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PubMed2005

Lacunar infarcts: functional and cognitive outcomes at five years in relation to MRI findings.

BACKGROUND: There are few long-term follow-up studies of patients with lacunar infarcts (LIs). The purpose of this 5-year follow-up study was to assess functional and cognitive outcome in relation to MRI findings. METHODS: 81 patients with a first-ever LI were followed for 5 years with respect to mortality, stroke recurrence, functional and cognitive outcome. T(2)-weighted MRI was performed at baseline and at 5 years. The presence of basal ganglia lesions and white matter lesions was scored according to the European Task Force rating scale. Functional outcome was assessed with the Oxford Handicap Scale (OHP). Cognition was assessed with the Mini Mental State Examination (MMSE). RESULTS: The 5-year mortality was 19%. Predictors for death were age (OR = 1.07, 95% CI 1.03-1.11), ischemic heart disease (OR = 2.1, 95% CI 1.1-4.1) and impairment score (OR = 1.16, 95% CI 1.02-1.32). 30% of the patients had a recurrent stroke. Predictors for recurrent stroke were diabetes mellitus (OR = 1.7, 95% CI 1.2-7.4) and amount of white matter lesions (OR = 1.7, 95% CI 1.2-2.7). 36% of the patients were functionally dependent (defined as OHP >2). Predictors for functional dependency were impairment score (OR = 1.71, 95% CI 1.12-2.59), MMSE (OR = 0.55, 95% CI 0.33-0.91) and stroke recurrence (OR = 84, 95% CI 9.4-745). 16% of the patients had cognitive impairment (defined as MMSE <24). Stroke recurrence and white matter score, but not basal ganglia score, were correlated to cognitive impairment. CONCLUSIONS: Many LI patients have a good functional outcome at 5 years. For older patients, for patients with an initial severe stroke, and with additional vascular risk factors, however, the prognosis is more severe, with an increased risk for mortality, stroke recurrence, and physical and cognitive decline.

Analysis of Variance↗
PubMed2001

Molecular markers and long-term recurrences in a large cohort of patients with sporadic adrenocortical tumors.

Genetic alterations, such as loss of heterozygosity (LOH) at the 17p13 and 11p15 loci and overexpression of the insulin-like growth factor (IGF)-II gene, are associated with the malignant phenotype in sporadic adrenocortical tumors. A high risk of recurrence after surgery for adrenocortical tumors is predicted in cases with regional invasion or distant metastases. However, patients with localized tumors also have a high risk of recurrence. Reliable prognostic markers are required to identify subjects at high risk of recurrence. The aim of this study was to assess the prognostic value of three molecular markers (17p13 LOH, 11p15 LOH, and overexpression of the IGF-II gene) by assessing disease-free survival in a large series of adult patients with sporadic adrenocortical tumors. Adult patients (114) were prospectively followed up from diagnosis of the disease to June 1999 or to death. Malignancy was initially diagnosed in 18 patients (McFarlane stage III: n = 1 and stage IV: n = 17). The remaining 96 patients with localized adrenal disease at diagnosis (stage I: n = 60 and stage II: n = 36) were at risk of recurrence. Histological grade was assessed according to Weiss criteria, and tumors were classified into two groups (Weiss score or=4). Tumor samples were analyzed for LOH at the 17p13 and 11p15 loci and for IGF-II gene mRNA content. 17p13 LOH was a strong predictor of shorter disease-free survival in univariate analysis (P = 0.001; relative risk, 27), as were histological grade (Weiss score >or=4; P = 0.00001; relative risk, 15), 11p15 LOH (P = 0.004; relative risk, 9), tumor size (size >5 cm; P = 0.006; relative risk, 18), and overexpression of the IGF-II gene (P = 0.01; relative risk, 5). In a Cox proportional hazards regression model, histological grade (P = 0.04; relative risk, 4.2) and 17p13 LOH (P = 0.009; relative risk, 21.5) were independently associated with recurrence. Molecular markers, particularly 17p13 LOH, are predictive of long-term outcome in patients with sporadic adrenocortical tumors. In patients who have undergone curative surgery, routine assessment of these tumor markers is a useful complement to histological scoring for predicting recurrence and guiding decisions for subsequent follow-up and management.

