Self-expanding Metal Stents in Malignant Obstruction of the Esophagus: A 25-Year Multicentric Study

Background: Self-expanding metal prostheses improve dysphagia in patients with incurable esophageal cancer (EC). New stents have been introduced, and chemoradiotherapy has been implemented for EC, changing patients' risk profiles. It is unknown whether this has affected palliation with stents. Patients and methods: Retrospective study in three centers in Medellín-Colombia; patients undergoing placement of palliative esophageal prostheses for malignant dysphagia (1997-2022). Major and minor complications after implantation, the influence of oncological therapies, and survival were evaluated for 1997-2009 (n = 289) and 2010-2022 (n = 318). Results: 607 patients underwent esophageal prostheses; 296 (48.8%) became complicated. It was higher in the second period (52.5% vs. 48.1%), as were major complications (20.8% vs. 14.2%, p = 0.033), with no differences in minor complications (33.9% vs 31.8%, p = 0.765). Also, 190 (31.3%) patients presented with recurrent dysphagia, stable in both periods. Migration increased over time (from 13.1% to 18.2%, p = 0.09). The most common minor adverse event was pain, increasing over time (from 24.9% to 33.95%, p < 0.01), and associated factors were chemoradiotherapy, absence of fistula, and squamous cell carcinoma. Acid reflux decreased in the second group (p = 0.038). Twelve percent of patients required another intervention for feeding. Survival was not impacted by time and use of stents. Conclusions: Stents are an alternative in non-surgical malignant dysphagia, although recurrent dysphagia has not decreased over time. Minor stent-related complications are increasing in association with the implementation of chemoradiotherapy.

Antecedentes: Las prótesis metálicas autoexpandibles mejoran la disfagia en pacientes con cáncer esofágico (CE) incurable. En las últimas décadas se han introducido nuevos tipos de stents y se ha implementado la quimiorradioterapia para el CE, generando cambios en los perfiles de riesgo de los pacientes. Se desconoce si estos cambios han afectado la paliación con stents. Pacientes y métodos: Estudio retrospectivo en tres centros de Medellín-Colombia; pacientes sometidos a colocación de prótesis esofágicas paliativas para disfagia maligna (1997-2022). Se evaluaron en dos períodos: 1997-2009 (n = 289) y 2010-2022 (n = 318), complicaciones mayores y menores después del implante, la influencia de las terapias oncológicas y la sobrevida. Resultados: Se evaluaron 607 pacientes sometidos a prótesis esofágicas. 296 (48,8%) se complicaron, y fue mayor en el segundo periodo (52,5% frente a 48,1%), al igual que las complicaciones mayores (20,8% frente a 14,2%, p = 0,033), sin diferencias en complicaciones menores (33,9% frente a 31,8%, p = 0,765). 190 (31,3%) pacientes presentaron disfagia recurrente, estable en ambos períodos. La migración aumentó con el tiempo (de 13,1% a 18,2%, p = 0,09). El evento adverso menor más frecuente fue dolor, que aumentó con el tiempo (de 24,9% a 33,95%, p < 0,01), y los factores asociados fueron quimiorradioterapia, ausencia de fístula y carcinoma de células escamosas. El reflujo ácido disminuyó en el segundo grupo (p = 0,038). El 12% de pacientes requirieron otra intervención para alimentarse. No se impactó la sobrevida con el tiempo y uso de stents. Conclusiones: Los stents son una alternativa en la disfagia maligna no quirúrgica, aunque la disfagia recurrente no ha disminuido con el tiempo. Las complicaciones menores relacionadas con el stent van en aumento, asociadas a la implementación de la quimiorradioterapia.

Paliación endoscópica con stent duodenal en cáncer gástrico estadio IV complicado con estenosis gastroduodenal / Endoscopic stenting for palliation of Stage IV gastric cancer with malignant gastric outlet obstruction. A clinical case / Paliação endoscópica com stent duodenal em câncer gástrico estágio IV complicado por estenose gastroduodenal. Caso clínico

