Maternal complications and procedures in pregnancy and at birth and wheezing phenotypes in children

RATIONALE: There is increasing interest in the potential influence of fetal and early life conditions on childhood wheezing. OBJECTIVES: To investigate the associations between maternal complications and procedures in pregnancy and at birth and the risk of various wheezing phenotypes in young children. METHODS: We studied 15,609 children, aged 6-7 yr, enrolled in a population-based study. Standardized questionnaires were completed by the children's mothers. RESULTS: Of the children, 9.5% (1,478) had transient early wheezing, 5.4% (884) had persistent wheezing, and 6.1% (948) had late-onset wheezing. Maternal hypertension or preeclampsia was associated with an increased risk of all three wheezing phenotypes (for transient early wheezing: odds ratio [OR], 1.40; 95% confidence interval [95% CI], 1.08-1.82; for persistent wheezing: OR, 1.59; 95% CI, 1.15-2.19; and for late-onset wheezing: OR, 1.47; 95% CI, 1.06-2.01). Use of antibiotics for urinary tract infections was associated with transient early wheezing (OR, 1.52; 95% CI, 1.16-2.00), whereas antibiotic administration at delivery was associated with both transient early wheezing (OR, 1.21; 95% CI, 1.01-1.46) and persistent wheezing (OR, 1.39; 95% CI, 1.10-1.75). Children who had a mother with diabetes were also more likely to have persistent wheezing (OR, 1.72; 95% CI, 0.99-3.00). Neither amniocentesis/chorionic villus sampling, nor weight gain in pregnancy, nor cesarean section was associated with the subsequent development of wheezing. Maternal asthma or atopy was not an effect modifier of the associations found. CONCLUSIONS: Some maternal complications during pregnancy and at delivery may increase the risk of developing different phenotypes of wheezing in childhood.     

A test of the symptom amplification hypothesis in patients with asthma

The present study sought to measure the accuracy of symptom reporting in patients with asthma by calculating the difference between a subjective rating of illness severity and an objective test of lung function (forced expiratory volume in 1 second). At issue was the hypothesis that self-reported "symptom amplification" or sensory awareness accounts for differences in the accuracy of symptom reporting. Spirometric examination was performed, and psychological tests of symptom amplification, emotional distress, and neuroticism were administered. Participants consisted of 42 consecutive patients seeking medical treatment of asthma. The disparity between symptom perception (assessed by a Borg scale) and a corresponding measure of lung capacity allowed us to identify patients who overreported their symptoms (amplifiers) along with those who underreported them (minimizers). After controlling for the effects of sex and psychological distress, a self-report measure of symptom amplification explained 15% of the variability in reporting accuracy. Related constructs such as somatization and neuroticism could not explain differences in reporting ability.     

Thoracoscopic resection of solitary lung metastases from colorectal cancer is a viable therapeutic option.

STUDY OBJECTIVES: The reported 5-year survival rate after pulmonary metastasectomy from colorectal carcinoma, usually accomplished through thoracotomy or median sternotomy, ranges from 9 to 47%. Video-assisted thoracoscopy (VAT) is employed routinely for many thoracic surgical procedures, but the main concern about this approach for resection of lung metastases is that VAT does not allow complete lung palpation to identify and remove metastases not detected by preoperative radiologic examinations. DESIGN: In this study, we reviewed our experience with thoracoscopic resection of single peripheral lung metastases from colorectal carcinoma with potentially curative intent. PATIENTS AND INTERVENTIONS: From July 1992 to September 1998, 24 patients (15 male, 9 female) with a mean age of 56 years, who previously had undergone resection for colorectal carcinoma and had a single limited and peripheral lung lesion identified by high-resolution CT, underwent thoracoscopic wedge resection of the lesions. RESULTS: No intraoperative complications developed. Three patients had minor postoperative complications successfully treated. In one case, we found a benign lesion, and this patient was excluded from the analysis. In the remaining cases, metastases from colorectal cancer were confirmed. The median follow-up was 29 months, ranging from 3 to 67 months. Thirteen patients (56.5%) developed recurrence of the disease, and 5 of them (21.7%) had local recurrence. Cumulative 5-year survival estimated by Kaplan-Meier method was 49.5%, not really different from the data reported in the literature. CONCLUSIONS: Thoracoscopic resection of single peripheral lung metastases from colorectal cancer with potentially curative intent seems effective and justified since the ultimate outcome of this highly selected group of patients seems to be not different from that obtained after a more invasive approach.     

