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STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
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Robert T. Eberhardt, MD
Although standard morphologic evaluation shows no evidence of residual leukemia gastritis from stress generic 10 mg metoclopramide fast delivery, a state of minimal residual disease exists gastritis diet ìòñ cheap metoclopramide 10 mg amex, with estimates for the remaining leukemia burden approaching approximately 10 billion cells chronische gastritis definition buy discount metoclopramide 10 mg on line. A number of laboratory techniques have been introduced in an effort to increase the resolution of detecting remaining leukemia cells (Table 46 gastritis diet ppt 10 mg metoclopramide. Although none of the available assays are ideal, current studies of minimal residual disease are attempting to establish the clinical validity of such measures and whether the results from these assays may form the basis for therapeutic decisions in individual patients. Despite the limitations of morphologic evaluation, clinical standards have been adopted to define outcomes and establish reference points from which therapies can be compared. The peripheral blood should not contain circulating blasts (in the absence of growth factor use), and there should be no evidence of extramedullary disease. The ability to achieve such a response has been directly correlated with survival and is a necessary first step in a curative treatment strategy. Although some research studies have chosen to categorize lesser responses and define partial remission (or response), the inability to morphologically clear leukemia cells from the bone marrow is a treatment failure with grave implications for the patient. Current treatment strategies divide therapy into two basic parts: induction and postremission therapy. The goal of postremission therapy is to eradicate minimal residual disease, thus preventing relapse and effecting a cure. Different approaches to postremission therapy have been used and defined by a number of studies. Consolidation therapy is used to describe immediate postremission treatment regimens that are similar to induction therapy. Maintenance is defined as therapy given in greatly attenuated doses over extended periods. Relapse is usually heralded by a change in a previously normal complete blood cell count. Reduction in normal cells or the reappearance of blasts in the peripheral blood occur frequently; isolated extramedullary relapse is infrequent. Examination of the bone marrow confirms the relapse by demonstrating more than 5% blasts. In situations in which there is only a borderline increase in blasts, it may be necessary to repeat the bone marrow examination in 1 to 2 weeks to confirm relapse. Successful clinical management requires a detailed understanding of likely complications accompanied by early therapeutic intervention designed to minimize life-threatening toxicities. With regard to these principles, much of the improvement seen in the care of leukemia patients in the last few years can be directly attributed to advances in supportive care. Infection and hemorrhage are the primary cause of death in patients with leukemia. Virtually all patients develop these complications after treatment with chemotherapy. Common regimens include an antipseudomonal penicillin or cephalosporin coupled with an aminoglycoside. Monotherapy with a third-generation cephalosporin, such as ceftazidime, or a carbapenem, such as imipenem, is an alternative. Changes in the initial antibiotic coverage are based either on the sensitivities of the organisms isolated or persistence of fever. Continued fever, despite 4 to 6 days of antibacterial therapy usually requires empiric antifungal therapy with amphotericin B. Additionally, patients with indwelling central venous catheters or other prosthetic devices may require the early institution of vancomycin. Patients who have a documented bacterial source of infection should complete at least a 10- to 14-day course of therapy, whereas those patients with evidence of infection secondary to invasive mycoses may require a more protracted course of therapy. Despite the accepted approach to empiric therapy in patients with leukemia and neutropenic fever, there is considerable controversy regarding infection prophylaxis, use of protected environments, reverse isolation, transfusion of granulocytes, or the use of hematopoietic growth factors to accelerate recovery. Immediate access to blood products is critical to sustain the patient; the hemoglobin level should be maintained at 8 g/dL or higher in patients with other medical comorbidities (pulmonary disorders or coronary heart disease). Hence, platelets are not only transfused in response to hemorrhage, but also to prevent hemorrhage. The routine use of platelet transfusions has had a significant effect on the incidence of hemorrhagic death. Patients who are either febrile or have other complicating medical conditions such as severe mucositis or ongoing coagulopathy, require prophylactic transfusions at higher levels. This may result either from alloimmunization in the patients who have received multiple transfusions or may be secondary to other medical conditions such as persistent fever or disseminated intravascular coagulation. This refractoriness poses a particularly difficult management problem for the clinician. The coagulopathy has been attributed to the release of procoagulants from the leukemia cells as they lyse. The contribution of increased fibrinolysis to this hemostatic disorder has come under scrutiny. Laboratory tests that are useful as indicators of coagulopathy include the platelet count, prothrombin time, activated partial thromboplastin time, thrombin time, fibrinogen, fibrin split products, and d-dimer. Clinical management relies on frequent monitoring of the patient with intervention