Adolescent↗
PubMed1999

Hepatic resection for metastatic colorectal adenocarcinoma: a proposal of a prognostic scoring system.

BACKGROUND: Hepatic resection for metastatic colorectal cancer provides excellent longterm results in a substantial proportion of patients. Although various prognostic risk factors have been identified, there has been no dependable staging or prognostic scoring system for metastatic hepatic tumors. STUDY DESIGN: Various clinical and pathologic risk factors were examined in 305 consecutive patients who underwent primary hepatic resections for metastatic colorectal cancer. Survival rates were estimated by the Cox proportional hazards model using the equation: S(t) = [So(t)]exp(R-Ro), where So(t) is the survival rate of patients with none of the identified risk factors and Ro = 0. RESULTS: Preliminary multivariate analysis revealed that independently significant negative prognosticators were: (1) positive surgical margins, (2) extrahepatic tumor involvement including the lymph node(s), (3) tumor number of three or more, (4) bilobar tumors, and (5) time from treatment of the primary tumor to hepatic recurrence of 30 months or less. Because the survival rates of the 62 patients with positive margins or extrahepatic tumor were uniformly very poor, multivariate analysis was repeated in the remaining 243 patients who did not have these lethal risk factors. The reanalysis revealed that independently significant poor prognosticators were: (1) tumor number of three or more, (2) tumor size greater than 8 cm, (3) time to hepatic recurrence of 30 months or less, and (4) bilobar tumors. Risk scores (R) for tumor recurrence of the culled cohort (n = 243) were calculated by summation of coefficients from the multivariate analysis and were divided into five groups: grade 1, no risk factors (R = 0); grade 2, one risk factor (R = 0.3 to 0.7); grade 3, two risk factors (R = 0.7 to 1.1); grade 4, three risk factors (R= 1.2 to 1.6); and grade 5, four risk factors (R > 1.6). Grade 6 consisted of the 62 culled patients with positive margins or extrahepatic tumor. Kaplan-Meier and Cox proportional hazards estimated 5-year survival rates of grade 1 to 6 patients were 48.3% and 48.3%, 36.6% and 33.7%, 19.9% and 17.9%, 11.9% and 6.4%, 0% and 1.1%, and 0% and 0%, respectively (p < 0.0001). CONCLUSIONS: The proposed risk-score grading predicted the survival differences extremely well. Estimated survival as determined by the Cox proportional hazards model was similar to that determined by the Kaplan-Meier method. Verification and further improvements of the proposed system are awaited by other centers or international collaborative studies.

Adenocarcinoma↗
PubMed1999

Should African-American men be tested for prostate carcinoma at an earlier age than white men?

