ECMO: back where we started, again.
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Decision Making↗
Biomedical subjects
J Zwischenberger
Publications and source records attributed to J Zwischenberger.
Bi-modality (chemo-radiation) versus tri-modality (chemo-radiation followed by surgery) treatment for carcinoma of the esophagus.
The purpose of the study was to investigate the difference in overall survival in patients with localized carcinoma of esophagus treated using chemo-radiation (bi-modality, BM) or chemo-radiation followed by surgery (tri-modality, TM). From 1981 to 1999, 65 patients were identified who had localized carcinoma of the esophagus treated with either concurrent chemo-radiation (BM, n=22) or concurrent chemo-radiation followed by surgery (TM, n=43) at the University of Texas Medical Branch at Galveston. All 65 patients received concurrent chemotherapy and external beam radiation. Radiation was delivered by linear accelerators (greater-than-or-equal 6 MV), except in one patient who had part of his treatment given by a Co-60 machine. Chemotherapy consisted of 5-fluorouracil and cisplatin plus minus vinblastine under different regimens. Median follow-up time was 10 months (range=1-195 months) for all patients. Of the 14 patients still alive, the median follow-up time was 32 months (range=2-192 months). No difference in overall survival was detected between the two treatment groups, BM vs. TM (P=0.394) despite a selection bias favoring the TM group. Five-year survival rates of the BM and TM groups were 17% and 18%, respectively; 10-year survival rates were 17% and 12%, respectively. The presence of significant past medical history (P=0.017) and a complete pathologic response in the TM group (P < 0.001) were significant independent predictors of survival. We did not find any difference in survival between chemo-radiation or chemo-radiation followed by surgery in patients with localized carcinoma of the esophagus. Use of biologic markers and functional imaging should be explored in order to segregate patients with different tumor biology for treatment using different treatment strategies.
Aged↗
Computed tomographic-pathologic correlation of gross tumor volume and clinical target volume in non-small cell lung cancer: a pilot experience.
CONTEXT: Computed tomographic (CT) scan data are used regularly in radiation treatment planning for patients with lung cancer. To our knowledge, the relationship of the CT images of tumors and their corresponding microscopic extent has not yet been studied in detail. OBJECTIVE: To correlate tumor sizes on CT with tumor sizes measured microscopically (ie, the gross tumor volume [GTV]-clinical target volume margin) in non-small cell lung cancers. DESIGN: Prospective pilot study. SETTING: Single institution. PATIENTS: Patients with operable non-small cell lung cancer were identified preoperatively. INTERVENTIONS: Once the surgical specimen was available, it was oriented with the surgeon and the pathologist. Seven whole-mount, cross-sectional histologic glass slides were made from 5 tumors using formalin fixation and hematoxylin-eosin staining. The pathologist then outlined the cancer-containing area under the microscope (Micro-GTV) and the area of surrounding inflammatory response (Micro-GTV + inflammation). Preoperative CT scans were used for outlining tumor on the corresponding slice (CT-GTV). MAIN OUTCOME MEASURES: Correlation of the areas of Micro-GTV, Micro-GTV + inflammation, and CT-GTV was performed. RESULTS: There was an obvious trend that the CT-GTV was bigger than the Micro-GTV, except in specimen 1, in which the 2 areas were about equal. However, on comparing the values for the CT-GTV and the Micro-GTV + inflammation, the difference between the 2 areas became smaller. CONCLUSIONS: Modern CT scans might overestimate the GTV in non-small cell lung cancer. The GTV-clinical target volume margin could actually be zero or even a negative value. The findings in this small study are interesting and provoking. Further study with a larger number of patients and more rigid quality control is warranted to confirm our findings.
Carcinoma, Non-Small-Cell Lung↗
Perioperative extracorporeal membrane oxygenation for tracheal reconstruction in congenital tracheal stenosis.
