Continuous recurrence of type 1 hepatorenal syndrome and long-term treatment with terlipressin and albumin: A new exception to MELD score in the allocation system to liver transplantation?

Background & Aims The recurrence of type 1 hepatorenal syndrome has been described in up to 20% of responders to terlipressin and albumin after the discontinuation of the treatment. Subsequent recurrence of type 1 hepatorenal syndrome may require long-term treatment with terlipressin and albumin. Methods We describe our experience of long-term administration of terlipressin as a bridge to LT in three patients with cirrhosis and recurrent type 1 hepatorenal syndrome. For all three patients we requested an "early transplant" which is an option recognized in our country to reduce waiting times for liver transplantation. Results All three patients were transplanted within 2months of onset of hepatorenal syndrome. All patients are still alive and none of them have developed chronic kidney disease. Conclusions The outcomes of these patients suggest that long-term treatment with terlipressin and albumin is effective and well tolerated in patients with continuous recurrence of type 1 hepatorenal syndrome and, therefore, should be considered an absolute priority criterion in the allocation system for liver transplantation

Breast complaints and age as indicators of breast diseases

Breast complaints seem to be related to the age of the patients, than to their pathology and in women over 55 years breast cancer is more frequent. We have looked for a definite correlation between patients\u2019 sign and symptoms, age and risk of benign or malignant breast diseases. From 1983 to 1994 we observed 2356 consecutive patients with breast disease who were asked to complete a questionnaire before clinical examination. Only 242 (10.3%) patients had already a mammography or breast ultrasonography. Patients were assigned by age to three groups: group A (40 years old or younger) = 47.3%, group B (41-55 years) = 26.9%, group C (over 55 years) = 23.8%. Pain was the most frequent complaint (58.8%) in group A whereas a breast lump was most commonly found in groups B and C. In only 49.5% of the patients a breast mass was really detected at clinical examination. Breast cancer was found in 240 (10.2%) patients (group A = 0.8%, group B = 12.8%, group C = 25.8%). The predominant finding in all groups was fibrocystic breast disease (FBD). A statistically significant correlation between malignancy and breast lump was evident only in groups B and C (P < 0.05) but no correlation between malignancy and pain was found in any group (P = NS). The occurrence of cancer in 541 patients with FNAB-confirmed FBD over a median follow-up of 56 months (range 12-140 months) was similar to that reported for the general population. Many patients with breast complaints do not have any breast disease and more than 90% of the examined patients do not have cancer. In women 40 years of age and under with no history of malignancy the cancer rate is very low (< 1%) and a significant correlation between breast complaints and risk of cancer does not seem to exist. There is a need for a better information as to the significance of breast complaints

Combined liver-kidney transplantation in a 15-year-old boy with alpha1-antitrypsin deficiency

Alphal-antitrypsin (alpha1-AT) deficiency is the most common genetic cause of liver disease in infants and children. The major clinical manifestations include liver disease (primarily in children) and emphysema in adults. For patients who progress to cirrhosis and liver failure, liver transplantation provides a metabolic cure for the deficiency and presumably prevents the associated complications. Several case reports in the pediatric literature describe glomerulonephritis in the setting of severe alpha1-AT deficiency, but this association is less well documented in adults. End-stage chronic kidney disease is a rare finding in the literature and kidney transplantation is the treatment of choice. We report on a 15-year-old boy with alpha1-AT deficiency and consequent end-stage liver disease and membranoproliferative glomerulonephritis rapidly progressing to renal failure, who successfully underwent combined liver-kidney transplantation

Does sensitivity of tumor markers CEA and CA 15-3 significantly correlate with any preoperative parameters in breast cancer patients with recurrnece ?

Introduction: The aim of this study was to evaluate the causes of false-negative results using serum tumour markers (TM) CEA and CA 15-3 in treatment options and breast cancer (BC) patients with recurrence. Methods: Sixty-two women (median age 55 years, range 35\u201383) who underwent curative surgery for BC (pT1pN0=21, pT2pN0=14, pT2pN1=24, pT3pN1=3) developed local recurrences (n=36), distant metastases (n=13) or contralateral BC (n=13) during a mean follow-up of 52 months (range 24\u2013148). Results: TM sensitivity in detection of BC recurrence was 40.3% (CEA) and 41.9% (CA 15\u20133), with a mean lead time of 5.6\ub13.1 months (range 3\u20139). No difference (PNS) was found between the sensitivity of TMin the detection of recurrence and (1) their pre-operative values (Fisher exact test), (2) the site of the recurrence (Chi-squared test), and (3) axillary lymph node (N0/N1) involvement (Chi-squared test) correlates (Student\u2019s t-test) only with the age of the patients (CA 15\u20133) and the size of the tumor CEA). Conclusions: In BC patients with recurrence the sensitivity of TM during paraffin-embedded specimens follow-up does not correlate with any specific pre-operative parameter

