC + bone marrow (BM) cells (9 pts). PBSC were collected after mobilization with chemotherapy +/- hematopoietic growth factors (GF). RESULTS: All patients engrafted > 0.5 x 10(9)/L polymorphonuclear cells (PMN) and > 50.0 x 10(9)/L Plt at a median of 12 (8-32) and 13 (9-365) days, respectively. Thirty-nine patients were evaluable for long-term graft performance, and their hematologic values at 30 and 100 days, at 6 months and at 1, 2, 3, 4 and 5 years were retrospectively analyzed. Steady counts were recorded over the years. None of the patients had late graft failure. CONCLUSIONS: PBSC given after high-dose chemotherapy ensure a fast hematologic recovery with stable graft performance up to five years after autograft. Though this is not definitive proof of the presence of uncommitted stem cells in the PBSC population, it gives further support to the idea that PBSC are as safe as bone marrow for long-term engraftment. A delayed or incomplete recovery of platelets may occur with low PBSC counts or when disease relapse occurs rapidly after autograft.

Effect of alpha IFN on unaggressive immunoproliferative disorders.

BACKGROUND: alpha-IFN is reported to be an effective treatment for a number of lymphoproliferative diseases. Little information is available at present on its effect in unaggressive immunoproliferative disorders. STUDY DESIGN AND RESULTS: In a prospective non randomized study, 57 patients with IgG or IgA MGUS, smouldering myeloma or stage I MM treated with alpha-IFN (3 MU 3 times a week for at least 6 months) were compared to 129 untreated similar patients. Four patients in the IFN group showed a monoclonal component reduction > 50% versus none in the control group, and 25% of patients suffered disease progression (MC increase > 50% and/or osteolytic lesions) in the IFN group as compared to 18% in the control group. CONCLUSIONS: alpha-IFN administration at the dose used is ineffective for the majority of patients with slowly proliferating immunoproliferative disorders; only a small subgroup of them may benefit from such a treatment.

High dose cyclophosphamide: stem cell mobilizing capacity in 21 patients.

In the present study we assess the antitumor effect and circulating stem cells (CSC) mobilizing capacity of high-dose cyclophosphamide (5 to 7 gr/m2, HDCY). This treatment was given to 21 patients with various hematologic malignancies (8 NHL, 5 MM, 4 HD, 3 CML) excluding 1 with neuroblastoma. All were eligible for later autologous blood stem cell transplantation (ABSCT). To reduce the hematologic toxicity of HDCY, GM CSF was simultaneously administered in 5 patients. HDCY produced a response (as defined by a > 50% reduction of previous tumor mass) in 3 out of 12 HD/NHL and 1 out of 3 MM. Patients with CML were not considered to be evaluable for tumor response. Cell collection yields after HDCY varied widely with a range of 1.5 to 169.9 x 10(4)/Kg (median 13.1) CFU-GM and 1.7 to 18.4 x 10(8)/Kg (median 5.8) MNC collected per patient. Hematologic recovery was rapid and sustained with a median of 16 (12-18) days to PMN > 0.5 x 10(9)/L and 14 (11-18) days to Plt > 100.0 x 10(9)/L. Granulocyte recovery was significantly faster after GM-CSF (13 vs 16 days to PMN > 0.5, p = 0.0008). Non hematologic toxicity consisted mainly of nausea and vomiting, but fatal complications occurred in 2 patients, from pulmonary infection in one and from tumor-lysis syndrome in the other. HDCY represents a useful means of increasing collection of CSC, but toxicity is not irrelevant. Whether a similar anti-tumor effect and mobilizing capacity would be offered by single lower intermediate doses of the drug is still to be ascertained.

High-dose cyclophosphamide, etoposide and BCNU (CVB) with autologous stem cell rescue in malignant lymphomas.