based on a deteriorating clinical status or worsening trend in a laboratory value such as fibrinogen. The hemostatic abnormalities typically abate after the leukemia burden has been reduced. Metabolic abnormalities can exist in the leukemia patient at presentation or with the institution of therapy. Rapid leukemia cell death releases intracellular metabolites, notably uric acid, potassium, and phosphorus, causing a life-threatening metabolic condition known as the tumor lysis syndrome. Uric acid, a product of purine metabolism, may then deposit in the joints, causing a gouty arthropathy or, more important, in the renal parenchyma or collecting system, resulting in renal failure. Prevention of these complications is usually accomplished by instituting vigorous hydration with a brisk urine output (greater than 150 mL/h) and administering allopurinol before beginning cytotoxic therapy. Alkalinization of the urine by adding sodium bicarbonate to the intravenous fluids, administering a carbonic anhydrase inhibitor (such as acetazolamide), or both are recommended in extreme cases, or in patients allergic to allopurinol, to increase the solubility of the uric acid. Complications, such as cardiac disturbances with hyperkalemia or the precipitation of calcium phosphate resulting in renal failure due to hyperphosphatemia, can be avoided in most cases with early attention to metabolic disturbances. Correction of these abnormalities is best accomplished by aggressive hydration with concominant diuresis to wash out the toxic by-product of the dying leukemia cells. Additional benefit may be gained by using oral phosphate binders (aluminum hydroxide or calcium acetate) to minimize absorption of additional phosphate from dietary sources. In situations in which hyperkalemia is complicated by renal insufficiency, cation exchange resins (Kayexalate) may be indicated. Extreme circumstances may require renal dialysis to correct multiple abnormalities. The ability to rapidly decrease the circulating blast number, however, is an important factor for survival in these patients. Instead, immediate treatment with chemotherapy should be undertaken with careful attention to the expected metabolic abnormalities discussed previously. Although it is possible to support patients for a period with supportive medical care, they ultimately succumb to the complications associated with bone marrow failure: infection or hemorrhage. Most patients seek medical attention for symptoms related to infection or bleeding, and these patients typically require immediate therapeutic intervention. Other patients are not candidates for cytotoxic therapy because of a poor performance status or other active severe medical comorbidities that complicate their care. The risks and potential benefits and alternatives should be carefully considered in each case and discussed with the patient and the family. Prognostic Features in Adult Acute Leukemia Historically, the diagnosis of acute leukemia has left the physician with few therapeutic options. Subsequently, a number of other single agents were demonstrated to have antileukemic activity at first in the laboratory and then later in the clinic.
Syndromes
The deflated right lung may be brought completely into the field by placing folded sponges behind the hilum (for elevation) gastritis medicine cvs generic metoclopramide 10 mg on line. Metastases may be resected with the lung inflated chronic gastritis for years discount metoclopramide 10mg online, but the metastases must be marked with a suture gastritis diet áèãñèíåìà discount 10 mg metoclopramide fast delivery, and metastases deep within the parenchyma may be difficult to resect with wedge excision alone gastritis eating habits discount 10mg metoclopramide with mastercard. Exposure of the left lower lobe through a median sternotomy may be more difficult than exposure of the other lobes because of the overlying heart. With appropriate gentle traction on the pericardium, the left lower lobe can be exposed readily and brought into the operative field. Technical aids, such as an internal mammary artery retractor, may provide for better exposure, particularly for basilar (left lower lobe) tumors or posterior hilar left lower lobe masses. The posterolateral thoracotomy is a familiar and "standard" approach to pulmonary resection for carcinoma of the lung, although several authors encourage median sternotomy for both resection of lung carcinoma 38 and for pulmonary metastases. Improvements in postoperative pain management with intercostal nerve analgesia, thoracic epidural analgesia, and patient-controlled analgesia can control or even eliminate postoperative pain. The posterior or posterolateral thoracotomy does provide better exposure for metastases located posterior and near the hilum, particularly on the left side, and limits the surgeon to one hemithorax. In only rare circumstances would bilateral thoracotomies be performed in the same patient during the same operation. Prior evaluation of patients with sarcomas and unilateral nodules demonstrated bilateral metastases in 38% to 60% of patients. A posterolateral thoracotomy approach may be required for left lower lobectomy in patients with obesity, cardiomegaly, or an elevated left hemidiaphragm. Nodules should not be "shelled out," because viable tumor cells remain on the periphery of the resected area. Mediastinal lymph nodes can also be examined for potentially rare involvement from pulmonary metastases. Even patients at increased physiologic risk from thoracotomy may tolerate a simple wedge resection of the lung without difficulty. The frequency of bilateral and occult metastases, particularly in sarcoma, precludes the use of thoracoscopy. Complications specific to thoracoscopic resection of pulmonary metastases have been described. The surgeon must consider the technical skills required, the desired objectives for the patient, the