肾脏病诊治:任重道远

重症多形红斑/史-约综合征 (Severe Multiformity Erythema/Stevens Johnson Syndrome,SJS) 是一种主要由药物引起的严重皮肤不良反应,通常起病急骤,全身症状较重,预后较差。SJS的早期诊断困难。早期识别并立即停用致病药物、控制感染是重要的治疗手段,目前尚无标准的全身系统治疗方案。本文报道1例广泛期小细胞肺癌患者接受抗肿瘤治疗后应用重组人粒细胞集落刺激因子 (recombinant human Granulocyte Colony Stimulating Factor,rhG-CSF) 引起 SJS 的病例, 经过停用致病药物并给予控制感染、伤口护理以及激素治疗后好转。     

小细胞肺癌的外科治疗

小细胞肺癌是原发性支气管肺癌中恶性程度最高的一种,占肺癌总数的15%～20%.临床特点是生长迅速,淋巴和血行转移早.多采用化疗为主的综合治疗.我院自1996年至2007年手术治疗小细胞肺癌66例获得较好的效果,现报告如下.     

Dose-intensive therapy for extensive-stage small cell lung cancer and extrapulmonary small cell carcinoma: long-term outcome.

Treatment for extensive-stage small cell lung cancer (ES SCLC) or extrapulmonary small cell carcinoma (EPSC) is typically palliative. We set out to determine progression-free survival (PFS) and overall long-term survival of ES SCLC and EPSC patients, physiologically aged < or = 60 years, responding to first-line chemotherapy followed by high-dose combination alkylating agents with hematologic stem cell support. Patients in first-line chemotherapy response underwent stem cell collection (marrow, peripheral blood progenitor cells, or both) followed by high-dose therapy with 1 of 2 regimens: CBP (cyclophosphamide, cisplatin, and carmustine) or ICE (ifosfamide, carboplatin, and etoposide) with or without etanidazole. Involved-field radiotherapy was given to selected patients with oligometastatic disease distributed in sites allowing for reasonable radiation ports, and prophylactic cranial radiotherapy was given upon recovery to patients in complete response (CR) or near-CR. A total of 36 patients were treated. Of 29 patients with ES SCLC, 6 (21%) had achieved CR, 18 near-CR, and 5 partial response prior to high-dose therapy. Of 7 patients with EPSC, 3 (43%) had achieved CR, 3 had achieved near-CR, and 1 had progression of disease prior to high-dose therapy. Thirteen ES SCLC patients received high-dose CBP. Of the remaining 23 patients with SCLC or EPSC, 17 were treated with ICE and 6 with ICE plus etanidazole, a hypoxic cell sensitizer. Treatment-related mortality was 11% (4 of 36 patients). For all patients, the median event-free survival (EFS) was 5 months. The 2- and 5-year survivals after intensification were 12% (95% confidence interval [CI], 5%-31%) and 9% (95% CI, 3%-27%), respectively. Of the 30 patients in or near CR prior to high-dose therapy, 5 remain continuously progression-free (2 ES SCLC, 3 EPSC) for a median of 55 months (range, 1-96 months) after high-dose therapy. By multivariate analysis, factors associated with more favorable EFS were the use of a more aggressive induction regimen (ICE), and the EPSC histology. These factors were also associated with more favorable overall survival. Other factors associated with more favorable overall survival were the use of short induction therapy (< or = 4 cycles) and younger age (<50 years). Except for high-dose ICE with etanidazole, the use of high-dose systemic therapy in ES SCLC and EPSC was associated with low treatment-related morbidity and mortality over the past 5 years. Late complications were infrequent, and most patients returned to full-time work and activity, barring disease recurrence. Nonetheless, few patients with ES SCLC have progression-free long-term survival. We conclude that high-dose therapy is not indicated as an approach for ES SCLC, except as part of an investigative trial. Conversely, 3 of the 7 patients with EPSC remain relapse-free (range, 1-96 months), warranting further phase II evaluation of this approach in this population.     

Autologous stem cell transplantation for small cell lung cancer.

Small cell lung cancer usually responds to radiation and chemotherapy, but cures are infrequent. Autotransplantation attempts to increase cures by intensifying the effects of chemotherapy. We studied 103 patients receiving high-dose chemotherapy with autologous hematopoietic stem cell transplantation (SCT) for small cell lung cancer in 1989-1997 at 22 centers participating in the Autologous Blood and Marrow Transplant Registry. Median age at transplantation was 50 years (range, 30-74 years). Fifty-five percent of patients were men. Forty-seven percent of patients underwent transplantation in 1989-1993 and 53% in 1994-1997. Most patients received peripheral blood stem cells alone (39%) or with bone marrow (44%); 18% received bone marrow alone. The 2 most common preparative regimens were cyclophosphamide/carmustine/cisplatin (CBP) (60%) and ifosfamide/carboplatin/etoposide (ICE) (28%). Median time from diagnosis to transplantation was 6 months (range, 1-34 months). Most patients underwent transplantation after partial response (66%) or complete response (27%) to combination therapy. The 100-day mortality was 11% (95% confidence interval [CI], 6%-18%). Three-year probabilities of survival and progression-free survival (PFS) were 33% (95% CI, 24%-44%) and 26% (95% CI, 17%-36%), respectively, for all patients. Factors negatively associated with outcome in multivariate analysis were age greater than 50 years, extensive-stage disease at presentation, and preparative regimens other than CBP or ICE. Three-year survival and PFS rates were higher in patients with limited versus extensive disease, 43% versus 10% (P < .001) and 35% versus 4% (P < .001), respectively. Patients older than 50 years had nearly twice the risk of death or progression as younger patients (relative risk, 1.7; 95% CI, 1.1-2.8). Autologous SCT produces long-term survival in some patients with small cell lung cancer; SCT outcomes appear better in young patients with limited-stage disease. Transplantation for patients with extensive disease does not appear to produce substantial benefit.     