Clinical value of serum markers in breast neoplasm: 5-years follow-up

Several serum markers have been proposed either for diagnosis or follow-up of women with breast cancer such as CEA, CA15-3 and more recently MCA. In this retrospective analysis we evaluated the correlation between breast cancer and serum markers and their changes related to surgical treatment, with a minimum 5-year postoperative follow-up. We evaluated retrospectively 66 women who underwent curative surgery for primary breast cancer. Patients with a pT value > 2 (calculated as a mean of the two maximum diameters) and all M+ were excluded, as well as patients with a discontinuous follow-up. Mean age was 61 years (median 61, range 31-87); 52 (78.8%) were older than 50 years. Patients were further divided into 3 groups: Group 1 (pTlpN0), Group 2 (pT2pN0) and Group 3 (pT2pN+). Mean pts age in the 3 groups was respectively: 53, 65 and 63 years. Preoperative CEA serum levels (normal values 0-10 ng/ mL) were available in all patients, and CA 15.3 levels (normal values &31 kU/L) only in 45 (68.1%). Markers were measured in the same Laboratory with high sensibility techniques. Further blood samples were collected at least at 6 months and 1, 2, 3 and 5 years after operation. Mean follow-up for the 62 alive patients was 88 months (median 78, range 60-138 months) and overall survival rate was 94.0%. Three patients died respectively 26, 52 and 54 months after operation of metastatic disease; another patient died of acute miocardial infarction 13 months after surgery. Student\u2019s t-test was used for statistical significance study. CEA mean serum concentration was 8.58\ub17.31 ng/mL (median 7.0, range 1-19) in Group 1; 5.55\ub15.44 (median 4.0, range 1-24) in Group 2; 6.28\ub16.66 (median 3.0, range 1-22) in Group 3. Preoperative CA 15-3 was available respectively in 16/19, 16/29 and 1308 patients in each group. Mean CA 15.3 value was 34.06\ub118.90 kU/L (median 34.0, range 12-82) in Group 1; 27.0\ub112.15 (median 26.50, range 8-53) in Group 2; 27.38 f 19.90 (median 27.38, range 7-81) in Group 3. No statistically significant difference was found among the 3 groups. Preoperative increased CEA serum levels was found in 14 (21.2%) patients and respectively in 709, l/29, 6/18 patients in each group; increased basal CA 15-3 serum levels was found in 14 (31.1%) patients and respectively in 7/16,4/16, 3/13 patients. CEA serum level at 6 months were 2.63\ub12.06 in Group 1; 2.72 f 1.77 in group 2; 4.22\ub13.28 in Group 3 and mean CA 15-3 levels were respectively 22.19\ub112.61, 19.19\ub14.93 and 15.46\ub19.50. Five years after operation, 62 patients were still alive. In these patients CEA levels were: 2.58\ub11.89 (Group l), 3.07\ub13.26 (Group 2), 2.29\ub11.07 (Group 3) and CA 15.3 levels were: 23.18\ub117.80 (Group l), 19.84 f 6.41 (Group 2), 16.77\ub15.37 (Group 3). Only in Group 1, a statistically significant difference in CEA and CA 15.3 levels (0 vs. 6 months and 0 vs. 5 years) was found. Ten (15.1%) patients showed relapse of malignancy during follow-up and mean relapse time was 40.3 months. In 7/10 and 3/10 patients respectively, CA 15-3 and CEA serum levels were increased at l-6 months before recurrence. Serum markers are not useful in diagnosis of breast cancer. In our 5 year long follow-up in a smaller group of ten pts who showed recurrence, elevation of serum CA 15.3 and CEA occurred respectively in seven and three pts with a mean of four months before evidence of relapse, while in the group of pts who had no evidence of recurrence (N=56) only in three cases was there an increase of serum CEA and CA 15.3 was discovered, in one case CEA and CA 15.3 increase was due to alcohol abuse and returned to normal. We conclude that serum markers CA 15.3 and CEA are useful during follow-up for the early detection of recurrences

Short- and long-term changes in bone mineral density following parathyroidectomy in male and female patients with primary hyperparathyroidism

