Long-term control or possible cure? Treatment of stage D2 prostate cancer under chemotherapy using cisplatin and estramustine phosphate followed by maximal androgen blockade

Metastatic prostate cancer (PC) is incurable by androgen deprivation therapy alone, due to the presence of androgen-independent/supersensitive cells in hormone-naive PC. A 67-year-old man was diagnosed with PC (Gleason score, 5 + 4) with multiple bone metastases. He was treated by chemohormonal therapy with cisplatin and estramustine phosphate (EMP) followed by maximal androgen blockade, and showed a complete response. As of the time of writing, no clinical or prostate-specific antigen recurrence has been observed for over 15 years, despite cessation of the treatment. This is the first report to indicate a possible cure of metastatic PC by chemohormonal therapy combined with appropriate anti-tumor drugs targeted to both androgen-independent and -dependent clones before the hormone-refractory state.     

Peri-operative glucocorticoid replacement therapy in transsphenoidal pituitary adenoma surgery: a prospective controlled study

Summary Background. We set out to prospectively study the peri-operative changes of the hypothalamic-pituitary-adrenal axis (HPA), and to test the hypothesis that the peri-operative corticoid replacement regimen used at the authors’ institution in patients with impaired HPA undergoing transsphenoidal pituitary adenoma surgery is adequate. Method. Thirty seven patients (21 females, 16 males, mean age 50.6 years) underwent transsphenoidal pituitary adenoma surgery (mean tumour diameter 20.6 mm, 13 tumours hormone-secreting). The HPA functions of these patients were classified as impaired (group A, n = 15) or preserved (group B, n = 22) according to the results of a pre-operative corticotrophin releasing-hormone test (CRHT). Eleven patients (9 female, 2 male, mean age 53.6 years) without pituitary adenomas and with a preserved HPA (as assessed by medical history and morning serum cortisol (MSC) measurements), undergoing decompressive surgery for degenerative lumbar disc disease, were also studied (group C). On the day of surgery, the patients of group A received 100 mg hydrocortisone (HC) replacement therapy, which was thereafter gradually tapered off in a standardised fashion. The patients of groups B and C were not treated with corticoids. Pre-operative, intra-operative and post-operative variables of these three patient groups were compared. Findings. The urinary free cortisol excretion (UFC) in group A declined from 6732 ± 7683 μg/d on the day of surgery to 305 ± 358 μg/d on the 10^th post-operative day. In group B, the respective UFC values were 12851 ± 16278 μg/d and 223 ± 235 μg/d. In both of these groups, the mean UFC did not fall into the normal range during the first ten post-operative days. On none of the post-operative days, was there a significant difference between the UFC of groups A and B. The UFC values of group C dropped from 177 ± 157 μg/d on the day of surgery to 87 ± 61 μg/d on post-operative day six, reaching the normal range from the 2^nd post-operative day onwards. All UFC values of group C were significantly lower than those of group A and B. None of the evaluated clinical, laboratory and MRI parameters, as disclosed by uni- and multivariate analysis, showed any significant influence on the peri-operative UFC values. Conclusions. The peri-operative UFC of pituitary adenoma patients with preserved HPA was very high, as compared to patients with degenerative lumbar disc disease. The present study showed for the first time, that the proposed regimen of peri-operative corticoid replacement therapy used in patients with pituitary adenomas and impaired HPA raised cortisol levels to match the physiological increase of UFC in patients with pituitary adenoma surgery and preserved HPA. However, although statistically not significant, the UFC of patients with pituitary adenomas and preserved HPA seemed considerably higher on the day of surgery than in patients with pituitary adenomas and HPA impairment. Although there is no evidence to make it mandatory, administration of 150 mg instead of 100 mg HC substitution on the day of pituitary adenoma surgery in patients with HPA impairment may be prudent. Correspondence: Rudolf A. Kristof, M.D., Universit?tsklinikum Bonn, Klinik und Poliklinik für Neurochirurgie, Sigmund-Freud-Str. 25, D-53105 Bonn, Germany.     

Prognosis of subacute low back pain patients according to pain response

Centralization of referred pain or failure to centralize has in earlier studies been shown to be a predictor of low back pain prognosis. Research suggests that there are differences in how males and females experience pain. The aim of this study was to evaluate the outcome after 1 year, and to evaluate the prognostic value of the pain response in a mechanical test at the first consultation at a spine clinic, and the influence of gender, in order to identify patients with especially high risk of chronicity. The patients in this study were low back pain patients, included consecutively from a spine clinic in Northern Denmark. The criteria for entering this spine clinic were neck or low back pain with radiating symptoms and a duration of 4–26 weeks, without satisfactory improvement after treatment in the primary care system. The 793 patients were categorised into four subgroups according to their pain response in a mechanical test performed at the initial examination: centralization, non-lasting centralization, peripheralization and no effect. The patients were instructed in doing specific exercises according to the test results. The four subgroups were compared after 1 year with regard to changes in back and leg pain, disability and return-to-work status. The statistical evaluation was undertaken for the study group as a whole and stratified according to gender. A significant improvement in all outcome measures was found in all the subgroups, among both men and women. There were no systematic or statistically significant differences in the prognosis between the four subgroups of patients. The proportion of Centralizers in this study was 18%. The mechanical test at baseline is important for deciding the subject-specific exercises, but when treated according to test results, the prognostic value of the test seems limited. The project is approved by the Regional Scientific Ethical Committee.     