Detection of small cell lung cancer bone marrow metastases by immunofluorescence

It is well known that small cell lung cancer (SCLC) has a high propensity to metastasize to the bone marrow and that such involvement has a prognostic significance. A more accurate detection of these bone marrow metastases is thus mandatory. In this study, we analysed the results of the detection of these metastases using an indirect immunofluorescence test. For this purpose, 3 anti-SCLC rat monoclonal antibodies (MoAbs) specific for 3 different antigens (LCA1, LCA2, LCA3) have been utilized to examine 59 bone marrow samples from patients at time of diagnosis and 20 samples from chemotherapy treated patients. Eight patients had bone marrow clearly involved by morphological analysis. They all had fluorescent cells recognized at immunodetection with at least 2 MoAbs positive for 7 out of the 8 samples. Fifteen samples, negative by morphological analysis, were proven positive by immunofluorescence. In 12 cases, involvement was detected only by 1 MoAb (6 anti-LCA1, 2 anti-LCA2, 4 anti-LCA3). A correlation was found between the number of samples proven positive by morphological analysis and the number of positive MoAbs for these samples (p less than 0.005). Among the bone marrow samples provided by the 32 limited disease patients, LCA positive cells were detected in 9 (28%) compared to 14 out of the 27 (52%) samples from extensive disease patients (p less than 0.05). We concluded that the indirect immunofluorescence with a panel of MoAbs increases the rate of detection of bone marrow SCLC metastases.     

非小细胞肺癌三维适形放射治疗的护理

三维适形放射治疗肺癌不良反应小,已经成为非小细胞肺癌（NSCLC）放射治疗的主流。我科自2007年1月至2008年1月采用三维适形放射治疗NSCLC患者586例,取得了较好的效果。现将护理体会报告如下：     

质子治疗非小细胞肺癌的系统评价**

背景：质子治疗能量大,侧向辐射小,其射束的深度剂量分布曲线在其末端形成博拉格峰,提高了肿瘤的局部控制率,减小了周围正常组织器官并发症的发生率。 目的：评价质子治疗非小细胞肺癌的临床疗效和安全性。 方法：检索PubMed、Cochrane library、EMBASE、中国期刊全文数据库、中国生物医学文献数据库、中文科技期刊全文数据库,收集质子治疗非小细胞肺癌的临床研究,提取数据,并采用方法学评价指标对纳入研究进行质量评价,对满足条件的数据采用RevMan5.0进行合并分析,对不能合并的进行描述。 结果与结论：共纳入11个临床研究,308例患者,主要为Ⅰ期临床试验。非小细胞肺癌的质子治疗2~5年局部控制率为57%~87%,2年和5年总生存率分别为62%~84%和29%,晚期毒性的发生率为10%。与光子治疗相比,质子治疗在正常肺组织及邻近重要器官的照射剂量方面的差异有显著性意义。说明质子治疗非小细胞肺癌很有临床应用的前景。但在质子治疗作为一种国际标准化的治疗方法应用于非小细胞肺癌患者前,尚需在各期患者中进行高质量大样本的临床研究。     

Detection of small cell lung cancer bone marrow metastases by tumor stem cell assay

Detection of small cell lung cancer (SCLC) bone marrow (BM) metastases has a prognostic implication in itself and a therapeutic interest in the setting of autologous bone marrow transplantation. In a prospective study involving 68 bone marrow samples, we compared SCLC detection results obtained using a tumor stem cell assay and those obtained using conventional morphology by light microscopy. In agar, tumoral cells were stimulated either by Salmon's conditioned medium or by epidermal growth factor (EGF). Tumoral clonogeneic cells were detected in 11 cases, although 7 of these were considered negative when investigated by light microscopy. On the contrary, metastases were detected by morphology in 8 instances where no growing colonies were revealed by tumor stem cell assay. The choice of stimulating factor did not seem critical since the number of colonies was similar in all the cases. We conclude that the tumor stem cell assay is useful in the detection of small cell lung cancer bone marrow metastases, particularly in cases where these metastases have failed to be recognized through light microscopy investigation. However, the sensitivity of this assay is low and should be complemented by other techniques such as immunodetection.