instrumentation available for manipulation of the lung and other thoracic organs, and an assessment of the risk of a "closed" versus "open" procedure. The obvious chest wall implant from tumor seeding has devastating effects on the patient. B: Video-assisted thoracic surgery resection was performed for complete resection of a granuloma. For example, patients followed for a minimum of 5 years (survivors) or until death provide an absolute 5-year survival rate (number patients alive of all patients studied); patients followed for varying periods. Actuarial survival and disease-free survival may be estimated using the method of Kaplan and Meier. Univariate analysis (or comparisons between groups) may be made using the generalized Wilcoxon test of Gehan 52 or log-rank test; if sample sizes are small, the Thomas exact test 53 may be used. Multivariate analysis evaluates the predictive ability of two or more prognostic indicators to provide additional prognostic value. Although identification of trends is helpful, analysis of factors that are associated with improved survival depend on a single histology and a group of patients sufficiently large from which to draw conclusions. Prognostic indicators have been reviewed to assess their association, singularly and in combination, with postresection survival in patients with pulmonary metastases and to assist clinically in better selecting appropriate patients for resection of pulmonary metastases. In addition, resectability, technique of resection, nodal spread, the number of metastases and their location, and re-resection may be examined postoperatively. Thirty-nine patients were deemed resectable and underwent one or more thoracic explorations for resection of their metastases. A multivariate analysis did not find any combination of factors to be more predictive than the number of nodules identified on preoperative tomograms. The only factor associated with improved survival after relapse (in the lungs) was complete resection of all metastases, rendering the patient disease-free (P =. The patients received three cycles of preoperative chemotherapy with methotrexate, Adriamycin, and cisplatin. Patients underwent surgery approximately 1 month later and received chemotherapy postoperatively (Adriamycin and ifosfamide). With chemotherapy and surgery for pulmonary metastases, the 3-year survival rate was 61%, compared to 79% in patients without metastases. Of all patients with pulmonary metastases who died, they died of progressive pulmonary metastases. Patients with synchronous pulmonary metastases with their primary tumor have a worse survival rate, even with chemotherapy and complete resection. Using multivariate analysis, the number of nodules (four or more) was the most significant prognostic indicator. The addition of tumor histology (malignant fibrous histiocytoma) improved the predictive ability of this model. A: Overall survival for patients with pulmonary metastases from soft tissue sarcoma. Patients were selected for surgery based on the potential for complete resection of their metastases. Patients with complete resection have an associated survival advantage over patients with incomplete resection or unresectable metastases. Five patients had a complete response (not surgically confirmed) and recurred 5 to 57 months later. Resectable patients had a median survival of 30 months and an actuarial 5-year survival rate of 25% (see. Complete resection was associated with an improved survival compared to unresectable patients (see. Postthoracotomy survival cannot be predicted from initial response to this chemotherapy regimen. In addition, the combination of both chemotherapeutic agents may be greater than either single agent. The value of chemotherapy as an adjuvant is unknown, but several studies suggest a modest relapse-free and survival benefit. Chemotherapy remains the major treatment modality for metastases in multiple sites. Resection of all disease in the lung may enhance postresection survival in these children with resectable metastases. Patients with four or fewer nodules have better survival than patients with four or more nodules. Biopsy of suspicious lesions is needed to confirm the presence of local recurrence or distant metastases. Poor 2-year survival rate (less than 10%) occurred in those patients with multiple recurrence sites. Resection of isolated metastases appears to benefit a portion of patients with metastatic disease. Other sites of metastasis include the skin and soft tissues of the head and neck, trunk, and extremities. Anderson Cancer Center in Houston, 84 102 patients with myxoid tumors had 33 distant recurrences. In this study, pleomorphic tumors more frequently recurred in the lung (10 of 18 patients recurred: three of ten extrapulmonary, seven of ten pulmonary) than did the myxoid tumors (P <. The location of metastases is commonly the lungs, lymph nodes, soft tissues, bone, liver, and other sites. Most patients (n = 61) had an intraabdominal primary site of high-grade leiomyosarcoma. Even with resection in 14 patients, all recurred; however, a median survival of 30 months was achieved. The opportunity for complete resection of hepatic metastases is rare, but complete resection of hepatic metastases must be considered to obtain a survival advantage. Even if synchronous lung metastases were present, complete resection of all metastases provided the patient with a survival of 11. Patients with prior colorectal neoplasms have had pulmonary metastases resected with prolonged postresection survival. An absolute distinction cannot be made between a single carcinomatous metastasis and a primary bronchogenic carcinoma except by direct visual comparison between the two neoplasms. As with other isolated pulmonary metastases, patients with pulmonary metastases from colorectal carcinoma may be resected safely with low morbidity and mortality and long-term survival (see.