Resumen: Introducción: el cáncer gástrico es la quinta neoplasia en frecuencia a nivel mundial. Su diagnóstico suele ser tardío. La estenosis gastroduodenal es una complicación frecuente, que condiciona el pronóstico y el tratamiento. Contamos con varias modalidades en cuanto a la paliación de esta complicación. Destacamos el tratamiento quirúrgico mediante derivación digestiva (gastroenteroanastomosis), y el tratamiento endoscópico, mediante colocación de un stent o prótesis metalica autoexpandible (PMA). El objetivo es exponer el caso clínico de una paciente portadora de un cáncer gástrico avanzado complicado con estenosis gastroduodenal en la cual se optó por la colocación de una PMA. La bibliografía comparativa entre ambas técnicas es controvertida. Existen estudios importantes que recomiendan la técnica quirúrgica frente a la endoscópica, y viceversa. Con este fin se han realizado múltiples trabajos. Los posibles beneficios de la paliación endoscópica son: menor estadía hospitalaria, rápido reintegro a la vía oral. El caso clínico expuesto por el contrario no se benefició de la menor estadía hospitalaria, en parte, por ser necesaria su internación por comorbilidades médicas. No presentó complicaciones posteriores relacionadas al procedimiento. Conclusiones: la elección de la técnica a utilizar deberá ser individualizada, teniendo en cuenta el paciente, sus comorbilidades, recursos técnicos, experiencia del personal, y recursos económicos. Se necesitan más estudios para demostrar beneficio de la técnica paliativa más adecuada.

Abstract: Introduction: gastric cancer is the fifth neoplasm in terms of global incidence and its diagnosis often comes late. Gastric outlet obstruction is a frequent complication that influences prognosis and treatment. Among the various modalities available for palliation of this complication, we stand out two: surgical treatment by means of a digestive derivation: gastrojejunostomy and endoscopic treatment, by placing a stent or a steel mesh self-expanding endoprosthesis (EMP). The study aims to present the clinical case of a patient carrier of advanced gastric cancer with gastric outlet obstruction, who was treated by placing a self-expandable metallic stent. Comparative bibliography of both techniques is controversial. A number of important studies recomend the surgical technique instead of endoscopic treatment, and viceversa. For this reason, several studies have been conducted. The potential benefits of endoscopic palliation are the following: shorter hospital stay, fast return to oral intake. However the clinical case presented did not benefit from a shorter hospital stay, since it required longer hospitalization, partly due to medical comorbilities. There were no complications after the procedure. Conclusions: the specific technique to treat the condition needs to be chosen for each individual case, considering the particular patient and his or her comorbilities, technical resources, the experience of the medical staff and economic resources. More studies are necessary to prove the benefits of the most appropriate palliative technique.

Resumo: Introdução: o câncer gástrico é a quinta neoplasia em frequência no mundo. Seu diagnóstico costuma ser tardio. A estenose gastroduodenal é uma complicação frequente, que determina o prognóstico e o tratamento. Existem várias modalidades quanto à paliação desta complicação entre os quais destacamos o tratamento cirúrgico por derivação digestiva: gastro enteroanastomose e o tratamento endoscópico, com colocação de Stent ou Prótese Metálica Autoexpansível (PMA). O objetivo deste trabalho é apresentar o caso clínico de um paciente com câncer gástrico avançado complicado por estenose gastroduodenal em que se optou pela colocação de PMA. A bibliografia comparativa entre as duas técnicas é controversa. Existem estudos importantes que preconizam a técnica cirúrgica em detrimento da endoscópica e vice-versa. Para isso, vários trabalhos foram realizados. Os possíveis benefícios da paliação endoscópica são: menor tempo de internação, rápida reintrodução à via oral. Neste caso o paciente não se beneficiou do menor tempo de internação, em parte, porque a internação foi necessária por comorbidades médicas. Não foram observadas complicações subsequentes relacionadas ao procedimento. Conclusões: a escolha da técnica a ser utilizada deve ser individualizada, levando em consideração o paciente, suas comorbidades, os recursos técnicos, a experiência da equipe e os recursos econômicos. Mais estudos são necessários para demonstrar o benefício da técnica paliativa mais adequada.