The management of a critical airway in infants and toddlers with congenital tracheal stenosis (CTS) continues to be an enormous challenge to the surgeon. Until recently, this condition often proved fatal. Improvements in surgical techniques, anesthetic management, and postoperative critical care have resulted in successful outcomes in children not long ago considered untreatable. However, issues such as the best operative approach and the optimal perioperative management are still unresolved. The diagnosis of CTS, often delayed, must be considered in any infant with stridor, wheezing, cyanosis, or recurrent episodes of pneumonia. Associated anomalies are the rule, including frequently vascular rings and rarely pulmonary agenesis. These defects can be repaired with conventional ventilatory support under cardiopulmonary bypass, or using extracorporeal membrane oxygenation (ECMO). We report our experience in which ECMO was used to support two patients with CTS during the perioperative period. ECMO proved to be both safe and practical, allowing unrushed, precise repair of the tracheal stenosis and providing brief postoperative support. Perioperative outcomes were excellent, although one of our patients died months after the repair. A review of the literature and our experience in which ECMO was used to provide cardiopulmonary support during repair of CTS showed uniformly successful perioperative outcomes.
Extracorporeal Membrane Oxygenation↗
Mediastinal atypical carcinoid and neurofibromatosis type 1.
We report a case of mediastinal atypical carcinoid in a 63-year-old woman with neurofibromatosis type 1 (NF-1), who presented with shortness of breath and a bulky mediastinal mass. Initial consideration was given to a neurogenic tumor. However, on thoracoscopic biopsy, the histologic appearance was consistent with an atypical carcinoid. Carcinoid tumors have been reported in association with NF-1 previously, but commonly in such unusual sites as the ampulla of Vater and duodenum and not in the thorax. The bulky, extensive, and highly vascular nature of the lesion precluded resection or debulking surgery. To our knowledge, there are no previous reports of atypical carcinoid of the lung or mediastinum in a patient with neurofibromatosis. This case report, therefore extends the spectrum of solid neoplasia in general and carcinoid tumors in specific, as they occur in association with NF-1.
Carcinoid Tumor↗
p53 and P-glycoprotein expression do not correlate with survival in nonsmall cell lung cancer: a long-term study and literature review.
This long-term study includes up to 13 years of follow-up on 56 patients who underwent surgical resection of nonsmall cell lung cancers (NSCLC) at the University of Texas Medical Branch. The purpose of this study was to investigate whether p53 and P-glycoprotein expression in the tumor correlates with survival. The study included 35 men and 21 women with mean age at diagnosis of 63.6 years and 58.0 years, respectively. Follow-up ranged from four to 156 months (mean, 52 mo). Actual five-year survival was 50% and 10-year survival was 22%. There were 25 patients who survived more than 60 months. Commercially available antibodies, DO-7 monoclonal antibody to p53 protein, and NCL-PGLyp polyclonal antibody to P-glycoprotein were used. p53 expression was seen in 45%, and P-glycoprotein expression was seen in 61% of the tumors, using standard immunohistochemical techniques. Expression of p53 showed correlation with Caucasian race and a better, although nonsignificant, five-year survival. P-glycoprotein expression showed a highly significant association with squamous cell carcinoma. No association was found between P-glycoprotein expression and survival. A negative association was seen between p53 and P-glycoprotein expression. Using nonparametric analysis, significant correlations were found between female sex and younger age at diagnosis of lung cancer compared with males, adenocarcinoma, and Caucasian race. Using Kaplan-Meier survival tables, significantly better five-year survival was seen with stage I tumors, negative lymph nodes at surgery, Caucasian race, and well-differentiated tumors. Stage I and negative lymph nodes at surgery showed an independent significant association with long-term (>5-yr) survival. This study indicates that p53 and P-glycoprotein may not be useful as immunohistochemical markers for guiding therapy and predicting survival in NSCLC.
ATP Binding Cassette Transporter, Subfamily B, Mem↗
Systemic gaseous microemboli during left atrial catheterization: a common occurrence?
