Primjena veno-venske izvantjelesne membranske oksigenacije kod pacijenata s limfomom i teškim akutnim respiratornim distresnim sindromom: serija slučajeva

Aim: To report the clinical courses of two patients, one with Hodgkin’s lymphoma (HL) and one with Non-Hodgkin’s lymphoma (NHL), who developed severe refractory acute respiratory distress syndrome (ARDS) and were treated with veno-venous extracorporeal membrane oxygenation (VV ECMO). Case report: Both patients developed chemotherapy-associated febrile neutropenia followed by pneumonia and ARDS, after which they were transferred to the intensive care unit. Their respiratory failure deteriorated despite endotracheal intubation with protective mechanical ventilation, at which point a decision for VV ECMO initiation was made. Both patients had complicated treatment courses and developed severe ECMO-associated complications. The most important complications of ECMO support in our HL patient were cardiac arrest; right atrial laceration with pericardial tamponade which needed surgical treatment; right leg ischemia which required transfemoral amputation; thrombosis within the membrane oxygenator; several septic episodes with severe hemodynamic instability; and right sided tension pneumothorax. Despite all difficulties, the patient was successfully weaned from ECMO. Unfortunately, he died prior to hospital discharge as a result of sepsis with multiple organ failure. The most significant ECMO-induced complications in our NHL patient were severe bleeding incidents, most notably diffuse oropharyngeal and continuous bilateral pulmonary hemorrhage; superimposed bacterial pneumonia; extensive pneumomediastinum and subcutaneous emphysema. Despite all therapeutic efforts, the patient died during ECMO treatment because of respiratory decompensation. Conclusions: The patients with hematologic malignancies (HMs) undergoing ECMO support have poor outcomes, with high rates of severe ECMO-induced complications. Further studies focusing on patient selection and issues concerning prevention, diagnosis and treatment of ECMO-associated complications are needed.Cilj: Prikazati klinički tijek dvoje pacijenata, pacijenta s Hodgkinovim limfomom i pacijentice s ne-Hodgkinovim limfomom, koji su razvili teški refraktorni akutni respiratoracijski distresni sindrom (engl. acute respiratory distress syndrome; ARDS) te su liječeni veno-venskom izvantjelesnom membranskom oksigenacijom (engl. veno-venous extracorporeal membrane oxygenation; VV ECMO). Prikaz slučaja: Nakon kemoterapije pacijenti su razvili febrilnu neutropeniju, pneumoniju i ARDS, nakon čega su premješteni u jedinicu intenzivnog liječenja. Unatoč orotrahealnoj intubaciji i protektivnoj mehaničkoj ventilacijskoj potpori, došlo je do pogoršanja njihova respiracijskog statusa te se odlučilo uvesti VV ECMO potporu. Imali su kompliciran klinički tijek praćen teškim komplikacijama povezanim s korištenjem ECMO-a. Kod pacijenta s Hodgkinovim limfomom razvile su se sljedeće komplikacije: kardijalni arest; laceracija aurikule desnog atrija s tamponadom perikarda, što je zahtijevalo kirurško liječenje; ishemija desne noge koja je zahtijevala transfemoralnu amputaciju; tromboza membranskog oksigenatora; nekoliko septičkih epizoda praćenih teškom hemodinamskom nestabilnošću te desnostrani tenzijski pneumotoraks. Iako se uspješno odvaja od ECMO-a, pacijent je preminuo na odjelu zbog sepse s multiorganskim zatajenjem. U pacijentice s ne-Hodgkinovim limfomom razvilo se difuzno orofaringealno i kontinuirano obostrano plućno krvarenje; sekundarna bakterijska pneumonija; opsežan pneumomedijastinum i subkutani emfizem. Unatoč svim mjerama potpore, pacijentica je preminula tokom liječenja ECMO-om zbog dekompenzacije respiracijskog zatajivanja. Zaključak: Pacijenti s hematološkim neoplazmama liječeni ECMO-om imaju loše terapijske ishode praćene čestim i teškim komplikacijama. Potrebna su klinička istraživanja s posebnom pažnjom na izbor pacijenata, prevenciju, dijagnozu i liječenje komplikacija povezanih s korištenjem ECMO-a

