ABSTRACT
BACKGROUND: The use of a diagnostic algorithm for metastatic cancer presentation (MCP) might enhance the diagnosis of primary tumors amenable to treatment with considerable savings both in time and diagnostic examinations. MATERIALS AND METHODS: From January 1992 to April 1997, all patients admitted with the diagnosis of MCP were prospectively studied. From each patient, a basic study consisting in a clinical interview, complete physical examination, standard blood testing with tumoral markers and chest X-ray were obtained. Patients with a negative basic study were classified as having a metastatic cancer of unknown origin (MUO); in these patients, a protocolized study (abdominal CT scan and mammography among women) were performed. Patients who after the application of the basic and protocolized studies had no primary tumor detected underwent an exhaustive investigation in order to validate the efficiency of the diagnostic algorithm. RESULTS: Two hundred twenty-one patients were included in the study. The mean age of patients was 63 years (range: 23-82). The main symptom was of bone (30%), neurological (24%), thoracic (16%) and abdominal (16%) origin. The basic study was positive for 138 patients (62.4%), with chest X-ray and physical examination yielding the highest number of diagnoses among these patients. The histology of metastases contributed to the definite diagnosis in 31 patients. Only PSA had a high sensitivity and specificity. Eighty-three patients were classified as MUO. The protocolized study diagnosed the primary tumor in 24 patients (30%), 20 by abdominal CT scan and four by mammography; eight of these patients were deemed to be amenable to treatment. The remaining 59 patients underwent an exhaustive study, and a diagnosis was made in 13; nevertheless, none of them was considered candidate for a specific treatment. Finally, 47 patients (21%) remained undiagnosed. The predominant primary tumors included sites at the lung (42%), prostate (6%) and breast (6%). The most common metastatic locations included bone (42%), central nervous system and liver (24%), and the most common histological types were adenocarcinoma (61%) and undifferentiated carcinoma (15%). CONCLUSIONS: Lung cancer and MUO represented 62% of MCP. The basic study oriented in two thirds of cases, and the physical examination and chest X-ray showed the highest diagnostic yield. The histology of metastases and PSA had a key, diagnostic relevance. A protocolized study based on abdominal CT scan and mammography (females) can identify the remaining treatable tumors.
Subject(s)
Abdominal Neoplasms/diagnostic imaging , Abdominal Neoplasms/secondary , Algorithms , Bone Neoplasms/diagnostic imaging , Bone Neoplasms/secondary , Thoracic Neoplasms/diagnostic imaging , Thoracic Neoplasms/secondary , Adult , Aged , Aged, 80 and over , Biomarkers, Tumor , Female , Humans , Male , Middle Aged , Physical Examination , Retrospective Studies , Tomography, X-Ray ComputedABSTRACT
Introducción. La aplicación de un algoritmo diagnóstico en el cáncer de presentación metastásica (CPM) podría facilitar, con un considerable ahorro de tiempo y exploraciones, llegar al diagnóstico de aquellos tumores primarios tratables. Material y métodos. Entre enero de 1992 y abril de 1997 se estudiaron de forma prospectiva todos los pacientes (pts) ingresados con el diagnóstico de CPM. Se les aplicó un estudio básico consistente en una historia clínica, un examen físico completo, una analítica estándar con marcadores tumorales y una radiografía de tórax. Se etiquetaron de cáncer metastásico de origen desconocido (CMOD) los pts con un estudio básico negativo, y en éstos se realizó un estudio protocolizado tomografía axial computarizada (TAC) (abdominopélvico y mamografía en mujeres). Aquellos pts en los que, tras la aplicación del estudio básico y el protocolizado no se detectó el tumor primario, fueron sometidos a un estudio exhaustivo a fin de validar la eficacia del algoritmo diagnóstico. Resultados. Se incluyeron 221 pts. La edad media era de 63 años (23-82). El síntoma principal fue óseo (30 por ciento), neurológico (24 por ciento), torácico (16 por ciento) y abdominal (16 por ciento). El estudio básico resultó positivo en 138 pts (62,4 por ciento); de éstos, la radiografía de tórax y la exploración física aportaron el mayor número de diagnósticos. La histología de las metástasis contribuyó al diagnóstico definitivo en 31 pts. Sólo el antígeno prostático específico (PSA) presentó una alta sensibilidad y especificidad. Fueron etiquetados de CMOD 83 pts. El estudio protocolizado diagnosticó el tumor primario en 24 pts (30 por ciento), 20 por TAC abdominal y 4 por mamografía; de éstos, 8 pts se consideraron tratables. En los 59 pts restantes se aplicó un estudio exhaustivo, hallándose el diagnóstico en 13; sin embargo, ninguno se consideró claramente merecedor de un tratamiento específico. Finalmente 47 pts (21 por ciento) quedaron sin diagnóstico. Los tumores primarios predominantes fueron pulmón (42 por ciento), próstata (6 por ciento) y mama (6 por ciento). Las localizaciones metastásicas más frecuentes fueron hueso (42 por ciento), sistema nervioso central e hígado (24 por ciento), y la histología, adenocarcinoma (61 por ciento) y carcinoma indiferenciado (15 por ciento). Conclusiones. El cáncer de pulmón y el CMOD representaron el 62 por ciento de los CPM. El estudio básico puede orientar dos tercios de los casos, siendo la exploración física y la radiografía de tórax las que tienen mayor rentabilidad diagnóstica. La histología de las metástasis y el PSA son de capital importancia. Un estudio protocolizado basado en la TAC abdominopélvica y la mamografía en mujeres puede identificar el resto de tumores tratables (AU)
Subject(s)
Middle Aged , Adult , Aged , Aged, 80 and over , Male , Female , Humans , Algorithms , Biomarkers, Tumor , Tomography, X-Ray Computed , Physical Examination , Retrospective Studies , Thoracic Neoplasms , Bone Neoplasms , Abdominal NeoplasmsABSTRACT
Avascular necrosis of the capitate bone in a 38-year-old man is presented. The patient was treated by intercarpal fusion of the capitate, lunate and scaphoid bone to relieve pain.