Background: In primary hyperparathyroidism (PHPT) the skeletal involvement is characterized by the loss of the cortical bone and consequently reducing bone mineral density (BMD), and parathyroidectomy (PTx) may lead to normalization of bone remodeling. The aim of this study was to correlate the results of PTx in male patients, and in pre- and postmenopausal women with PHPT. Patients and methods: Sixty-two patients (median age 57 years, range 23-82 years) with PHPT underwent osteodensitometry using a dual-energy X-ray absorptiometry with BMD measurement at the L2-L4 region: (1) 2-5 weeks before surgery, (2) 12-15 months, and (3) 23-26 months after successful PTx. There were 14 (22.6%) men aged 56.58\uf0b112.66 years (Goup A), 12 (19.4%) premenopausal women aged 42.5+/-8.22 years (Group B), and 36 (58.0%) postmenopausal women aged 63.03+/-7.54 years. A significant (p=0.00, Student\u2019s t-test) difference in age between Group B and C was found. Main baseline serum biochemical data were the following (Groups A, B, C): calcium 2.946+/-0.26, 2.971+/-0.27, 2.938+/-0.26 mmol/L, p=NS; bone alkaline phosphatase: 61.71+/-22.21, 61.75+/-33.36, 97.31+/-73.74 U/L, p=NS; creatinine: 79.64+/-14.67, 69.25+/-17.52, 82.0+/-24.26 micromol/L, p=NS; PTH: +/-64.64+/-87.55, 192.67+/-133.25, 175.19+/-132.06 ng/L, p<0.05 between male and female patients. Results: None of the Group C patients received estrogen replacement therapy at any time, and no Group B patient used oral contraceptives. Preoperative BMD (g/cm2) values were (Groups A, B, C): 0.867+/-0.134, 0.853+/-0.061, 0.749+/-0.143; p<0.05 between Group A and C. Postoperative values were: (1) 12-15 months after PTx: 0.942+/-0.212 (+8.65%), 0.921+/-0.048 (+7.97%), 0.835+/-0.152 (+11.48%), and (2) 23-26 months after PTx: 0.987+/-0.215 (+4.77%), 0.948+/-0.075 (+2.93), 0.863+/-0.152 (+3.35%), respectively. A significant (p<0.05) difference was found between baseline and one-year BMD only in Group B patients. Conclusions: In patients with PHPT, at long-term follow-up, BMD of the lumbar spine significantly improves after PTx in premenopausal women, suggesting a higher bone sensitivity to serum PTH normalization

Long-term follow-up study in breast cancer patients using serum tumor markers CEA and CA 15-3.

The aim of this study was to evaluate CEA and CA 15-3 changes in patients surgically treated for breast cancer. One hundred and three women (median age 59 years, range 31-83 years) with pT1-2, pN0-1, M0 breast cancer were followed up for at least 5 years. CEA and CA 15-3 serum levels were measured before operation and every 6 months during follow-up. The diagnostic sensitivity of CEA and CA 15-3 was 22.3% and 33.3% respectively. There was a significant difference (p < 0.01) between pre- and post-operative (6 months and 5 years after surgery) mean CEA serum levels independent of TNM staging. During follow-up, 21 (20.4%) patients showed recurrence of cancer and overall CEA and CA 15-3 sensitivity was 38.1% and 61.1%, with 98.8% and 91.2% specificity, respectively. Tumor marker measurement may be useful in post-surgical follow-up, but at present they are neither sensitive nor specific enough for early diagnosis of malignancy

Sensitivity of serum tumor markers CEA and CA 15-3 in breast cancer recurrences and correlation with different prognostic factors

The aim of this study was to evaluate the correlation between serum tumor markers CEA and CA 15-3 in breast cancer (BC) patients with disease relapse and different prognostic parameters at first operation. Sixty-two women (median age 55 years, range 35-83 years) who had undergone curative surgery for pT1-2 pN0-1 M0 breast cancer developed local recurrences, distant metastases or contralateral BC during a median relapse time of 53 months (range 25-149 months). Sensitivity of CEA, CA 15-3, and CEA + CA 15-3 together was 40.3%, 41.9% and 59.7%, respectively. No correlation (p = NS) was found between tumor markers sensitivity and type of recurrence, surgical procedure, histologic subtypes and hormone receptors rate. CEA significantly (p < 0.01) correlated with the size of the tumor and axillary node status and CA 15-3 with the age of the patients. In conclusion, CEA and CA 15-3 should be considered complementary in detecting BC recurrences but their sensitivity is low and independent of the majority of the prognostic parameters that may be considered before relapse