BACKGROUND: There have recently been challenges to testing high risk populations, i.e., African-American men younger than 50 years, for prostate carcinoma (PCa). The mortality rate of patients with PCa between ages 40 and 60 years is nearly 3 times greater among African-American men (AAM) compared with white men (WM). The literature in support of testing AAM at an earlier age than WM is sparse. Therefore, the authors present clinical and histologic data that support the testing of AAM at a younger age, utilizing data on patients with clinically localized PCa. METHODS: Examination of consecutive radical prostatectomy specimens from AAM and WM was performed from January 1991 to June 1996 among AAM and WM at Wayne State University, Harper Hospital, Detroit, Michigan. International, salvage prostatectomy, and neoadjuvant hormonal therapy patients were excluded, as were patients with lymph node metastasis. The authors examined biochemical recurrences of PCa in this cohort of men treated from January 1991 through December 1995. Univariate analysis of contingency tables was performed, using chi-squared-tests to assess the correlation between stage and race after stratification of patients by age group. Biochemical recurrence was analyzed using the Kaplan-Meier method and the log rank test. RESULTS: The authors examined radical prostatectomy specimens from 759 patients and biochemical recurrence outcome of 655 patients. AAM patients ages 50-69 years had higher prostate specific antigen levels, worse Gleason scores, more advanced stages of disease, and a higher recurrence rate. However, among men ages 70-79 years, there was no difference in these parameters between AAM and WM. Among men ages 40-49 years, a larger sample size is necessary to make meaningful comparisons. CONCLUSIONS: Data on the outcomes of men treated for clinically localized PCa demonstrated more advanced disease and more frequent recurrence among young AAM than among WM, young and of advanced age. These differences in disease severity and recurrence, in addition to the disproportionate mortality among young AAM, are strong evidence that AAM should be tested for PCa at an earlier age than WM.

Black or African American↗
PubMed1996

[Therapy of post-stroke depression with fluoxetine. A pilot project].

Depression is a common but often unrecognized complication after cerebrovascular stroke. Tricyclic antidepressants (TCA) have been found to be effective in poststroke depression, but side effects such as orthostatic hypotension, arrhythmia limit their wider use. In this pilot study the effects of treatment with the specific serotonin reuptake inhibitor (SSRI) fluoxetine (20 mg) in 10 severely depressed patients (HAM-D score between 27 and 35) after cerebrovascular stroke were investigated. Four patients dropped out of the study prematurely because of worsening of their condition (n = 4) and one patient discontinued the study because of transfer to a nursing home. After 3 weeks of fluoxetine treatment there was a significant amelioration in all the measured scores (HAM-D, Beck, CGI and Barthel: P < 0.05). At the end of the study one patient with recurrent cerebrovascular lesions still had an HAM-D score of 25, but the other four patients had HAM-D scores between 6 and 11. The physical rehabilitation scores measured with the Barthel Index showed negative correlations with the HAM-D, Beck and CGI scores for most items; this has to be interpreted with caution considering the number of patients involved in this investigation. The authors suggest that future double blind trials are warranted to test the efficacy of fluoxetin therapy for poststroke depression. Methodological problems in connection with pharmacological trials in these severely ill patients are discussed.

Aged↗
PubMed2004

Double-blind comparison of hepatitis C histological recurrence Rate in HCV+ Liver transplant recipients given basiliximab + steroids or basiliximab + placebo, in addition to cyclosporine and azathioprine.

BACKGROUND: Hepatitis C virus (HCV) recurrence in HCV+ liver transplant recipients is almost inevitable and may be promoted by immunosuppression. We compared the amount of liver damage with regard to usage of steroids and basiliximab. METHODS: A total of 140 HCV+ adult liver transplant recipients were randomly allocated to basiliximab + steroids or basiliximab + placebo (plus cyclosporine and azathioprine). Primary endpoint: hepatitis C histological recurrence (liver damage as for Ishak grading score >or=8 by biopsy at 12 months); secondary endpoints: treatment failure (death, graft loss, patient withdrawal), biopsy proven acute rejection (BPAR), treated acute rejection (tAR), allograft and patient survival rates at 12 months. RESULTS: Any significant difference has been observed in the 12-month hepatitis C histological recurrence rate (41.2% basiliximab + steroids, 37.5% basiliximab + placebo, P = 0.354). The treatment failure rate was significantly higher in basiliximab + steroids (28.8%) than in basiliximab + placebo (15.6%), P = 0.03; the combination test for the evaluation of the joint hypothesis resulted in a borderline nonsignificant overall result (P = 0.059). BPAR rate was significantly lower in the group treated with steroids (24.3% basiliximab + steroids, 39.4% basiliximab + placebo, P = 0.04), while the tAR rate was similar (29.7% basiliximab + steroids and 37.9% basiliximab + placebo). Any significant differences in 1-year graft and patient survival rates have been observed (72.9% and 84.8% basiliximab+steroids; 81.5% and 89.0% basiliximab + placebo). CONCLUSIONS: Results suggest that steroid-free therapy is associated with a significantly lower treatment failure rate, although histological recurrence rate of hepatitis C is similar in the two groups. This benefit is not offset by an evident increase in graft rejection rate requiring treatment.