Subject(s)
Carpal Bones/diagnostic imaging , Osteonecrosis/diagnostic imaging , Adult , Arthrodesis/methods , Carpal Bones/pathology , Carpal Bones/surgery , Humans , Magnetic Resonance Imaging , Male , Osteonecrosis/pathology , Osteonecrosis/surgery , RadiographyABSTRACT
The reported frequency of splenomegaly in sarcoidosis has ranged from 1% to 40%. Splenomegaly has been associated with clinical evidence of more extensive extrathoracic sarcoidosis. In a previous study, we reported that splenomegaly was associated with a poor outcome of the disease. The aim of the present study was to describe the characteristics of the sarcoidosis patients with splenomegaly seen at our institution. Of 284 sarcoidosis patients, followed up at our hospital, 16 (5.6%) had splenomegaly on physical examination. These patients showed other extrathoracic manifestations as well, and all but two showed intrathoracic involvement. Eleven patients received corticosteroid therapy. Splenectomy was done in three patients, but the natural history of their sarcoidosis remained unaltered two years after diagnosis. The results of this study disclosed that patients with splenomegaly had evidence of extensive pulmonary and extrathoracic sarcoidosis with a poor prognosis in spite of steroid therapy.
Subject(s)
Sarcoidosis/complications , Splenomegaly/complications , Adolescent , Adult , Aged , Female , Humans , Male , Middle Aged , Prednisone/therapeutic use , Prognosis , Retrospective Studies , Sarcoidosis/drug therapy , Sarcoidosis, Pulmonary/complications , Splenectomy , Splenomegaly/surgeryABSTRACT
From 1988 to 1992, 27 of 855 cases of Escherichia coli bacteremia in nonneutropenic adult patients observed at our hospital were due to ciprofloxacin-resistant (CIPRO-R) strains. Eighteen episodes (67%) were community acquired, and nine (33%) were nosocomially acquired. Overall, the rates of E. coli bacteremia caused by CIPRO-R strains increased steadily from 0% in 1988 to 7.5% in 1992 (P < 0.01). There was a statistically significant correlation between the incidence of CIPRO-R E. coli bacteremia and the upward trend in fluoroquinolone (norfloxacin and ciprofloxacin) use in the community (r = 0.974; P = 0.005) as well as in the hospital (r = 0.975; P = 0.005). When we compared the 27 case patients with 54 simultaneous control patients who had ciprofloxacin-susceptible E. coli bacteremia, the case patients more frequently had chronic underlying diseases (71 versus 37%; P = 0.004), urinary tract infection (74 versus 50%; P = 0.03), prior surgery (22 versus 6%; P = 0.02), and prior fluoroquinolone use (63 versus 4%; P < 0.001). A logistic regression analysis identified prior quinolone use as the only independent risk factor for CIPRO-R E. coli bacteremia. In conclusion, our study shows a significant correlation between ciprofloxacin resistance and fluoroquinolone use and indicates that prior fluoroquinolone use seems to be the most important risk factor for CIPRO-R E. coli bacteremia.
Subject(s)
Bacteremia/drug therapy , Ciprofloxacin/therapeutic use , Escherichia coli Infections/drug therapy , Escherichia coli/drug effects , Adult , Aged , Case-Control Studies , Ciprofloxacin/pharmacology , Drug Resistance, Microbial , Female , Humans , Male , Middle AgedABSTRACT
BACKGROUND: The involvement of the nervous system in sarcoidosis occurs with a frequency of approximately 5%. The aim of this study was to review the frequency and characteristics of the neurologic manifestations of the a series of sarcoidosis. METHODS: During a period of 18 years (1974-1991) 270 patients were diagnosed with sarcoidosis in the Hospital de Bellvitge-Prínceps d'Espanya. The diagnosis of neurosarcoidosis was performed in those presenting neurologic symptoms no attributable to other causes. The clinical histories were retrospectively reviewed collecting clinical, radiologic, analytic, therapeutic and evolutive data. RESULTS: Fourteen patients (5.1%) were diagnosed of neurosarcoidosis. Neurologic symptomatology was the first manifestation of the disease in 12 (85%). All showed extra-neurologic manifestations of sarcoidosis with the lung being the most frequently affected organ (78%). The clinical picture consisted of cranial neuropathy in 11 cases of which nine presented peripheral facial paralysis and 4 cases involvement of the central nervous system. In 13 patients the treatment schedule included glucocorticoids. All the patients (100%) with alteration of the central nervous system continued with active disease at 2 years while this only occurred in 33% of the cases with paralysis of the cranial pairs. CONCLUSIONS: The frequency of neurosarcoidosis in the authors' series was similar to that described in the literature and its most frequent clinical form was cranial neuropathy. The treatment of choice was glucocorticoid and the involvement of the cranial pairs presents a better prognosis than that of the central nervous system.
