[A retrospective analysis comparing colposuspension and retropubic mid-urethral sling as preventive anti-incontinence measures during laparoscopic sacrocolpopexy]. / Analisi retrospettiva di confronto tra colposospensione e sling retropubica medio-uretrale come misure preventive anti-incontinenza in corso di sacrocolpopessia laparoscopica.

AIM: The aim of this paper was to compare two anti-incontinence procedures during laparoscopic sacrocolpopexy (LSC) to prevent postoperative stress urinary incontinence (SUI). METHODS: Retrospective analysis of 90 continent hysterectomized patients with vaginal vault prolapse treated with LSC plus colposuspension (group A, N.=30), LSC plus retropubic mid-urethral sling (group B, N.=30), or LSC alone (group C, N.=30). RESULTS: De novo SUI rate resulted significantly (P<0.05) lower in group B than C. No difference was detected regarding de novo urge urinary incontinence. Total reoperation rate resulted significantly (P<0.05) higher in group A than B and lower in group B than C. CONCLUSION: When associated to LSC for preventing SUI, colposuspension and retropubic mid-urethral sling are effective and safe, even if mid-urethral sling seems to provide the best risk/benefit profile.

Clinical and pharmacologic study of the epirubicin and paclitaxel combination in women with metastatic breast cancer.

PURPOSE: A pharmacokinetic interaction may cause increased cardiotoxicity of paclitaxel (PTX) and high cumulative dose of doxorubicin. We tested antitumor activity, tolerability, and pharmacokinetics of the lesser cardiotoxic epirubicin (EPI) and PTX (ET combination). PATIENTS AND METHODS: Twenty-seven women with untreated metastatic breast cancer, median age of 56 years, and prominent visceral involvement (74%) were studied. Three-weekly EPI (90 mg/m(2)) and PTX (200 mg/m(2) over 3 hours) were given for a maximum nine cycles. EPI was administered 24 hours before PTX (E --> T) in cycle 1, and 15 minutes before PTX (ET) thereafter. EPI, epirubicinol (EOL), EPI-glucuronide (EPI-glu), EOL-glucuronide (EOL-glu), PTX, and 6alpha-OH-PTX were measured in plasma and urine in 14 women. RESULTS: Patients received 205 cycles of ET and a median EPI dose of 720 mg/m(2). Grade 4 neutropenia (49% of cycles) was the most frequent toxicity. Cardiac contractility was decreased in five patients. Mild congestive heart failure occurred in two (7.4%). Response rate was 76% (28% complete). Median overall survival was 29 months. On the basis of intrapatient comparison in the first 24 hours of E --> T and ET cycles, PTX did not affect EPI disposition, but significantly increased plasma exposure to EOL (by 137%), EPI-glu (threefold) and EOL-glu (twofold). Urinary excretion of EPI dose went from 8.2% in E --> T to 11.8% in ET cycles. Clearance of PTX was 30% slower in ET than E --> T. ET cycles caused lower neutrophil nadir than E --> T (644 +/- 327 v 195 +/- 91, P <.05) CONCLUSION: ET is feasible, devoid of excessive cardiac toxicity, and active. A reciprocal pharmacokinetic interference between the two drugs has pharmacodynamic consequences, and suggests a direct effect of PTX on EPI metabolism requiring ad hoc investigation.

Long-term cardiac sequelae in operable breast cancer patients given adjuvant chemotherapy with or without doxorubicin and breast irradiation.

PURPOSE: To investigate long-term cardiac sequelae associated with anthracycline use in adjuvant chemotherapy of patients with early breast cancer. PATIENTS AND METHODS: All 1,000 patients from three prospective trials of adjuvant chemotherapy containing doxorubicin (n = 637, median total dose of 294 mg/m(2)) or not containing the anthracycline (cyclophosphamide, methotrexate, and fluorouracil [CMF] regimen alone, n = 363) were analyzed for the relative incidence of congestive heart failure (CHF) and myocardial infarction (MI) during 14 years of follow-up. The 462 women continuously free of disease as of February 1996 were recalled, and 355 consented to undergo evaluation including 12-lead ECG and cardiac ultrasound with determination of left ventricular ejection fraction (LVEF) to assess the relative incidence of abnormalities in long-term survivors. RESULTS: Among the 1,000 patients, there were six cases of CHF and three cases of MI. Cumulative cardiac mortality accounted for 0.4% (doxorubicin-treated = 0.6%; CMF-treated = 0). Eighteen (5%) of the 355 patients undergoing cardiac evaluation after median 11 years of follow-up presented systolic dysfunction as defined by pathologic (< 50%, n = 8) or borderline (50% to 55%, n = 10) LVEF. Systolic dysfunction was higher in doxorubicin-treated (15 of 192; 8%) than in CMF-treated patients (three of 150; 2%). Breast irradiation had a significant impact on the occurrence of early CHF (four of 116; 3%), but not on systolic dysfunctions. CONCLUSION: At longer than 10 years of follow-up, the use of doxorubicin at a total dose commonly applied in regimens of adjuvant chemotherapy does not lead to cardiac clinical sequelae that counter-balance the benefit of treatment in patients with operable breast cancer who may be cured of their disease.

[Left valvular involvement in carcinoid: description of a case]. / Coinvolgimento valvolare sinistro da carcinoide: descrizione di un caso.

Right-sided valvular heart disease is a common complication of metastatic carcinoid tumors. On the contrary, left valve involvement is a rare finding. In our report we describe a patient in whom the subsequent involvement of right and left heart valves was documented by 2D and Doppler echocardiography. The patient was a 46-year-old woman who, in the last three years, complained of face flushing, postprandial diarrhea and shooting epigastric pain lasting for hours. She came at our observation for increasing dyspnoea, peripheral edemas and asthenia. 2D-echocardiography and Color Doppler revealed a severe tricuspid regurgitation and a turbulent blood flow across the pulmonary valve. An Angiographic examination confirmed the severe tricuspidal regurgitation and disclosed a mild pulmonary stenosis. These findings were associated with high 5 hydroxyndole acetic acid (5-HIAA) urinary excretion and the presence of a liver metastasizing ileal carcinoid tumor. Some months later, a new 2D echo-Doppler examination showed thickening and reduced motion of the posterior mitral leaflet, associated with regurgitation and an aortic insufficiency without evident structural valvular abnormalities. Even if carefully investigated no right-to-left shunt was found.

Liver hemodynamic flow balance by image-directed Doppler ultrasound evaluation in normal subjects.

Image-directed Doppler ultrasonography of main hepatic vessels (hepatic artery, portal vein, hepatic veins, and inferior vena cava (IVC)] was performed in 22 healthy volunteers, 20 years to 65 years of age. For each vessel an estimate was made of the diameter, velocity time interval (VTI), volume blood flow in relation to heart rate (stroke volume in L/min/beat), and body size (blood flow index in L/min/m2 body surface area). Moreover, a hemodynamic hepatic balance to define a range of values in normal population was described. The summation of flow of hepatic veins and IVC flow, just over renal veins, (= IVC subhepatic flow) was significantly correlated with the IVC flow rate before entrance into the atrium (R2 = 0.90). Hepatic artery flux plus portal vein flux plus subhepatic vein flux was also related to IVC flux before right atrium entrance (R2 = 0.92). This study confirms the utility and efficiency of Doppler ultrasonography in understanding liver flow hemodynamic balance.