Adrenal Cortex Hormones↗
PubMed2006

[Prognostic factors of early recurrence of colorectal liver metastases and their usage in clinical praxis].

Liver surgery for colorectal liver metastases (CLM) is very often followed by recurrence. The prediction of early relapse of CLM is important for successful treatment, long disease free period and for long survival of patients, because it could help us to choose adequate surgical and oncological treatment. The authors present contemporary overview of the prognostic factors of early CLM recurrence and their possible use in prognostic scoring systems. These could be very helpful in clinical practice.

Colorectal Neoplasms↗
PubMed2003

Time trends in biochemical recurrence after radical prostatectomy: results of the SEARCH database.

OBJECTIVES: To determine whether in the prostate-specific antigen (PSA) era stage and/or grade migration of patients treated with radical prostatectomy (RP) has occurred. We also examined whether the biochemical recurrence rates after RP have changed with time. METHODS: A total of 1654 patients from the Shared Equal Access Regional Cancer Hospital (SEARCH) database were analyzed for time trends in age, preoperative PSA level, clinical stage, biopsy Gleason score, prostatectomy Gleason grade, pathologic stage, margin status, and recurrence rates after RP. Results were stratified into three 4-year blocks of time between 1988 and 2002 for analysis. RESULTS: The preoperative PSA level, patient age, tumor stage, rate of capsular penetration, and lymph node involvement decreased with time. Both biopsy and pathologic Gleason grade steadily increased with time. The positive margin rate and incidence of seminal vesicle involvement remained stable. On multivariate analysis, only serum PSA level (P <0.001) and biopsy Gleason score (P <0.001) were significant independent predictors of the time to recurrence after RP. The year of surgery was not a significant independent predictor of biochemical recurrence after RP in multivariate analysis. CONCLUSIONS: Despite lower stage and lower PSA levels with time, we found no improvement in PSA recurrence rates over time. This may reflect lead-time bias in detecting PSA recurrence by the use of more sensitive PSA assays in recent years.

Age Factors↗
PubMed1983

Methotrexate and 5-fluorouracil in sequence in squamous head and neck cancer.

5-Fluorouracil (5-FU), when preceded by methotrexate (MTX), results in synergistic tumor cell kill both in vitro and in vivo in mice. Since MTX concentrations 10 microM or greater maximize the synergy in vitro, we administered sequential MTX-5-FU as follows: MTX 125-250 mg/m2 i.v. followed 1 hr later by 5-FU 600 mg/m2 i.v. Leucovorin (LV) rescue 10 mg/m2 i.v. was given at hr 24, then 10 mg/m2 p.o. every 6 hr for 5 doses. One-hour and 24-hr serum MTX levels were monitored and 24-hr serum creatinine levels obtained. A weekly schedule was adhered to where possible, although most patients had at least one course delayed during the first month of treatment because of toxicity. Maintenance was every 2 wk. Since our initial report (Proc Am Soc Clin Oncol 21:473, 1980), a total of 35 squamous cell head and neck cancer patients, 12 with de novo and 23 with recurrent or metastatic disease, have been treated. Overall response rate is 71%, 65% in recurrent patients, 83% in de novo patients. Complete response rate was 11%. Median response duration for recurrent patients was 3.6 mo. With all deaths scored as disease-related and a minimum follow-up of 18 mo in all patients, a median survival of 11.5 mo for the 23 recurrent and 12 mo for the de novo patients was seen. Pretreatment performance status affected survival with Eastern Cooperative Oncology Group (ECOG) 0-1 patients living significantly longer than bedridden patients (p less than 0.001). Toxicity was either hematologic or gastrointestinal, with diarrhea, the limiting toxicity, accounting for the one drug-related death. The MTX/5-FU combination sequence may provide significant long-lasting palliation in patients with recurrent squamous head and neck cancer.