Best 10mg metoclopramide. Gastritis Symptoms: Try These Natural Remedies for Gastritis.
More recently atrophische gastritis definition 10 mg metoclopramide amex, aggressive curative approaches to remove and replace these adjacent structures have been reported gastritis diet 21 order metoclopramide 10 mg, with some long-term survivors gastritis upper right quadrant pain order metoclopramide 10 mg fast delivery. Invasion of the mediastinal pleura chronic gastritis meaning purchase 10 mg metoclopramide fast delivery, pericardium, or mediastinal fat also constitutes T3 disease. In many instances, en bloc resection of the involved mediastinal tissue can accomplish a complete resection. In such patients, whenever possible, technical resectability should be determined preoperatively. Of 225 patients analyzed in this series, only 22% had tumors that could be completely resected, 44% had totally unresectable disease and, in 34%, tumors were incompletely resected. In this sole report of the results of mediastinal invasion, brachytherapy was used in incomplete resections, with a surprising 22% survival rate in this small subset of patients. A more recent reanalysis of this group of patients confirmed a 30% to 40% 5-year survival rate in patients with completely resected T3N0 disease. Tumors invading the diaphragm frequently spread along the diaphragmatic pleura, and most patients present with a malignant pleural effusion (T4) that usually is unresectable. In the occasional patient, focal diaphragmatic invasion can be completely resected by lobectomy and en bloc resection of the diaphragm, replacing this structure with a synthetic mesh or fabric. Even with completely resected tumors, of 32 patients with lymphatic metastases in T3 lesions, only 20% survived 5 years, and few if any survive 5 years when mediastinal nodes are involved. The existence of N2 disease remains the most controversial area for primary surgical management of lung cancer. Although potentially resectable, once ipsilateral mediastinal or subcarinal lymph nodes (or both) are involved by tumor, the ultimate prognosis is much worse. When disease is diagnosed preoperatively either by noninvasive or invasive staging techniques, fewer than 10% of all patients treated with primary surgery survive 5 years, no matter the adjuvant therapy. Selectivity is important before considering surgery for patients with preoperatively identified N2 disease. Adverse prognostic factors include multiple levels of N2 disease, multiple lymph nodes at one level involved with tumor, adenocarcinoma, and extranodal spread of disease. More than 75% of patients with N2 disease present with disease extending beyond one lymph node station. Single-station lymph node involvement with microscopic foci of disease not clinically apparent on clinical staging constitutes most of the subset of patients with minimal N2 disease. This early-stage disease is usually discovered at the time of thoracotomy or at pretreatment mediastinoscopy. Five-year survival rates after surgical resection are 10% to 20% and are higher when a complete resection is performed (Table 31. Incomplete (R1, R2) resection results in a noncurative treatment, with few if any patients surviving beyond 3 years. Patients found to have multiple lymph node stations involved at final pathologic staging also fare poorly. At the time of surgery, a complete mediastinal lymph node dissection is warranted whenever N2 disease is suspected or known. This more advanced, bulky, or multistation N2 disease usually can be identified preoperatively and is termed clinical N2 disease. It is considered by most surgeons to be inoperable by primary surgery, with few 5-year survivors identified after surgical resection. For most of these patients, primary radiotherapy is still considered the standard treatment for local control. Recognition of prognostic and surgical factors that predict for specific anatomic failure patterns can allow selection of patients for local, systemic, or combined therapy. The rate of isolated distant failure for T1N1 patients is 33% and provides a clear need for developing effective prophylactic therapy for systemic and central nervous system spread. For T2N1 disease, the isolated local failure rate is 14%, and the distant failure rate is 36%, again demonstrating the need for effective adjuvant systemic therapy. When no adjuvant therapy is used for these more advanced patients, thoracic recurrence occurs in approximately 20% of patients even if the resection margins are negative, and distant metastases become even more common, suggesting that both failure patterns need to be addressed if survival is to be improved. For sleeve lobectomies, isolated local