Orthotopic liver transplantation for carcinoid tumour metastatic to the liver: anesthetic management.

PURPOSE: To report the anesthetic management of a patient with carcinoid tumour metastatic to the liver who presented for orthotopic liver transplantation. Anesthetic implications of metastatic carcinoid tumour on liver transplantation and the use of octreotide are discussed. CLINICAL FEATURES: A 51-yr-old woman with intestinal carcinoid tumour metastatic to the liver presented for orthotopic liver transplantation, a recent treatment option for patients with extensive hepatic carcinoid metastases and disabling symptoms unresponsive to conventional therapy. Despite continuous administration of the somatostatin analogue octreotide via a hepatic artery infusate pump, the patient suffered from daily break through symptoms, which included flushing, palpitations, paroxysmal hypertension, and dyspnea. The patient presented to the operating room with sinus tachycardia and severe arterial hypertension. Octreotide and phentolamine were used to prevent further mediator release and to control the paroxysmal hypertension. Midazolam, fentanyl, thiopental, succinylcholine, vecuronium, and isoflurane were used to induce and maintain anesthesia safely. An intravenous octreotide infusion was initiated after induction and continued throughout the case. Infrequent and non-threatening peaks in arterial blood pressure were readily treated with small intravenous doses of vasoactive drugs and octreotide. No other manifestations of the carcinoid syndrome occurred. The patient had an uneventful recovery and was discharged on postoperative day #6. CONCLUSION: The patient safely underwent orthotopic liver transplantation for treatment of symptomatic carcinoid tumour metastatic to the liver. The anesthetic management followed recent recommendations favouring the use of octreotide to prevent patients from becoming symptomatic. Outlined dosing regimen for octreotide provided satisfactory hemodynamic stability.

[Immunohistochemical tumor markers in infiltrating ductal breast carcinoma]. / Marcadores tumorales inmunohistoquímicos en carcinoma ductal infiltrante de la mama.

BACKGROUND: Immunohistochemical techniques allow the study of tumoral markers with predictive or prognostic value. AIM: To study tumoral markers in mammary carcinoma and to relate these markers with age and tumoral histological grade. MATERIAL AND METHODS: The expression of nuclear estrogen receptor (RE), nuclear progesterone receptor (PGR), p53 and c-erb-B2 proteins was analyzed in 382 cases of infiltrating ductal carcinoma of the breast. RESULTS: The histological grade was I in 22% tumors, II in 56% and III in 23%. Forty nine percent of tumors had positive staining for RE, 41% for RPG, 45% for p53 and 57% for c-erb-B2. Correlation was found between histological grade and expression of RE, p53 and c-erb-B2 between RE and PGR, RE and c-erb-B2 and between c-erb-B2 and p5. RE expression correlated with age. CONCLUSIONS: A reliable and rapid evaluation of these markers can be achieved using immunohistochemical staining. The present results are similar to other biochemical and immunohistochemical studies.

Effects of oral administration of zinc and diiodohydroxyquinolein on plasma zinc levels of uremic patients.

Patients with chronic renal failure often have low plasma zinc (Zn) levels. Some factors that may account for abnormal Zn metabolism in these patients are low dietary Zn intake, a specific Zn transport defect, or absence of intestinal Zn ligand. In this study Zn supplementation and a Zn-chelating drug, diiodohydroxyquinolein (DQ), were used to assess the effects of Zn intake and Zn transporters on Zn plasma levels in patients with chronic renal failure. To meet this objective, 20 uremic patients were randomly assigned to one of the following groups of treatment: group 1 received placebo; group 2 Zn sulfate (100 mg/day p.o.), group 3 DQ (80 mg/day p.o.), and group 4 received Zn sulfate plus DQ at the same dosages as in groups 2 and 3. The Zn plasma levels were measured in venous samples, before and after 1 and 2 weeks of treatment, by atomic absorption spectrophotometry. The Zn plasma levels increased in group 2 patients from 8 +/- 0.2 to 10 +/- 0.4 and 11 +/- 0.9 mumol/l by the end of the 1st and 2nd weeks of treatment, respectively. In group 4 patients, the Zn plasma levels increased even more: from 9 +/- 0.1 to 14 +/- 1.6 and 13 +/- 2.1 mumol/l respectively. The plasma Zn concentration of group 1 and 3 patients remained at basal levels. These results show that DQ, when given along with Zn sulfate supplements, causes a greater increase in plasma Zn levels than that caused by either drug given alone.

[Changes in the clinical presentation of primary hyperparathyroidism. Analysis of 84 cases]. / Cambio en la presentación clínica del hiperparatiroidismo primario. Análisis de 84 casos.

During the last two decades, the clinical presentation of primary hyperparathyroidism (PHP) has changed due to the routine use of multiphasic biochemical screening tests. We assessed 84 patients with PHP treated in our service between 1977 and 1991. The yearly incidence increased from 1.6 to 7.6 patients/year with the introduction of multiphasic biochemical testing in our hospital in 1982; likewise the proportion of asymptomatic patients increased from 12.5 to 40.7%. The most frequent presenting symptoms were bone pain and renal colic. Nineteen percent of patients were over 70 years old and this age group had distinct clinical features. The plasma chlorine/phosphorus ratio was abnormal in 95% of cases; on the contrary only 7 of 18 patients had a urinary calcium excretion over 300 mg/day. Cervical ultrasound, performed in 45 patients had a positive predictive value of 78% to localize the lesion. Bone density was below fracture threshold in 50% of studied patients. The principal surgical finding was the presence of adenoma. Twenty one percent of patients had symptomatic hypocalcemia during the first week after surgery; however, only 2.5% of patients continued to have hypocalcemia one month after surgery. One patient had an inferior laryngeal nerve damage and two a cervical hematoma. It is concluded that the introduction of massive calcium measurements has allowed an early diagnosis of asymptomatic PHP, specially in elderly people.