Carcinoma, Squamous Cell↗
PubMed2003

Endoscopic color Doppler ultrasonographic evaluation of recurrent esophagogastric varices following endoscopic injection sclerotherapy.

BACKGROUND: Endoscopic injection sclerotherapy (EIS) for treatment of esophagogastric varices is well established in Japan. However, varices may still recur unpredictably following EIS. We studied this problem using endoscopic color Doppler ultrasonography (ECDUS) and specifically examined esophagogastric blood flows. METHODS: Prophylactic EIS was performed by intravariceal injection of 5% ethanolamine oleate (EO) in 49 patients with esophageal varices secondary to liver cirrhosis. No patient had documented hepatocellular carcinoma (HCC) before EIS, and patients who developed HCC during follow-up were excluded. We performed ECDUS before EIS, and 2 weeks and 2 years later. The esophagogastric intra- and extramural venous blood flows, including flow in the azygos vein, were compared between these observations. Gastric intramural blood flow and changes in extramural gastric blood flow, including the azygos vein flow, were scored. Dynamic computer tomography (CT), ultrasonography (US), and color Doppler-ultrasonography (CDUS) were also performed before EIS and 1 month following the procedure. Thereafter, patients underwent CT and US examinations every 6 months for 2 years to detect any development of porto-systemic shunts or HCC. RESULTS: The average number of EIS procedure per patient was 3.1+/-0.8 (mean+/-SD), and the total amount of sclerosant injected was approximately 33.5+/-6.5 ml. The overall recurrence rate over the 2-year follow-up was 36.7%. The gastric intra- and extramural blood flows did not differ between those patients with or without major shunts before EIS. In patients with recurrent variceal formation, the gastric intramural blood flow score following EIS (2.1+/-0.5) was significantly higher than that in patients without recurrence (0.8+/-0.6) (P<0.01). In addition, gastric extramural blood flow score following EIS (0.8+/-0.6) was significantly lower in patients with recurrence than that in those without recurrence (1.7+/-0.5) (P<0.01). The same differences held after exclusion of patients with major shunts. The gastric intramural blood flow score in patients with recurrent variceal formation (2.1+/-0.4) was significantly higher than that in patients without recurrence score (P<0.01). Moreover, gastric extramural blood flow score in patients with recurrent variceal formation (1.0+/-0.7) was significantly lower than in patients without recurrence (1.6+/-0.5) (P<0.01). CONCLUSIONS: Two characteristics were observed in patients with recurrent cases of esophageal varices 2 weeks following EIS. The first was the maintenance of gastric intramural blood flow. The second was the absence of dilation of the gastric extramural blood vessels. These observations may enable us to predict the recurrence of esophagogastric varices using ECDUS within 2 weeks following EIS.

Journal Article↗
PubMed2005

Microvessel density for melanoma prognosis.

AIMS: Two-hundred and four accessible cases of malignant melanoma from the Grampian region of Scotland, collected over a period of 4 years, were studied for standard prognostic indicators for comparison with microvessel density. METHODS AND RESULTS: The range of tumour thickness varied from in-situ melanoma to 14.8 mm. Microvessel density was assessed using the Chalkley technique on sections immunostained with CD31 antibody to identify endothelium. Vessel counts were performed in the peritumoral host tissue of all specimens. Strong correlation was observed between microvessel density at the tumour edge and tumour thickness (P < 0.001). Multifactorial regression analysis confirms Chalkley estimation as a reliable predictor of the risk of recurrence of melanoma (P < 0.005). The predictive value was found to be superior to the Breslow score, for tumours more than 2 mm thick. CONCLUSIONS: Microvessel assessment of primary melanoma using the Chalkley score technique provides reliable prognostic information on the risk of recurrence of the tumour, particularly for melanomas deeper than 2 mm. It remains to be seen whether this methodology can predict response to novel anti-angiogenic therapies currently entering trials.