Surgical strategies of biventricular conversion from single-ventricle palliation for the complex congenital heart defects / 中华胸心血管外科杂志

Objective:To explore and summarize the surgical strategies of biventricular conversion from single-ventricle palliation for the complex congenital heart defects in this study.Methods:From April 2017 to December 2019, a total of 14 cases with complex complex congenital heart defects who had planned to undergo single-ventricle palliation were finally accepted biventricular conversion. According to the development and anatomical characteristics of the ventricles, they were divided into two groups: ventricular well development group(9 cases), all of which showed complex intracardiac defects, and the ventricles well developed, including 4 cases of double outlet right ventricle with remote ventricular septal defect, 2 cases of transposition of great arteries combined with ventricular septal defect and left ventricular outflow tract obstruction, one case of congenitally corrected transposition of the great arteries combined with double outlet right ventricle and interrupted aortic arch, one case of double outlet right ventricle with subpulmonary ventricular septal defect and atrioventricular connection inconsistency, one case of pulmonary atresia with ventricular septal defect. Ventricular unbalanced development group(5 cases), all of which were functional single ventricle, including 3 cases of heterotaxy and 2 cases of unbalanced complete atrioventricular septal defect. The operation time, postoperative complications, death, cardiac function and reoperation of the two groups were compared.Results:There was one early death, with a mortality rate of 7.1%. In the ventricular well development group, the average waiting time for biventricular conversion was(56.4 ± 38.9) months. One case died after the operation. The early complications included 2 case of arrhythmias, 3 cases of pleural effusions and 2 cases of pulmonary infections. In the ventricular unbalanced development group, the average waiting time for biventricular conversion was(20.4 ± 15.8) months, and the average of left ventricular end-diastolic volume was(33.6 ± 2.1) ml/m 2. The early complications included 2 cases of low cardiac outputs, one case of arrhythmia and one case of renal failure. There was no significant difference in operation time, intubation time and ICU time between the two groups. The patients were followed up for 4 months to 3 years, and there was no death. In the ventricular well development group, one case was reoperated due to the obstruction of the anastomosis between the superior vena cava and the right atrial appendage. In the ventricular unbalanced development group, one case was implanted with a permanent pacemaker due to the degree Ⅲ atrioventricular block. The NYHA grade of the whole group was Ⅰ-Ⅱ. Conclusion:Whether the complex congenital heart defects with the ventricles well developed or unbalanced, the comprehensive evaluation before the planned single-ventricle palliation will be helpful to find the appropriate cases for biventricular conversion. According to its anatomical characteristics performed the corresponding biventricular conversion can obtain a satisfied clinical outcomes, although the long-term results still need further follow-up.

Feasibility and clinical value of computed tomography-guided125I brachytherapy for pain palliation in patients with retroperitoneal lymph node metastases

Aims: The aim was to evaluate the feasibility and clinical value of computed tomography (CT)-guided125 I brachytherapy for pain palliation in patients with retroperitoneal lymph node metastases. Materials and Methods: A total of 23 patients with retroperitoneal lymph node metastases and those who had moderate-to-severe pain from January 2014 to December 2018 were enrolled in the study. The primary tumors included pancreatic (n = 12), gastric (n = 4), hepatocellular (n = 4), colorectal (n = 2), and esophageal carcinomas (n= 1). Patients were treated with CT-guided percutaneous125 I brachytherapy during the study. The Brief Pain Inventory-Short Form was used to record and compare pain intensity and interference by pain. Treatment-related complications were also evaluated according to the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer Late Radiation Morbidity Scoring Criteria. Statistical analysis was performed using SPSS software version 22.0 Results: The primary success rate of125 I seed implantation was 95.7% (22 of the 23 patients). As pain evolved, the patients achieved obvious pain palliation ratings for “worst pain” and “average pain” at 72 h and 4 weeks after brachytherapy, respectively, whereas “pain right now” at 12 weeks was significantly relieved after brachytherapy. No serious complications developed during the perioperative period. Conclusions: In the treatment of intractable carcinomatous pain in patients with retroperitoneal lymph node metastases, CT-guided125 I brachytherapy is a feasible and effective modality for pain palliation

Sacrum metastasis in carcinoma gall bladder: an unusual presentation

Disseminated blood-borne metastases from carcinoma of the gall bladder are uncommon and usually occur late. The most common site of extra-abdominal metastasis is lung followed by brain. Skeletal metastases in carcinoma gall bladder are very rare. To date there have only been a few case reports of bone metastasis in carcinoma gall bladder at the time of presentation. Authors here present a rare case of carcinoma gall bladder that progressed to isolated sacrum metastasis.