OBJECTIVE: Gaseous microemboli during cardiac surgery have been implicated as a potential cause of postoperative neurologic injury. Any monitoring technique that exposes the systemic circulation to atmospheric pressure could introduce gaseous microemboli, causing cerebral microembolization. The incidence of carotid artery gaseous microemboli was studied during left atrial catheter insertion. DESIGN: Prospective clinical study. SETTING: Tertiary care university hospital. PARTICIPANTS: Twelve patients undergoing elective cardiac surgery. INTERVENTIONS: Perioperatively, a 5-MHz continuous wave Doppler probe was positioned over the left carotid artery to maximally record blood flow signals. The criteria used for detecting a gaseous microembolus were a sudden increase in the amplitude of the visual signal by 30% and a characteristic audible sound. MEASUREMENTS AND MAIN RESULTS: Numbers of microemboli at three timepoints (before and during left atrial catheter insertion and during catheter flushing) were assessed using the Friedman test. No emboli were detected before left atrial catheter insertion. When compared with the preinsertion time period, statistically (p < 0.05) significant numbers of gaseous microemboli were found in six patients during catheter insertion (3 +/- 1 microemboli; range 1 to 7 microemboli) and in five patients during catheter flushing (5 +/- 2 microemboli; range 1 to 12 microemboli). There was a tendency for patients with lower filling pressures to entrain more microemboli during insertion (r = 0.44; p = 0.149). No patient showed evidence of gross neurologic dysfunction postoperatively, although sensitive neurologic testing was not performed. CONCLUSIONS: Left atrial catheter insertion and flushing can cause systemic gaseous microemboli in more than 50% of patients. Although the number of microemboli introduced is relatively small, extreme care should be used during left atrial catheter insertion.
Adult↗
Esophagectomy in the septuagenarian.
As the population continues to age, older patients are being referred for thoracic surgical procedures with increasing frequency. From 1985 through 1992, 38 patients (32 men, 6 women) 70 years of age or older underwent esophagectomy for primary esophageal carcinoma. Histologic findings included adenocarcinoma in 28 (74%) and squamous carcinoma in 10 (26%). Patients suffered dysphagia for a mean of 3.8 months (range, 0 to 30 months) and had a mean weight loss of 5.8 kg (range, 0 to 22 kg). The tumors ranged from 1 to 14 cm in length and averaged 4.7 cm. Preoperative chemotherapy and radiation therapy were administered in 11 patients (46%). Clinical staging suggested all patients were curable, and esophagectomy was performed in a transthoracic fashion in 27 (71%) and from a transhiatal approach in 11 (29%). Cervical anastomoses were undertaken in 16 patients (42%). The mean blood loss was 1,165 mL and ranged from 500 to 4,000 mL. The mean number of transfused units was 2.3 (range 0 to 8 U). Overall operative mortality was 18% (7 of 38). Major morbidity included pneumonia in 11 (29%), anastomotic leak in 4 (11%), chylothorax in 4 (11%), pulmonary embolus in 3 (8%), and stroke and myocardial infarction in 1 patient each (3%). Three patients have been cured of their esophageal cancer with survivals of 65, 70, and 72 months and an additional 7 patients are still alive. Three patients (8%) have been lost to follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)
Adenocarcinoma↗
[Finger Microtremor--an experimental study (author's transl)].
This paper deals with the recording of finger microtremor using a self-constructed apparatus (amplitudes 0.5 to 0.05 mm). 32 healthy subjects aged 7 to 60 years were examined by means of a test set permitting the exact recording of the amplitudes and frequencies of the right middle finger movement. Special attention was given to the vertical plane of the tremor in order to permit more exact demonstration. Frequencies of 5 to 12 cps. were recorded, the mean frequency being 7.55+/-1.12 cps. The minimum amplitude was 0.02 and the maximum recorded amplitude amounted to 1.4 mm, with a mean amplitude of 0.12+/- 0.07 mm. No significant differences in amplitude or frequency were noted with respect to age or sex. This method is useful in the accurate quantitative assessment of every kind of tremor.
Action Potentials↗
[Long-term EEG investigations at the withdrawal of young polytoxicomanic addicts].
Serial EEG examinations (an average of three recordings in 14 weeks) are reported from adolescent inpatients (19 in number) who had been weaned of multiple drug abuse of an average duration of 2 years. At first examination seven had a normal EEG, 11 had a moderately abnormal EEG, and one had a markedly abnormal one. At final examination 13 had a normal EEG, five had a moderately abnormal EEG and three had definitely abnormal EEG's. The majority of the patients showed a decrease (significant at the 5% level), others an increase in EEG abnormalities. The relationship between the EEG changes in the course of the series on the one hand and the previous drug abuses is discussed.
Adolescent↗