多学科协作诊治模式下运行结直肠癌综合治疗的临床对照研究

目的探讨四川大学华西医院结直肠外科多学科协作（MDT）诊治模式的运行效果。方法回顾性分析从2006年12月至2007年5月，在四川大学华西医院结直肠外科住院治疗的大肠癌患者的病历资料，比较MDT组与非MDT组的疗效。结果MDT组围手术期住院时间及外科住院时间少于非MDT组（P〈0．05），但住院总时间上2组间差异无统计学意义（P〉0．05）。在手术治疗结果上，MDT组肿瘤手术切除率高于非MDT组（P〈0．05）。从术后早期并发症的发生情况分析，MDT组术后早期肠梗阻发生率低于非MDT组（P〈0．05），但吻合口漏和吻合口出血发生率2组间差异无统计学意义（P〉0．05）。经过5～10个月的随访，MDT组的患者术后肿瘤复发率低于非MDT组（P〈0．05），而术后吻合口狭窄和肠梗阻的发生率，2组间差异无统计学意义（P〉0．05）。结论结直肠肿瘤MDT模式针对大肠癌采用综合治疗方案，不仅有利于治疗方案的合理时间分配，而且提高了治疗效果。但对于MDT模式的影响因素尚缺乏系统性研究，同时还需将MDT模式中手术治疗的多模式环节进一步完善，以推出更为细化的围手术期MDT模式。     

乳腺癌辅助内分泌治疗概况

乳腺癌的内分泌治疗是激素依赖型乳腺癌患者重要的辅助治疗之一,分为手术治疗和非手术治疗,近年来手术及放射去势治疗逐渐被药物治疗替代。雌激素受体和／或孕激素受体阳性,是目前临床应用内分泌治疗的重要指标。绝经前后患者内分泌环境的生理差别决定了用药方式的不同。绝经前患者主要抑制卵巢产生雌激素,而绝经后患者主要抑制芳香化酶的功能。本文旨在对乳腺癌患者内分泌常用药物进行简要介绍,并就他莫西芬及芳香化酶抑制剂进行重点介绍。     

妊娠合并急性阑尾炎的诊治

目的探讨妊娠期急性阑尾炎的诊治处理及对母婴预后的影响。方法回顾性分析46例妊娠期急性阑尾炎的诊治资料。结果延误诊治6例治疗后3例流产,及时诊断并手术治疗36例母婴平安。明确诊断后保守治疗8例,5例妊娠期复发再予手术。结论妊娠期急性阑尾炎影响母婴安全的主要原因是延误诊断和延误治疗(手术)。明确诊断、及时手术,并辅以保胎治疗是确保母婴安全的重要措施。     

儿童习惯性髌骨脱位的诊治体会

目的探讨儿童习惯性髌骨脱位的诊断和治疗。方法儿童习惯性髌骨脱位患儿21例,全部采用膝关节外侧软组织松解、内侧关节囊紧缩、半侧髌韧带内移或胫骨粗隆内移术等联合手术。结果本组21例患儿,经6个月～3年随访,检查膝关节功能,屈曲膝关节90°,髌骨不再脱位,疗效均较满意。结论采用膝关节外侧软组织松解、内侧关节囊紧缩、半侧髌韧带内移或胫骨粗隆内移术等联合手术治疗儿童习惯性髌骨脱位,疗效确定,且年龄越小,手术效果越好。     

内、外固定加中药治疗浮肘损伤

浮肘损伤是指同一肢体的肱骨干和尺桡骨干或干骺端骨折使肘关节极不稳定,呈链枷关节,造成肘关节漂浮的一种病理改变的高能量损伤。此类损伤病情严重且复杂,常合并皮肤、肌肉、肌腱、神经及血管损伤,治疗上有一定特殊性,自2005年至2007年共收治26例浮肘损伤,     

血管内治疗外伤性颈内动脉损伤

目的探讨血管内治疗对外伤性颈内动脉损伤的临床价值。方法16例外伤性颈内动脉损伤患者,经DSA造影证实为假性动脉瘤3例、岩部巨大蛇性动脉瘤及颈内动脉起始部动脉瘤各1例以及颈内动脉海绵窦瘘11例,分别采用可脱落球囊、电解可脱式弹簧圈（GDC）或带膜内支架对损伤部位进行动脉内栓塞治疗。结果对3例假性动脉瘤及1例岩部巨大蛇性动脉瘤患者以可脱落球囊闭塞患侧颈内动脉成功。9例颈内动脉海绵窦瘘（CCF）在保持颈内动脉通畅的情况下采用球囊成功栓塞瘘口,1例CCF予以GDC填塞海绵窦;其余1例CCF两次球囊栓塞均失败,但术后24h患侧凸眼明显回缩,间断按压患侧颈内动脉1周后患者临床症状和体征消失。1例颈内动脉起始部动脉瘤行带膜内支架成功植入,动脉瘤被旷置,颈内动脉保持通畅。结论血管内治疗是外伤性颈内动脉损伤安全有效的治疗方法。     

烟雾病的临床研究进展

烟雾病是颈内动脉末端进展性狭窄、闭塞及脑底出现异常血管扩张网所致的脑出血性或缺血性疾病,伴脑底部异常血管网形成为其特点。此病在临床上主要有脑缺血和出血两类表现,成年患者经常表现为出血症状,而儿童患者多表现为短暂缺血发作或中风。数字减影血管造影（DSA）仍是诊断该病的金标准。血管重建手术是目前该病的主要治疗方法。