Chinese expert consensus on surgical treatment of congenital heart disease (8): Series of procedures for univentricular heart / 中国胸心血管外科临床杂志

@#In patients with a functionally univentricular heart, the Fontan strategy achieves separation of the systemic and pulmonary circulation and reduction of ventricular volume overload. Contemporary modifications of surgical techniques have significantly improved survival rate. However, the resulting Fontan physiology is associated with high morbidity. Despite large improvements in outcomes of contemporary Fontan patients, a large burden of disease exists in this patient population. In face of the imbalance of medical resources in China and different understanding of Fontan treatment in various regions, there is no consensus on the current status of Fontan strategy, surgical technique and perioperative treatment. By reviewing large amounts of literature, assessing survival rate and risk factors for mortality and complications of the Fontan circulation, knowledge sharing from tens of experts, we achieved a consensus on many aspects of palliation of Fontan. We hope this consensus will help Chinese colleagues further continue their efforts to improve surgical outcomes of the univentricular heart patients.

Palliative radiotherapy in locally advanced and metastatic carcinoma of lung with two radiotherapy regimens: A randomized comparative study from tertiary health-care cancer center

Background: Worldwide, leading cause of cancer mortality is lung cancer. Approximately 63,000/year new lung cancer cases reported in India. Around 80–85% of patients of lung cancer is non-small cell histology (non-small cell lung cancer) and over >90% of patients presented locally advanced and metastatic disease. Hence, in these patients, population curative treatment approach with radiotherapy (RT) and chemotherapy in most of the time is non-viable option yielding short survival and relatively poor prognosis. In majority of such cases, the only aim of treatment remains palliative, the main aim is to improve quality of life. Although there are other medical management of symptoms palliation, radiation therapy is the cheapest option, quite effective, time efficient, and well tolerated in providing relief from symptoms. The rate of palliation of symptoms is quite high for chest pain and hemoptysis at 60–80%, whereas cough and dyspnea are improved in only 50–70%. For intrathoracic disease with obstructive symptoms, 30 Gy/10# over 2 weeks are generally recommended. Patients with poor performance status, advanced age, and associated comorbidity at the time of diagnosis, for which daily RT over 2–3 weeks is logistically difficult, 1–2 fractions have been utilized with good results. There are multiple randomized trials showed that both short and long RT course were equally effective for symptoms control. Aims and Objectives: The aims of our study are to compare the outcome, symptom control and assess toxicity profile in locally advanced lung cancer patient with 17 Gy/2 fractions (8.5 Gy/fraction, × 2 fractions) only on Saturdays over 2 weeks versus 30 Gy/10 fractions (3 Gy/fraction) over 2 weeks and to compare quality of life. Materials and Methods: This study was a single-institutional, prospective, open-labeled, randomized controlled study. Eligible patients were age ≥18 years with histopathologically proven lung carcinoma which was inoperable Stage III or IV disease and too locally advanced to curative concurrent chemoradiation, pulmonary symptoms attributable to the primary tumor, Eastern Cooperative Oncology Group (ECOG) performance status ≤3, and adequate hematologic (hemoglobin >10 g/dl; absolute neutrophil count >1500; platelet count >100,000/ml; and hepatic and renal function calculated creatinine >60 ml/min). Patients with bleeding diathesis, emphysematous bullae, poor respiratory function or reserve, pregnancy, and ECOG performance status >3 were excluded from the study. Results: Age, stage, histopathology, and pre-treatment symptoms score between two groups were comparable and statistically not significant. Pain in chest due to lung cancer was decreased in both arms due to treatment (at treatment completion Arm A = 47.62 and Arm B = 38.09). However, at the 2nd follow-up, difference between two arms was statistically significant where Arm A = 27.78 and Arm B = 15.00; P = 0.005. Global health status of patients in this study was improved in both arms due to treatment. Physical functioning emotional functioning, role functioning, global health status, cognitive functioning, and social functioning were improved in both arms due to treatment and kept improving during follow-up, but difference between two arms was not significance. Conclusions: Although overall symptom palliation, toxicity profile, and quality of life parameters are almost equal in both arms, patients with short expected survival, 8.5 Gy × 2 fractions would be preferable, limiting the number of hospital visit to a minimum. On the other hand, 3 Gy × 10 fractions schedule can be chosen for those patients with longer expected survival and better ECOG status, due to prolong duration of palliative response.