Treatment of differentiated thyroid cancer: the role of 131I and new guidelines

Karcinomi štitne žlijezde u stalnom su porastu. Papilarni i folikularni su najčešća varijanta i sa karcinomom Hurthleovih stanica nazivaju se diferencirani karcinomi štitne žlijezde te imaju bolju prognozu u odnosu na medularni i anaplastični. Ovisno o proširenosti i tipu karcinoma, postoji šest različitih metoda liječenja: operativno liječenje, terapija jodom-131, supresivna terapija levotiroksinom, radioterapija vanjskim snopom, ciljana terapija i kemoterapija. Temeljno liječenje diferenciranih karcinoma čine operativna terapija i potom primjena 131I. Primarni karcinom može se ukloniti lobektomijom ili totalnom tireoidektomijom. Totalna tireoidektomija češće se koristi zbog velike učestalosti multicentričnosti tumora i zahvaćenosti oba režnja žlijezde te je pokazala manji rizik od recidiva tumora većih od 1 cm. U liječenju metastatskog i rekurentnog karcinoma operacija je korisna kod resekcije ograničenih simptomatskih metastaza ili regionalnih limfnih čvorova, posebice kada je tumor refrakteran na 131I. Radiojodna terapija primjenjuje se nakon totalne tireoidektomije kako bi uništila sve preostale stanice zdravog i tumorskog tkiva štitnjače, bilo malignog ili suspektnog, te recidiva bolesti. Radioterapija vanjskim snopom i kemoterapija koriste se najviše u pacijenata čiji je karcinom neresektabilan, metastazirao ili čije stanje zahtijeva palijativnu terapiju zbog uznapredovale bolesti. Kemoterapija uglavnom ne daje zadovoljavajuće rezultate. Ciljana terapija je noviji modalitet liječenja koji daje odlične rezultate i sve se više koristi u slučaju proširene bolesti, recidiva ili metastaza koji su refrakterni na 131I. Prva linija sistemske ciljane terapije su inhibitori tirozin kinaze, čija primjena ima poseban značaj u liječenju karcinoma štitne žlijezde refrakternih na jod-131.Thyroid cancers are on the rise. Papillary and follicular are the most common variants and with Hurthle cell cancer are called differentiated thyroid cancers. They have good prognosis compared to medullary and anaplastic. Depending on the extent and type of cancer, there are six different treatment methods: surgery, iodine-131 therapy, levothyroxine suppressive therapy, external beam radiotherapy, targeted therapy, and chemotherapy. The basic treatment consists of surgical therapy and the use of 131I. Primary cancer can be removed by lobectomy or total thyroidectomy. Total thyroidectomy is more commonly used due to the high frequency of multicentric tumours of the gland and has shown lower risk of tumour recurrence greater than 1 cm. In the treatment of metastatic and recurrent cancer, surgery is useful in resection of limited symptomatic metastases or regional lymph nodes, especially when the tumour is refractory to 131I. Radioiodine therapy is applied after total thyroidectomy to destroy all remnant cells and malignant thyroid tissue or recurrence of the disease. External beam radiotherapy and chemotherapy are mostly used in patients whose cancer is unresectable, metastatic, or whose condition requires palliative therapy due to advanced disease. Chemotherapy generally does not give satisfactory results. Targeted therapy is a newer treatment modality that gives excellent results and is increasingly used in case of extended disease, recurrence or metastasis that is refractory to 131I. The first line of systemic targeted therapy are tyrosine kinase inhibitors, the use of which is of particular importance in the treatment of thyroid cancers refractory to 131I

Treatment of differentiated thyroid cancer: the role of 131I and new guidelines

Karcinomi štitne žlijezde u stalnom su porastu. Papilarni i folikularni su najčešća varijanta i sa karcinomom Hurthleovih stanica nazivaju se diferencirani karcinomi štitne žlijezde te imaju bolju prognozu u odnosu na medularni i anaplastični. Ovisno o proširenosti i tipu karcinoma, postoji šest različitih metoda liječenja: operativno liječenje, terapija jodom-131, supresivna terapija levotiroksinom, radioterapija vanjskim snopom, ciljana terapija i kemoterapija. Temeljno liječenje diferenciranih karcinoma čine operativna terapija i potom primjena 131I. Primarni karcinom može se ukloniti lobektomijom ili totalnom tireoidektomijom. Totalna tireoidektomija češće se koristi zbog velike učestalosti multicentričnosti tumora i zahvaćenosti oba režnja žlijezde te je pokazala manji rizik od recidiva tumora većih od 1 cm. U liječenju metastatskog i rekurentnog karcinoma operacija je korisna kod resekcije ograničenih simptomatskih metastaza ili regionalnih limfnih čvorova, posebice kada je tumor refrakteran na 131I. Radiojodna terapija primjenjuje se nakon totalne tireoidektomije kako bi uništila sve preostale stanice zdravog i tumorskog tkiva štitnjače, bilo malignog ili suspektnog, te recidiva bolesti. Radioterapija vanjskim snopom i kemoterapija koriste se najviše u pacijenata čiji je karcinom neresektabilan, metastazirao ili čije stanje zahtijeva palijativnu terapiju zbog uznapredovale bolesti. Kemoterapija uglavnom ne daje zadovoljavajuće rezultate. Ciljana terapija je noviji modalitet liječenja koji daje odlične rezultate i sve se više koristi u slučaju proširene bolesti, recidiva ili metastaza koji su refrakterni na 131I. Prva linija sistemske ciljane terapije su inhibitori tirozin kinaze, čija primjena ima poseban značaj u liječenju karcinoma štitne žlijezde refrakternih na jod-131.Thyroid cancers are on the rise. Papillary and follicular are the most common variants and with Hurthle cell cancer are called differentiated thyroid cancers. They have good prognosis compared to medullary and anaplastic. Depending on the extent and type of cancer, there are six different treatment methods: surgery, iodine-131 therapy, levothyroxine suppressive therapy, external beam radiotherapy, targeted therapy, and chemotherapy. The basic treatment consists of surgical therapy and the use of 131I. Primary cancer can be removed by lobectomy or total thyroidectomy. Total thyroidectomy is more commonly used due to the high frequency of multicentric tumours of the gland and has shown lower risk of tumour recurrence greater than 1 cm. In the treatment of metastatic and recurrent cancer, surgery is useful in resection of limited symptomatic metastases or regional lymph nodes, especially when the tumour is refractory to 131I. Radioiodine therapy is applied after total thyroidectomy to destroy all remnant cells and malignant thyroid tissue or recurrence of the disease. External beam radiotherapy and chemotherapy are mostly used in patients whose cancer is unresectable, metastatic, or whose condition requires palliative therapy due to advanced disease. Chemotherapy generally does not give satisfactory results. Targeted therapy is a newer treatment modality that gives excellent results and is increasingly used in case of extended disease, recurrence or metastasis that is refractory to 131I. The first line of systemic targeted therapy are tyrosine kinase inhibitors, the use of which is of particular importance in the treatment of thyroid cancers refractory to 131I