Eighteen patients with malignant lymphoma, 10 non-Hodgkin's and 8 Hodgkin's, were treated with high-dose CVB (cyclophosphamide 4 x 1.5 g/m2, etoposide 4 x 250-400 mg/m2, carmustine 4 x 150-200 mg/m2), followed by autologous peripheral blood stem cells (PBSC, 13 patients) or bone marrow (BM, 5 patients) transplantation. At the time of autograft 6 patients were in complete remission (CR), 3 in partial remission (PR) and 5 in relapse (4 sensitive, 1 resistant), whereas 4 had progressive disease. All CR patients had poor prognostic features at presentation. PBSC were collected at the time of rapid hematologic recovery after intense chemotherapy by means of a cell separator. All patients engrafted. Median time to achieve > or = 0.5 x 10(9)/l polymorphonuclear cells (PMN) and > or = 50 x 10(9)/l platelets was 13 days for both cell types in PBSC autografted patients, versus 20 and 28 days respectively in BM autografted patients. A significant advantage of PBSC over BM was found in terms of time needed to recover either PMN > or = 0.5 and PMN > or = 1 x 10(9)/l (p = 0.01). Autograft-related toxicity consisted mainly of moderate severity interstitial pneumopathy (3 patients), and veno-occlusive disease (1 patient) that resolved completely. Of the 12 patients autografted with detectable disease, 6 (50%) obtained a CR. Seven out of 18 autografted patients (39%) had disease progression within 1 to 5 months of autograft. The projected progression-free survival is over 50% at 4 years and it was significantly longer in patients with sensitive disease than in those with resistant disease (p = 0.01). The efficacy and the low toxicity of CVB suggest that autograft with PBSC may be proposed for the primary treatment of poor prognosis malignant lymphomas.

A new pericentric inv(8) in acute nonlymphocytic leukemia.

Chromosome studies were carried out on unstimulated bone marrow cells from a patient with a diagnosis of acute nonlymphocytic leukemia (FAB M6 ANLL). Cytogenetic analysis revealed a mosaic chromosome pattern 46,XX/46,XX,inv(8)(p21q24). This pericentric inversion has not been previously described in ANLL. Because, fragile sites, zinc finger gene loci, and the MYC protooncogene have been localized to band 8q24, a putative role for these sites and genes could be considered.

High-dose therapy and autologous transplantation in amyloidosis-AL.

A 53-yr.-old woman with amyloidosis AL was treated with high-dose chemotherapy and autologous stem cell infusion in an attempt to suppress the amyloid secretion. A diagnosis of MGUS had been made six years earlier. During the last year her disease had progressively shifted to a full-blown picture of amyloidosis AL, with renal failure, proteinuria, renal amyloid deposition and plasma cell sheets in the marrow. After an unsuccessful attempt with standard-dose chemotherapy, she received a high-dose regimen of busulphan (14 mg/Kg) and melphalan (40 mg/m2), followed by the infusion of both autologous bone marrow and peripheral blood stem cells. She had full and prompt engraftment, but eight weeks post-graft developed interstitial pneumonitis: CMV was isolated. The patient died while in the intensive care unit. In the literature, this is the first case of amyloidosis AL treated with high-dose therapy and autologous transplantation.

ANLL patients with normal karyotype are not a homogeneous prognostic group.

BACKGROUND AND METHODS: Karyotype in ANLL is referred as an independent prognostic factor. The prognosis of diploid ANLL subjects has been defined as "good" by some authors, or, more recently, "intermediate" by others. This is a retrospective study on 30 consecutive heavy treated ANLL diploid patients with the aim to make a correlation among age, normal karyotype and response. Chromosomal banding studies were performed at presentation with GTG technique. Diploid patients were divided into two age groups < 60 years (17 cases) and > or = 60 (13 cases). Data were analyzed by NCSS software. RESULTS AND CONCLUSIONS: CR rate for the two diploid age groups was 94% and 38% respectively (p = 0.002). Median DFS and overall survival were 14.4 and 23.3 months, 4 and 5 months for the two subgroups respectively: these data were not statistically significative. The probability of achieving CR was not affected by blood counts and Karnofsky performance status on admission, but only by age. Though ANLL patients with the same karyotype have the same course regardless of other prognostic factors, this does not occur in our series of diploid patients. We suggest that a normal karyotype, at least as defined with the GTG technique, does not characterize a homogeneous group of patient. Heterogeneity in this group might be due to submicroscopic or molecular genetic changes; it can enhance the age as prognostic factor.