Palliative treatment with radiotherapy in patients of advanced esophageal carcinoma

Background: Esophageal carcinoma is high prevalence in Asia, including India and most of the patients present in advanced and inoperable stage. Most of the patients have poor nutritional status and low performance status. These patients are unable to tolerate radical treatment. Prognosis of these patients is very poor. There are no enough data of prospective study in palliation of dysphagia of the patients with inoperable esophageal carcinoma with radiotherapy in Eastern India. Objectives: The main objective of our study was palliation of dysphagia of the patients with inoperable esophageal carcinoma with radiotherapy. Materials and Methods: The study was done with 43 patients with histopathologically proven squamous cell carcinoma and/or adenocarcinoma at thoracic esophagus, intraluminal brachytherapy feasible. Patients were received external beam radiotherapy palliative dose 30 Gy in 10 fractions for 2 weeks followed by intraluminal high-dose rate brachytherapy 6 Gy per fraction per week for 2 weeks. Results: In our study, the mean age of the patients was 58 years (age range 48 years–70 years). 1 month after completion of intraluminal brachytherapy, a number of patients with improvement of dysphagia were 34 (79%). The improvement of dysphagia was maintained 25 (73.5%) patients at 3-month completion of treatment and 14 (56%) patients at 6-month completion of treatment. The median duration of dysphagia relief was 5.2 months. Post-radiotherapy complications as chest pain were seen in 10 (23.2%) patients, esophageal strictures were developed in 7 (16.3%) patients, ulcerations were in 4 (9.3%) patients, and esophageal fistula was developed in 1 (2.3%) patient. Conclusion: The patients with advanced inoperable or metastatic esophageal carcinoma and poor performance status, palliative radiotherapy are effective modality of treatment for the improvement of dysphagia.

Staged Repair after Hybrid Palliation for Interrupted Aortic Arch with Systemic Outflow Tract Obstruction / 대한흉부외과학회지

Surgical management of interrupted aortic arch (IAA) with systemic outflow tract obstruction is clearly a challenge. If both ventricles are adequate, the Yasui operation is a useful option. Otherwise, a staged approach through initial hybrid palliation and delayed biventricular repair, tailored to the degree of obstructed outflow, serves to avoid a high-risk neonatal procedure. Herein, we present a patient with IAA and severe systemic outflow tract obstruction whose treatment involved hybrid palliation, followed by a Yasui operation.

Value of MSCT in follow-up of functional single ventricle after Fontan palliation / 中国医学影像技术

Objective To explore the value of MSCT in follow-up of functional single ventricle (FSV) after the Fontan palliation. Methods Data of MSCT and cardioangiography (CAG), as well as clinical information of 32 FSV patients after the Fontan procedures were analyzed retrospectively. All patients underwent MSCT examinations with individually manual triggered dual-phase scanning. Qualitative assessment of Fontan conduit structures and post-operative complications were performed. The diameters of pulmonary arteries and descending aorta at the level of diaphragm were measured to calculate McGoon index, in order to evaluate pulmonary artery development. The correlation between diameters of pulmonary artery and pressure of pulmonary artery in diastole phase, as well as between McGoon index and resistent index of pulmonary artery were analyzed. Results MSCT detected 3 cases of right atrio-pulmonary connection, 10 cases of total cavopulmonary connection, 11 cases of extracardiac Fontan and 8 cases of Y-graft Fontan conduits. Moreover, 8 cases of post-operative complications were detected with MSCT, including 2 cases of pulmonary arteriovenous malformations, 3 cases of aortopulmonary collaterals, 2 cases of mural thrombus in the Fontan pathway and 1 case of ventricular aneurysm. The diameters of left and right pulmonary artery measured on MSCT were (1.36±0.22) cm and (1.40±0.15) cm, both negatively correlated with the pressure of pulmonary artery in diastole phase (r=-0.755, -0.678, both P<0.001). McGoon index showed negative correlation with the resistent index of pulmonary artery (r=-0.676, P<0.001). Conclusion With advanced imaging post-processing technology and individual scanning scheme, MSCT can supply several important indicators in the follow-up for patients with FSV after Fontan palliation, showing important clinical value.

Endoscopic Palliation for Biliary and Pancreatic Malignancies: Recent Advances

Malignancies of the pancreatobiliary system are usually unresectable at the time of diagnosis. As a consequence, a majority of these cases are candidates for palliative care. With advances in chemotherapeutic agents and multidisciplinary care, the survival rate in pancreatobiliary malignancies has improved. Therefore, there is a need to provide an effective and long-lasting palliative care for these patients. Endoscopic palliation is preferred to surgery as the former is associated with equal efficacy and reduced morbidity. The main role of endoscopic palliation in the vast majority of pancreatobiliary malignancies includes biliary and enteral stenting for malignant obstructive jaundice and gastric outlet obstruction, respectively. Recent advances in endoscopic palliation appear promising in imparting long-lasting relief of symptoms. Use of radiofrequency ablation and photodynamic therapy in malignant biliary obstruction has been shown to improve the survival rates as well as the patency of biliary stents. The emergence of endoscopic ultrasound (EUS) as a therapeutic tool has enhanced the capability of minimally invasive palliation in pancreatobiliary cancers. EUS is a valuable alternative to endoscopic retrograde cholangiopancreatography for the palliation of obstructive jaundice. More recently, EUS is emerging as an effective primary modality for biliary and gastric bypass.