Adult↗
PubMedDate not supplied

Is reoperation for recurrence of glioblastoma justified?

The purpose of the present study was to determine the effect of surgery on the time length and quality of survival in patients with recurrent glioblastoma multiforme. Two groups were compared; the first included 18 patients who underwent surgery at the time of tumour recurrence. The second group included 36 patients who did not undergo surgery at the time of tumour recurrence. Both groups were matched according to the following criteria: gender, age, Karnofsky Performance Scale (KPS) score, at the time of initial surgery and of tumour recurrence, extent of initial surgery, interval between initial surgery and tumour reccurence. Both groups received conventional treatment after initial surgery. There are no statistically significant differences between the two groups as regards to the previously mentioned criteria. After tumour recurrence, the median survival time was 5 months in the group of patients undergoing a second resection and 2 months in the group of patients not undergoing repeat surgery. The difference was statistically significant on univariate analysis. Moreover, the median length of time spent in an acceptable condition (KPS >/=60) from the time of tumour recurrence was found to be significantly longer in patient who underwent a second resection (4 months) compared with patients who did not undergo repeat surgery (1 month). Even in a relatively favorable subgroup of reoperated patients, the survival benefit although significant was only 3 months. It was impossible to completely match the two groups of patients suggesting that the difference might have been even less. Although symptomatic improvement is modestly achieved by repeat surgery, its transient nature necessitates clear discussion with patient and family on an individual basis.

Adult↗
PubMed2006

Quality of life after radiofrequency ablation combined with transcatheter arterial chemoembolization for hepatocellular carcinoma: comparison with transcatheter arterial chemoembolization alone.

OBJECTIVE: Comprehensive studies are scarce with regard to the quality of life (QOL) of hepatocellular carcinoma (HCC) patients after transcatheter arterial chemoembolization (TACE) and/or radiofrequency ablation (RFA) treatment. The purpose of this study was to examine the impact of TACE alone and that of the TACE followed by RFA (TACE-RFA) on QOL in HCC patients. METHODS: QOL was measured using the Functional Assessment of Cancer Therapy-General (FACT-G) (Version 4.0) questionnaire, translated into Chinese, as a measure of QOL among Chinese HCC patients. Prospectively, 83 patients in both TACE group (n = 40) and TACE-RFA group (n = 43) completed the questionnaire at baseline and 3 months after treatment, respectively. RESULTS: The TACE-RFA group resulted in a significantly higher total QOL score, socio-family well-being score, and functional well-being score than that of TACE group, 3 months after respective treatment. Liver function, tumor recurrence and complication, age, income were the most important factors affecting the QOL of HCC patients after treatment. The logistic regression analyses showed that Child-Pugh Class and tumor recurrence after treatment were independent predictors of post-treatment QOL scores of HCC patients. CONCLUSIONS: The overall QOL of HCC patients in TACE-RFA group was maintained at a relatively higher level than that of TACE group. TACE followed by RFA appeared to be more favorable than TACE alone with respect to QOL.

Aged↗
PubMed1986

Fall risk index for elderly patients based on number of chronic disabilities.