Anaplastic thyroid carcinoma: clinical outcome of 30 consecutive patients referred to a single institution in the past 5 years

OBJECTIVE: Treatment options for anaplastic thyroid carcinoma (ATC), which is one of the most lethal human malignant tumors, include surgery, chemotherapy and radiotherapy usually combined in a multimodal approach, to improve survival and avoid death from local invasion. However, there is no standard protocol for ATC treatment and the optimal sequence within multimodal therapy is debated. We retrospectively report the clinical outcome of 30 ATC patients referred consecutively to the Oncological Endocrinology Unit of San Giovanni Battista Hospital (Turin, Italy) between 2000 and 2005. DESIGN: Patients were treated by one of the following approaches: i) surgery followed by adjuvant-combined chemoradiotherapy; ii) neo-adjuvant chemoradiotherapy followed by surgery and adjuvant chemotherapy; or iii) chemotherapy alone. The surgical procedures were classified as 'maximal debulking' or 'palliative resection'. Maximal debulking entailed total or near-total thyroidectomy and complete resection of all gross tumor or minimal residual disease adherent to vital structures, independently of the presence or absence of distant metastases. In palliative resections, macroscopic residual disease was left in the neck. Survival of patients stratified by treatment was assessed. RESULTS: Analysis of multivariate hazard ratios showed that maximal debulking followed by adjuvant chemoradiotherapy was the only treatment that modified survival of ATC patients (hazard ratio= 0.23, 95% CI: 0.07-0.79), even if factors determining poor prognosis or increased surgical risk were present. CONCLUSIONS: Despite the overall grim outcome of ATC, these results justify an attempt at maximal debulking surgery, followed by adjuvant chemoradiotherapy, possibly in all ATC patients.     

Neoplastic circulating endothelial-like cells in patients with acute myeloid leukaemia

Accumulating evidence suggests that angiogenesis may play a key role in the pathogenesis of leukaemic disorders. Several studies have shown that bone marrow-derived endothelial cells (EC) may contribute to tumour angiogenesis and that in the peripheral blood of cancer patients there is an increased amount of circulating ECs (CECs) that may participate to new vessel formation. In this report, we showed that, in seven acute myeloid leukaemia (AML) patients with known cytogenetic abnormalities, CEC levels were significantly increased in comparison with controls and that a significant proportion of these CECs carried the same chromosomal aberration as blast cells (20-78%, mean value 42.1% of CECs). Most of CECs (mean value 74.4%) displayed immunophenotypic features of endothelial progenitor cells as they expressed CD133, a marker gradually lost during EC differentiation and absent on mature EC. These findings suggest a possible direct contribution of AML-related CECs to tumour vasculogenesis and possibly to the spreading and progression of the disease.     

Role of axillary ultrasound examination in the selection of breast cancer patients for sentinel node biopsy

BACKGROUND: Sentinel node biopsy (SNB) is a time-consuming procedure that can be avoided in presence of axillary metastases. The aim of this study was to assess the accuracy of ultrasound scan (US) in the prediction of axillary nodes status in patients scheduled for SNB. METHODS: Axillary US was performed and when feasible, a core biopsy of suspicious nodes was taken. The nodal status as assessed by US and/or core biopsy was compared with final histology. RESULTS: Of the 132 patients enrolled, 31 (23.5%) had suspicious axillary nodes according to US; 19 (61.3%) were true positive, whereas 12 cases (38.7%) were not. In 14 of 31 suspicious cases an US-guided core-biopsy was taken, which in 11 of 14 cases (78.5%) confirmed the neoplastic involvement. Overall, core biopsy of the nodes correctly predicted the final histology in 13 of 14 cases (92.8%). CONCLUSIONS: The US of axillary nodes, possibly associated with core biopsy, improved the preoperative evaluation of breast cancer patients scheduled for SNB.     