Treatment of Bone Metastasis with Bone-Targeting Radiopharmaceuticals / 대한핵의학회잡지

Bone is a common metastatic site of cancer. Bone metastasis reduces life expectancy and results in serious symptoms and complications such as bone pain, pathological fractures, and spinal cord compression, decreasing quality of life by restricting sleep and mobility. Treatment for bone metastasis includes drugs (pure analgesics, hormones, cytotoxic chemotherapy, and bisphosphonates, among others), external radiation therapy, surgery, and radionuclide therapy using bone-targeting radiopharmaceuticals. Particulate radiation with α- or β-rays is used as a bone-targeting radiopharmaceutical in radionuclide therapy. β-Emitters have lower energy and a longer range than α-emitters and have less tumoricidal activity and deliver more radiation to adjacent normal tissue. Therefore, the main therapeutic effect of bone-targeting β-emitters such as ⁸⁹Sr-dichloride is bone pain palliation rather than enhanced survival. In contrast, α-emitters such as ²²³Ra-dichloride have high energy and a short range, resulting in greater tumoricidal activity and less radiation damage to adjacent normal tissue. Treatment with bone-targeting α-emitters can improve survival and decrease bone pain. This review focuses on the principles and clinical utility of several clinically available bone-targeting radiopharmaceuticals in metastatic bone disease.

Combination of TACE and Sorafenib Improves Outcomes in BCLC Stages B/C of Hepatocellular Carcinoma: A Single Centre Experience

ABSTRACT Background & Aim. Transarterial chemoembolization (TACE) or sorafenib is recommended for hepatocellular carcinoma BCLC stages B and C respectively. We studied the role of combination of TACE and sorafenib in BCLC stages B/C. Material and methods. We undertook an observational study on a cohort of cirrhotics with HCC from August 2010 through October 2014. Patients in BCLC stages B/C who had received TACE and/or sorafenib were included. mRECIST criteria were used to assess tumor response. The primary end point was overall survival. Results. Out of 124 patients, 47.6% were in BCLC-B and 52.4% in BCLCC. Baseline characteristics were comparable. The predominant etiology was cryptogenic (37.2% and 38.5%, p = NS). 49.1% in BCLC-B and 56.9% in BCLC-C had received TACE+sorafenib. In BCLC-B, the overall survival improved from 9 months (95% CI 6.3-11.7) using TACE only to 16 months (95% CI 12.9-19.1) using TACE+sorafenib (p < 0.05). In BCLC-C, addition of TACE to sorafenib improved the overall survival from 4 months (95%CI 3-5) to 9 months (95%CI 6.8-11.2) (p < 0.0001). As per mRECIST criteria, patients on TACE+sorafenib had reduced progressive disease (37.8% vs. 83.3%), improved partial response (43.2% vs. 3.3%) and one had complete response compared to those on sorafenib alone (p < 0.0001) in BCLC-C but not in BCLC-B group. Hand foot syndrome was noted in 27.7% patients on sorafenib and post TACE syndrome in 80.2% patients, but both were reversible. No major adverse events were noted. Conclusion. TACE+sorafenib was more effective than TACE or sorafenib alone in HCC BCLC stages B or C with a significant survival benefit and improved tumour regression especially in BCLC-C patients.

The Illness Experience: Palliative Care Given the impossibility of Healing / La experiencia de la enfermedad: Cuidados Paliativos Dada la imposibilidad de curación / A Experiência do Adoecer: Os Cuidados Paliativos diante da Impossibilidade da Cura

This paper presents a reflection about being terminally ill and the various ways that the subject has at its disposal to deal with this event. The objective is to understand the experience of palliation for patients undergoing no therapeutic possibilities of cure. The methodology of this study has the instruments to semi-structured interview, the participant observation and the field diary, and the Descriptive Analysis of Foucault’s inspiration how the narratives of the subjects were perceived. The Results of paper there was the possibility of looking at the experience of illness through the eyes of a subject position assumed by the very sick. As conclusion we have than when choosing palliative care, the terminally ill opts for a way to feel more comfortable and resists the impositions of the medical model of prolonging life.