The present study was designed to identify prospectively the individual chronic characteristics associated with falling among elderly persons and to test the hypothesis that risk of falling increases as the number of chronic disabilities increases. Seventy-nine consecutive admissions to three intermediate care facilities were evaluated. Twenty-five of the subjects became recurrent fallers. The nine risk factors included in the fall risk index were mobility score, morale score, mental status score, distant vision, hearing, postural blood pressure, results of back examination, postadmission medications, and admission activities of daily living score. A subject's fall risk score was the number of index factors present. The proportions of recurrent fallers increased from 0 percent (0 of 30) in those with 0 to three risk factors, to 31 percent (11 of 35) in those with four to six factors, to 100 percent (14 of 14) in those with seven or more factors. Falling, at least among some elderly persons, appears to result from the accumulated effect of multiple specific disabilities. Some of these disabilities may be remediable. The mobility test, the best single predictor of recurrent falling, may be useful clinically because it is simple, recreates fall situations, and provides a dynamic, integrated assessment of mobility.

Accidents↗
PubMed1999

The effect of a Mensendieck exercise program as secondary prophylaxis for recurrent low back pain. A randomized, controlled trial with 12-month follow-up.

STUDY DESIGN: A prospective, randomized, controlled trial with a stratification block design in which a Mensendieck exercise program was compared with the experience of a control group. OBJECTIVE: To evaluate the effect of a Mensendieck program on the incidence of recurrent episodes of low back pain in patients with a history of the condition who currently are working. SUMMARY OF BACKGROUND DATA: One episode of low back pain increases the risk of further episodes of the condition. The Mensendieck approach combines education and exercise. This approach has been used for many years in Scandinavia and the Netherlands. However, the effects on low back pain have not been evaluated previously in a randomized, controlled trial. METHODS: A total of 77 men and women, mean age 39.6 years (range, 21.2-49.8 years), who had finished treatment for a low back pain episode, were stratified according to incidence of low back pain episodes and symptoms of sciatica over the preceding 3 years. The patients were assigned at random to either the Mensendieck program or a control group. The Mensendieck group received 20 group sessions of exercises and ergonomic education in 13 weeks. At 5- and 12-month follow-up examinations, the patients were assessed for recurrence of low back pain, days of sick leave, low back pain, and functional scores. RESULTS: After 12 months, there was a significant reduction in recurrent low back pain episodes in the Mensendieck group compared with the control group (P < 0.05). There was a trend toward fewer days of sick leave because of low back pain in the Mensendieck group, but no significant differences between the groups. There was reduction in pain and improvement in function in both groups, with no significant differences between the groups. CONCLUSIONS: A secondary prophylaxis Mensendieck exercise program of 20 group sessions significantly reduced the incidence of low back pain recurrences in a population with history of the condition. However, there were no differences between the groups with regard to days of sick leave, low back pain, and function.

Activities of Daily Living↗
PubMed1996

A prospective trial of self-expanding metal stents in the palliation of malignant esophageal obstruction after failure of primary curative therapy.

BACKGROUND: Self-expanding metal stents have been shown to be safe and effective for the primary palliation of patients with inoperable malignant esophageal obstruction. We sought to determine their safety and efficacy in patients who fail curative therapy. METHODS: Seventeen patients with esophageal carcinoma who had recurrent dysphagia after radiation, surgery, or chemoradiation therapy for esophageal carcinoma were studied. All patients had recurrent dysphagia, and an uncovered metal stent was inserted for palliation. Patients were followed-up at 4-week intervals until death. Palliation was measured by a dysphagia score and the Karnofsky index. RESULTS: Seventeen patients with recurrent dysphagia after primary treatment with surgery (n = 4), radiation (n = 11), and chemoradiation (n = 2) received uncovered Wallstents for palliation of dysphagia. The dysphagia score improved by at least 1 point in all patients. Thirteen of 17 patients had a 2 point improvement in the dysphagia score. The Karnofsky index improved significantly (from 58 +/- 3 to 66 +/- 3, p = 0.0002). Fourteen of the 17 patients had patent stents until death. Three of 12 patients (25%) died of stent-related complications (bleeding in 1, septic complications in 2 patients). CONCLUSIONS: Patients with recurrence of esophageal carcinoma after surgery can be successfully treated with metal stents, but patients who have received radiation therapy with curative intent may be at greater risk for complications because of radiation-induced tumor necrosis and vascular changes in the esophageal wall. Larger prospective studies are necessary to clarify this issue.