Mediastinal carcinosis involving the esophagus in breast cancer: the "breast-esophagus" syndrome: report on 25 cases and guidelines for diagnosis and treatment

INTRODUCTION: Breast metastases of mucosal/submucosal layers of the esophagus are extremely rare: esophageal involvement is usually part of a mediastinal carcinosis. AIM: We report the largest series to date of 25 cases of metastatic esophageal involvement from breast cancer, discussing both diagnostic techniques and treatment options. MATERIALS AND METHODS: Twenty-five female patients with a history of breast cancer referred for secondary esophageal involvement (1980-2006) were studied. RESULTS: All patients presented with worsening dysphagia. Twenty-four had undergone surgery for breast cancer a median of 10 years earlier: 1 had received chemoradiotherapy, and 17 had adjuvant radiotherapy/telecobalt therapy following breast surgery. Endoscopic biopsy/cytology were negative for cancer in 17 of 19 patients; in 9 patients, the diagnosis was made with thoracoscopy/laparoscopy. Immunohistochemical staining was done in 10 patients (ER and/or PrR positive). Fifteen patients presented with distant metastatic involvement. Therapy was directed toward dysphagia relief, mostly with endoscopic dilations/prostheses. Complications (4 perforations) occurred only in those 15 patients who had endoscopic dilations/prostheses. Fifteen patients had cytoreductive therapy. Nine of 25 patients are still alive. The median overall survival was 7 months; 1-, 3-, and 5-year survival rates were 44%, 16%, and 8%, respectively. CONCLUSIONS: A "breast-esophagus" syndrome can be defined: it is often diagnosed only after excluding other diseases or after relief of dysphagia with adequate therapy. The presence of distant metastases helps the diagnosis of esophageal involvement from mediastinal carcinosis, while diagnosis is a problem in case of mediastinal/pleural disease only: in this case, exploratory thoracoscopy is mandatory for a final diagnosis. Given the high related risk of perforation from endoscopic procedures (dilations/prostheses), the treatments of choice are currently hormone therapy or chemotherapy/radiotherapy.     

Developing and Implementing an Advanced Communication Training Program in Oncology at a Comprehensive Cancer Center

Cancer patients report significant levels of unmet needs in the realm of communication. Communication skills training programs have been shown to improve clinical communication. However, advanced communication skills training programs in oncology have lacked institutional integration, and thus have not attended to institutional norms and cultures that may counteract explicit communication skills training. We developed and implemented an advanced communication skills training program made up of nine teaching modules for faculty, fellows, and residents. Training included didactic and experiential small group work. Self-efficacy and behavior change were assessed for individual participants. Since 2006, 515 clinicians have participated in this training program. Participants have shown significant gains in self-efficacy regarding communicating with patients in various contexts. Our initial work in this area demonstrates the implementation of such a program at a major cancer center to be feasible, to be acceptable, and to have a significant impact on participants' self-efficacy.     

Liver resection with intraoperative and laparoscopic ultrasound: report of 32 cases

Background  Careful staging of hepatic tumors is mandatory for appropriate selection of patients for liver resection. Number and relationships of liver nodules are issues of utmost importance when evaluating resectability. Sensitivity of preoperative imaging for secondary lesions has been reported between 60–75% with spiral contrast-enhanced computed cosmography (CT), 80–85% with magnetic resonance imaging (MRI), and 90–96% with intraoperative ultrasound (IOUS). Also for primary lesions IOUS has been reported to allow detection of liver nodules in 17% and modify surgical strategy in 10%. The aim of this study was to point out the usefulness of open (IOUS) and laparoscopic (LIOUS) ultrasound in patients undergoing hepatic surgery for liver tumors. Methods  In the years 2004–2006, 50 patients, mean age 66 years (range 44–76 years) were evaluated for resective surgery at the General Surgery Department of Monaldi Hospital, Naples, Italy. All of them were studied with biphasic CT and transabdominal ultrasound. Eighteen (36%) were judged unresectable. The others were scheduled for laparoscopy and LIOUS, by means of an ALOKA SSD–5500 (Aloka Co. Ltd. Tokyo, Japan), equipped with linear flexible tip laparoscopic probe. Results  Six patients (18.7%) were excluded because of pathology diffusion; 26 (81.3%) were resected, using ultrasonic shears (Harmonic ACE, Ethicon Endo-Surgery, Cincinnati Oh., USA) for parenchymal transection, 3 (11.5%) laparoscopically and 23 (88.5%) after laparotomy. IOUS was repeated in the latter group. LIOUS spared useless laparotomies in six patients (18.7%) and, coupled with IOUS, found undetected nodes in five patients (19.2%), changing surgical strategy in three patients (11.5%). Conclusion  In our experience LIUOS and IOUS proved to be of utmost importance both in the selection of patients for resective surgery and in planning surgical approach. Ultrasonic shears device and systematic pedicle clamping sped up resection time and reduced intraoperative bleeding.