Este artículo presenta una reflexión acerca de ser un enfermo terminal y las diversas formas que el sujeto tiene a su disposición para hacer frente a este evento. Nuestro objetivo fue comprender la experiencia de pacientes sin posibilidad terapéuticas de cura, sometidos a los cuidados paliativos. La metodología de este estudio cuenta con los instrumentos de entrevista semiestructurada, la observación participante y el diario de campo. Las narrativas de los sujetos han sido analizadas bajo la analítica descriptiva de inspiración foucaultiana. Os Resultados nos dicen que la posibilidad de ver la experiencia de la enfermedad a través de la óptica de una posición de sujeto asumida por el propio enfermo. La conclusión es que es posible el sujeto enfermo terminal elegir los cuidados paliativos como una manera de sentirse más cómodo y para resistir a las imposiciones del modelo médico de la prolongación de la vida.

O presente trabalho traz uma reflexão a respeito do ser um doente terminal e das várias maneiras que o sujeito tem a seu dispor para lidar com esse acontecimento. Nosso objetivo foi compreender a experiência da paliação por sujeitos doentes sem possibilidades terapêuticas de cura. A metodologia deste estudo teve como instrumentos a Entrevista Narrativa, a Observação Participante e o Diário de Campo, sendo a Análise Descritiva de inspiração foucaultiana o modo como as narrativas dos sujeitos foram percebidas. O resultado do estudo mostrou a possibilidade de olhar a experiência do adoecer através da ótica de uma posição de sujeito assumida pelo próprio enfermo. E concluímos que ao escolher os cuidados paliativos, o doente terminal opta por um modo de se sentir mais confortável e resiste às imposições do modelo médico de prolongamento da vida.

Homoeopathy In Breast Cancer.

Background: Health and disease is nothing but two-fold conditions of human life. It is not so easy to define health and disease in a strict sense. As long as man is able to fulfill his aspirations and satisfy the needs, he/she is said to be healthy. Disease is the life under altered condition. Out of all diseases by hearing the name cancer of which is sufficient enough to invoke fear and sense of insecurity in every body’s mind. Fear is the greatest Killer of a Patient Remaining healthy is not only an individual obligation but also a social responsibility. Homoeopathy, Allopathic, Ayurvedic, Unani, and Siddha systems of medicine are there to take care of body system in their own ways of diagnosis and treatment. So it is a demand of time for every Homoeopath to explore the unveiled drug efficacy for treating the malignancy effectively & making it possible to strengthen unpaved path to steer ahead successfully.

Curación, paliación y supresión. Conceptos y antecedentes / Cure, palliation and suppression. Concepts and background

Desde la creación de la doctrina homeopática los conceptos de curación, paliación y supresión han causado inquietud, ya que en muchos círculos médico homeopáticos se tiene la percepción de que la supresión y la paliación son dos acciones que no se deben realizar, o peor aún, se tiene la idea equivocada de que la supresión homeopática no existe. Por eso, muchos médicos pasan buena parte de su vida profesional tratando de conseguir la “curación” de sus pacientes, por imposible o riesgosa que parezca. Pero, ¿por qué se le teme tanto a la supresión? ¿Por qué se piensa que la paliación es jugar con los pacientes? Quizás a lo largo de los años del desarrollo doctrinario se han malinterpretado las definiciones que Samuel Hahnemann otorgó a estos conceptos. Así, en el presente artículo se describen estos términos de manera general y se profundiza en la forma en que se aplican en el ámbito homeopático, con la finalidad de generar un contexto más amplio al respecto...

Since the creation of homeopathic doctrine, the healing concepts palliation and suppression have caused concern because in many homeopathic medical circles there is a perception that the suppression and palliation are two actions that cannot be performed, or even worse, it has the misconception that homeopathic suppression doesn´t exist. Therefore, many doctors spend much time in their professional lives trying to get the “cure” for their patients, as risky and impossible as it may be. But, why worry about suppression? Why think that palliation is playing with patients? Perhaps over the years of doctrinal development, the definitions that Samuel Hahnemann gave about these concepts have been misinterpreted. So, in this article these terms are described in general and explore in a deep way on how they are applied in the homeopathic field in order to generate a broader context about it...