Treatment of differentiated thyroid cancer: the role of 131I and new guidelines

Karcinomi štitne žlijezde u stalnom su porastu. Papilarni i folikularni su najčešća varijanta i sa karcinomom Hurthleovih stanica nazivaju se diferencirani karcinomi štitne žlijezde te imaju bolju prognozu u odnosu na medularni i anaplastični. Ovisno o proširenosti i tipu karcinoma, postoji šest različitih metoda liječenja: operativno liječenje, terapija jodom-131, supresivna terapija levotiroksinom, radioterapija vanjskim snopom, ciljana terapija i kemoterapija. Temeljno liječenje diferenciranih karcinoma čine operativna terapija i potom primjena 131I. Primarni karcinom može se ukloniti lobektomijom ili totalnom tireoidektomijom. Totalna tireoidektomija češće se koristi zbog velike učestalosti multicentričnosti tumora i zahvaćenosti oba režnja žlijezde te je pokazala manji rizik od recidiva tumora većih od 1 cm. U liječenju metastatskog i rekurentnog karcinoma operacija je korisna kod resekcije ograničenih simptomatskih metastaza ili regionalnih limfnih čvorova, posebice kada je tumor refrakteran na 131I. Radiojodna terapija primjenjuje se nakon totalne tireoidektomije kako bi uništila sve preostale stanice zdravog i tumorskog tkiva štitnjače, bilo malignog ili suspektnog, te recidiva bolesti. Radioterapija vanjskim snopom i kemoterapija koriste se najviše u pacijenata čiji je karcinom neresektabilan, metastazirao ili čije stanje zahtijeva palijativnu terapiju zbog uznapredovale bolesti. Kemoterapija uglavnom ne daje zadovoljavajuće rezultate. Ciljana terapija je noviji modalitet liječenja koji daje odlične rezultate i sve se više koristi u slučaju proširene bolesti, recidiva ili metastaza koji su refrakterni na 131I. Prva linija sistemske ciljane terapije su inhibitori tirozin kinaze, čija primjena ima poseban značaj u liječenju karcinoma štitne žlijezde refrakternih na jod-131.Thyroid cancers are on the rise. Papillary and follicular are the most common variants and with Hurthle cell cancer are called differentiated thyroid cancers. They have good prognosis compared to medullary and anaplastic. Depending on the extent and type of cancer, there are six different treatment methods: surgery, iodine-131 therapy, levothyroxine suppressive therapy, external beam radiotherapy, targeted therapy, and chemotherapy. The basic treatment consists of surgical therapy and the use of 131I. Primary cancer can be removed by lobectomy or total thyroidectomy. Total thyroidectomy is more commonly used due to the high frequency of multicentric tumours of the gland and has shown lower risk of tumour recurrence greater than 1 cm. In the treatment of metastatic and recurrent cancer, surgery is useful in resection of limited symptomatic metastases or regional lymph nodes, especially when the tumour is refractory to 131I. Radioiodine therapy is applied after total thyroidectomy to destroy all remnant cells and malignant thyroid tissue or recurrence of the disease. External beam radiotherapy and chemotherapy are mostly used in patients whose cancer is unresectable, metastatic, or whose condition requires palliative therapy due to advanced disease. Chemotherapy generally does not give satisfactory results. Targeted therapy is a newer treatment modality that gives excellent results and is increasingly used in case of extended disease, recurrence or metastasis that is refractory to 131I. The first line of systemic targeted therapy are tyrosine kinase inhibitors, the use of which is of particular importance in the treatment of thyroid cancers refractory to 131I