Endothelium-derived Relaxing Factor Inhibits Shear Stress-induced Platelet Aggregation.

The effect of endothelium-derived relaxing factor (EDRF) and related compounds on platelet aggregation in response to physiological and pathological levels of arterial wall shear stress (30-120 dyne/cm(2)) was investigated. Platelets in plasma, or washed platelets, aggregated markedly in response to shear stresses generated by a cone-plate viscometer. Pre-treatment of platelets with the S-nitrosothiol compounds S-nitroso-N-acetylcysteine or S-nitrosocysteine, or with nitric oxide (NO) or SIN-1 (which is non-enzymatically metabolized to NO), resulted in decreased platelet aggregation in response to shear stress. Non-hydrolyzable analogues of cyclic guanosine 3',5'-monophosphate (cGMP) also inhibited shear stress-induced platelet aggregation, and specific pharmacological manipulations of NO and cGMP (with methylene blue or the cGMP phosphodiesterase inhibitor M&B 22 984) resulted in alterations of intraplatelet levels of cGMP that correlated with the degree of inhibition of shear stress-induced platelet aggregation. These results demonstrate that EDRF and related compounds inhibit platelet aggregation that is initiated by shear stress, and suggest that this physiologically relevant mechanism of platelet aggregation may be regulated by intraplatelet cGMP.

The monoclonal antibody AG-1, a potent stimulator of human platelets, interacts with a low molecular weight GTP-binding protein.

AG-1 is a monoclonal antibody that binds to human platelets and causes aggregation and secretion. Previous work has established that these responses result from phospholipase C-mediated hydrolysis of phosphatidylinositol 4,5-bisphosphate (PIP2). To determine the mechanism by which this ligand induces signals for platelet activation, we performed a series of experiments examining the platelet binding site for AG-1. AG-1 immunoprecipitates from radioiodinated human platelet plasma membranes a protein of Mr 21,000. AG-1 immunoprecipitated proteins separated by SDS-PAGE, transferred to nitrocellulose, and incubated with [alpha 32P]GTP demonstrate binding of the radiolabeled GTP to the Mr 21,000 protein. A 100-fold molar excess of unlabeled GTP inhibits completely this binding of [alpha 32P]GTP. These results indicate that AG-1 interacts with a low Mr GTP-binding protein on the surface of platelets and suggests that either the protein recognized by AG-1 or a coprecipitating molecule of similar Mr is a low Mr GTP-binding protein that may function in platelet extracellular signal transduction.

[Primary hyperparathyroidism: usefulness of high resolution echography in local diagnosis]. / Hiperparatiroidismo primario: utilidad de la ecografía de alta resolución en el diagnóstico localizatorio.

Recent reports show a better surgical outcome in primary hyperparathyroidism when an accurate preoperative localization of the lesion in available. We performed high resolution sonography in 23 consecutive patients (20 women) with biochemically proven hyperparathyroidism. Twenty two of them were operated on and their sonographic reports were compared to the surgical and pathological findings (20 adenomas, 1 carcinoma and 1 hyperplasia). One patient did not have surgery but the sonogram was compared to a Tl 201-Tc99 scintigram that suggested an adenoma. Sonography showed a single parathyroid tumor in 17 patients and failed to demonstrate a lesion in six. There were two false positives and 6 false negatives. The sensitivity was 71.5% and the positive predictive value was 88%. Three out of 6 patients with a negative sonography had an adenoma located out of reach for the method. Our results show that the high resolution sonography is a useful, non invasive method to localize abnormally enlarged parathyroid glands in hyperparathyroidism and we think it should be performed in every patient with a biochemical diagnosis of this disease.

Conservative treatment of early breast cancer.

At our Institution, the treatment policy for early carcinoma of the breast (T1-2, NO, AJC) is lumpectomy followed by radiotherapy to the breast and peripheral lymphatics. From October 1976 until December 1982, 171 patients have been admitted and treated. Radiotherapy was administered with 60 Co, 5.000 cGy in 5 weeks to the breast and lymphatics plus a boost to the scar giving q.s.p. 6.400 cGy at maximum tumor depth. With a minimum follow-up of 3 years and a median follow-up of 61.7 months the locoregional control was 94.2% and survival at 8 years with no evidence of disease (NED) was 77.2% with an overall survival rate of 90%. No difference in NED survival rate was found between Stage I and II. There was a tendency to better survival rate in those patients older than 50 years and also for post menopausal patients, however the difference did not reach statistical significance (66.7% NED survival at 8 years for premenopausal and 81.8% NED survival for post menopausal, also at 8 years, p = 0.056 Gehan). The time elapsed between surgery and radiation therapy (between 1 and 2 months) was found to be nonsignificant. Only 1 out of 171 patients had axillary dissection. The importance or lack of it, is discussed.