Pain Palliation in Patients with Bone Metastases Using Magnetic Resonance-Guided Focused Ultrasound with Conformal Bone System: A Preliminary Report

PURPOSE: We evaluated the safety and effectiveness of the Magnetic Resonance-guided Focused Ultrasound (MRgFUS) with the ExAblate Conformal Bone System for the palliation of painful bone metastases. MATERIALS AND METHODS: Our Institutional Review Board approved this study, and all patients gave informed consent prior to enrollment. A total of six painful metastatic bone lesions in five patients were treated using MRgFUS with the ExAblate Conformal Bone System for pain palliation. The follow-up sessions were at 3 days, 2 weeks, 1, 2, and 3 months, and 1 year after treatment. Efficacy was evaluated by the changes in visual analog scale (VAS) scores. At 3-months and 1-year follow-ups, unenhanced computed tomography and contrast-enhanced MR imaging examinations were performed. All adverse events were assessed to evaluate treatment safety. RESULTS: All patients showed significant pain relief within 2 weeks. Two patients experienced complete pain reduction that lasted for 1 year. Two other patients showed pain relief measured as VAS scores of 2 and 4 on their last follow-up. Although the remaining patient had experienced significant pain relief in two lesions, the VAS score re-increased on his last follow-up. The size of the enhancing soft tissue mass in metastatic lesions decreased, and new bone formation was seen on follow-up images. Although adverse events were not serious, non-specific leg pain and second degree skin burn were noted. CONCLUSION: MRgFUS was demonstrated to be effective palliative treatment within 2 weeks in selected patients with painful bone metastases.

Pain Palliation in Patients with Bone Metastases Using Magnetic Resonance-Guided Focused Ultrasound with Conformal Bone System: A Preliminary Report

PURPOSE: We evaluated the safety and effectiveness of the Magnetic Resonance-guided Focused Ultrasound (MRgFUS) with the ExAblate Conformal Bone System for the palliation of painful bone metastases. MATERIALS AND METHODS: Our Institutional Review Board approved this study, and all patients gave informed consent prior to enrollment. A total of six painful metastatic bone lesions in five patients were treated using MRgFUS with the ExAblate Conformal Bone System for pain palliation. The follow-up sessions were at 3 days, 2 weeks, 1, 2, and 3 months, and 1 year after treatment. Efficacy was evaluated by the changes in visual analog scale (VAS) scores. At 3-months and 1-year follow-ups, unenhanced computed tomography and contrast-enhanced MR imaging examinations were performed. All adverse events were assessed to evaluate treatment safety. RESULTS: All patients showed significant pain relief within 2 weeks. Two patients experienced complete pain reduction that lasted for 1 year. Two other patients showed pain relief measured as VAS scores of 2 and 4 on their last follow-up. Although the remaining patient had experienced significant pain relief in two lesions, the VAS score re-increased on his last follow-up. The size of the enhancing soft tissue mass in metastatic lesions decreased, and new bone formation was seen on follow-up images. Although adverse events were not serious, non-specific leg pain and second degree skin burn were noted. CONCLUSION: MRgFUS was demonstrated to be effective palliative treatment within 2 weeks in selected patients with painful bone metastases.

Update on Pancreatobiliary Stents: Stent Placement in Advanced Hilar Tumors

Palliative drainage is the main treatment option for inoperable hilar cholangiocarcinoma to improve symptoms, which include cholangitis, pruritus, high-grade jaundice, and abdominal pain. Although there is no consensus on the optimal method for biliary drainage due to the paucity of large-scale randomized control studies, several important aspects of any optimal method have been studied. In this review article, we discuss the liver volume to be drained, stent type, techniques to insert self-expanding metal stents, and approaches for proper and effective biliary drainage based on previous studies and personal experience.

Update on Pancreatobiliary Stents: Stent Placement in Advanced Hilar Tumors

Palliative drainage is the main treatment option for inoperable hilar cholangiocarcinoma to improve symptoms, which include cholangitis, pruritus, high-grade jaundice, and abdominal pain. Although there is no consensus on the optimal method for biliary drainage due to the paucity of large-scale randomized control studies, several important aspects of any optimal method have been studied. In this review article, we discuss the liver volume to be drained, stent type, techniques to insert self-expanding metal stents, and approaches for proper and effective biliary drainage based on previous studies and personal experience.