Aged↗
PubMedDate not supplied

Prognostic value of the percentage of positive fragments in biopsies from patients with localized prostate cancer.

OBJECTIVE: To assess the prognostic value of the percentage of positive fragments (PPF) in biopsies from patients with localized prostate cancer (PCa) undergoing radical prostatectomy. MATERIALS AND METHODS: During the period from March 1991 to November 2000, 440 patients were selected. Cases receiving neoadjuvant or adjuvant hormone therapy, or adjuvant radiotherapy, were excluded, as were cases presenting Gleason scores higher than 6 at biopsy. PPF was defined as the total number of fragments divided by the total number of biopsy fragments times 100. This variable was initially divided into categories from 0 to 25%, 25.1% to 50%, 50.1 to 75% and 75% to 100%. During the postoperative period, patients were assessed every 2 months for 1 year, then every 6 months for 5 years, and then yearly. Biochemical recurrence was defined as serum PSA higher than or equal to 0.4 ng/mL. Median follow-up was 60 months. RESULTS: One hundred and nine (24.8%) of the 440 patients under study had biochemical recurrence. In the univariate analysis, PPF significantly influenced disease-free survival (log-rank, p < 0.001), and patients with PPF between 75 and 100% presented a risk of a biochemical recurrence of the disease 3 times higher than patients with PPF between 0 and 25% (p < 0.001). After the Cox regression analysis, both serum PSA (p = 0.001) and PPF (p < 0.001) showed to be independent predictive factors for disease-free survival following surgery. CONCLUSION: PPF measurement in biopsy is a simple and practical method, which should be routinely used as a predictive factor for biochemical recurrence in patients with PCa presenting Gleason scores between 2 and 6.

Biopsy↗
PubMed1997

PCNA and p53 in urinary bladder cancer: correlation with histological findings and prognosis.

BACKGROUND: This study aimed to immunohistochemically examine the expression of proliferating cell nuclear antigens (PCNA) and p53 protein in transitional cell carcinomas (TCC) of the urinary bladder, and to investigate possible correlations of this expression with the tumor grade or stage, tumor recurrence, and prognosis of the disease. MATERIALS AND METHODS: The immunohistochemical status of the PCNA and p53 proteins were determined on paraffin-embedded sections from 128 patients with TCC of the urinary bladder, using PC-10 and DO7 as the primary antibodies. Positive stainings were represented by scores (Labeling Index; LI, %) calculated as the percent of positive cells among all neoplastic cells counted. The findings were compared to the patients' histopathological features. Patients who underwent transurethral resection were divided into groups with "low" and "high" scores for PCNA and p53, respectively, and the tumor recurrence rate was compared among the groups. Patients who underwent total cystectomy were similarly divided into "low" and "high" score groups, and survival rates of the groups were compared. RESULTS: PCNA expression was observed in 66 of 128 patients (51.6%), with a mean labeling index of 26.6%. Overexpression of p53 was observed in 65 of 128 patients (50.8%), with a mean labeling index of 35.3%. There were significant correlations of the PCNA and p53 indices with both histological grade and stage of the tumor. In the TUR group, there were no statistically significant differences in recurrence rate between the groups with high or low scores for either PCNA or p53. In the total cystectomy group, there was a significant correlation between survival rate and positive staining for PCNA, but not for p53. The relationship between 2 parameters, PCNA and p53 scores, was not significant (linear correlation coefficient, r = 0.67). CONCLUSIONS: PCNA and p53 status in transitional cell carcinomas of the urinary bladder is related to the histopathological findings. We also suggest that immunohistochemical staining for PCNA provides significant clinical information which may be useful in the initial selection of therapy. However, overexpression of p53 does not appear to represent an independent prognostic marker in bladder tumors.

Adult↗