failure rates are more common than distant failures, ranging from 30% to 52%. Isolated local failure rates are particularly high if the procedure is performed to conserve parenchyma in patients with compromised pulmonary function. Second primary lung cancers occur frequently in all surviving patients at a rate of approximately 1% each year. This trial randomly assigned 210 patients to receive 50 Gy in 25 fractions after surgery versus observation alone. The locoregional failure rate (as first site of failure) was reduced from 41% to 3% with radiotherapy for all node-positive patients. The Council reported higher local recurrences in 276 patients in the surgery-only arms of the trials. It has been shown to improve local control in patients with mediastinal nodal disease but has no proven survival benefit. Positive Margins (R1, R2 Resections) the presence of microscopic disease after curative surgery for early-stage disease at the bronchial resection margin, chest wall, or vascular margin may adversely affect the prognosis of patients. Yet, despite data that suggest that adjuvant radiotherapy reduces local recurrence, the retrospective literature regarding the efficacy of radiotherapy to improve local control is conflicting. Intraoperative brachytherapy was used as an adjuvant treatment in 23 patients undergoing video-assisted thoracoscopic limited resections (wedge resections) who were unable to tolerate conventional resections. In 141 randomly assigned patients, there was a trend for increased time to recurrence and for prolonged overall survival favoring chemotherapy. The survival of the control immunotherapy group was similar to that of earlier patients treated with surgery alone, and the authors attributed the improved survival in the chemotherapy arm to the effects of chemotherapy. No benefit was identified for chemotherapy, but only 53% of assigned patients completed chemotherapy. A large intergroup study in the United States is testing the value of four cycles of cisplatin plus etoposide (the first two cycles given with concomitant radiotherapy) versus radiotherapy alone in patients with completely resected N1 or N2 disease. It is possible that recurrence rates in early-stage disease are too low to be effectively influenced by adjuvant chemotherapy. An alternative concept of influencing survival rates in these patients is focused on a reduction in the incidence of second primary malignancies. A large North American intergroup study randomly assigning patients with stage I disease to postoperative placebo versus cis-retinoic acid chemopreventive therapy has been completed, but the results have yet to be reported. An interesting Japanese study using 1 to 2 years of oral Tegafur in early-stage lung cancer has demonstrated a survival benefit and reduction of second primary tumors in the treated group. Because of the minimal effect of chemotherapy as assessed in the foregoing recent metaanalysis, larger trials of adjuvant chemotherapy are being carried out in North America and Europe. Patients with completely resected disease should be offered inclusion in these randomized trials whenever possible. Reports of survival in patients with tumors arising in the superior sulcus after combined preoperative radiotherapy (where no previous survivals occurred) also contributed to the initial enthusiasm of a preoperative radiotherapy-alone approach. Subsequently, a few randomized trials were initiated to answer this question with larger cohorts of patients. With a minimum follow-up of 4 years in surviving patients, no increase in survival was noted in the pretreatment group. The use of radiotherapy as a single preoperative modality is no longer studied consistently, owing to the advent of effective chemotherapeutic agents. Most current trials investigate the use of preoperative concomitant chemoradiotherapy. However, the same studies revealed that patients with ipsilateral mediastinal lymphadenopathy large enough to be clinically apparent on a plain chest radiograph had only an 18% resectability rate and only an 8% 3-year survival rate. A program was developed that used preoperative combination chemotherapy with high-dose cisplatin (120 mg/m 2), vinca alkaloids, and mitomycin. Overall, 60% of patients underwent complete resections, and 12% had pathologic complete responses at surgery. The median survival was 19 months for all patients and 27 months for those with complete resections. The 3-year survival rate for the completely resected patients was 44%, a significant improvement over the prior surgery-only experience, in which the 3-year survival rate for clinically evident N2 disease was only 8% (P =.
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