手术切除治疗NSCLC脑转移瘤的预后情况及影响因素分析

目的探讨手术切除治疗非小细胞肺癌(NSCLC)脑转移瘤的预后情况并分析其影响因素。方法选取79例外科手术治疗的NSCLC脑转移瘤患者,观察其术后转归情况及临床资料,对患者性别、年龄、KPS评分、病理类型、脑转移瘤大小、术后治疗方案等可能影响预后的因素进行单因素分析及Cox多因素分析。结果 79例中67例术前存在神经系统症状,手术治疗后65例(97.01%)神经系统症状明显缓解或消失。79例NSCLC脑转移瘤患者1 a、2 a、3 a生存率分别为48.10%、21.52%、10.13%。单因素分析发现,KPS评分、术后放疗、靶向治疗、颅外转移和原发灶控制情况对患者术后生存期有显著影响(P0.05);而患者年龄、性别、病理类型、肿瘤直径与术后生存期无明显影响(P0.05)。Cox多因素分析发现,KPS评分、术后放疗、靶向治疗、颅外转移和原发灶控制情况是影响NSCLC脑转移瘤患者生存期的独立因素(P0.05)。结论外科手术治疗能有效改善NSCLC脑转移瘤患者神经系统不良症状,影响术后患者生存时间的因素包括KPS评分、术后放疗、靶向治疗、颅外转移和原发灶控制情况。     

立体定向放射外科治疗脑转移瘤预后影响因素的研究

目的对立体定向放射外科(SRS)治疗脑转移瘤的预后影响因素进行研究。方法回顾性研究SRS治疗115例脑转移瘤患者的临床资料,采用统计学方法分析影响其预后的因素。结果 115例脑转移瘤患者中位生存期12个月。单因素分析结果表明年龄、KPS评分、出现脑转移的时间、脑转移灶数目、脑转移瘤体积及原发病灶的治疗方法对患者生存期有影响(P0.05);多因素分析结果表明影响脑转移瘤预后的主要因素为KPS评分、出现脑转移的时间、脑转移瘤体积(P0.05)。结论 SRS是治疗脑转移瘤有效的方法。KPS评分、出现脑转移的时间、转移瘤体积是影响其预后的主要因素。     

肺癌脑转移214例生存及预后分析

目的 探讨各种因素对214例肺癌脑转移病例生存的影响,分析可能影响预后的因素.方法 对1992年1月至2001年12月浙江省肿瘤医院收治的214例肺癌脑转移病例资料进行回顾性分析.共有35例(16.4%)颅内单发转移瘤接受手术切除,其中单纯手术10例,手术联合全脑放疗8例,手术联合化疗2例,手术联合全脑放疗和化疗15例,单纯全脑放疗10例,单纯化疗36例,全脑放疗联合化疗104例,支持治疗29例.生存期定义为从患者接受治疗开始至死亡或随访结束的时间.应用Kaplan-Meier方法 计算1、3、5年生存率和中位生存期并描绘生存曲线,long-rank试验评价组间生存差异,Cox回归多因素分析影响肺癌脑转移预后的各种因子.结果 214例肺癌脑转移病例的中位生存期为10个月(95%C/9.06～10.94),1、3、5年累积生存率分别为7.46%、1.14%和0.根据患者的年龄、性别、病理类型和原发肿瘤分期及颅外脏器转移数目分析患者生存率,显示各组生存差异无统计学意义.各治疗方式中位生存期以联合手术、放化疗的综合治疗方式生存期最长(17个月),而手术联合化疗组和支持治疗组分别为3个月和4个月(P=0.00).Cox回归多因素分析表明治疗方式是惟一的独立预后因素.结论 对肺癌脑转移病例的积极治疗是有益的,其中联合手术治疗和全脑放疗、化疗等手段的综合治疗是最有效的.患者的年龄、性别、TNM分期和病理类型等因素和预后无明显相关.     

立体定向放射外科治疗脑转移瘤的疗效及相关因素分析

目的 回顾性研究立体定向放射外科(SRS)治疗脑重要功能区转移瘤,分析影响疗效的因素.方法 98例患者175个病灶经SRS治疗.肺癌转移占81.6%.单发病灶46例(46.9%),多发病灶52例(53.1%).应用德国产Brainlab X-刀,一次治疗病灶在5个以内.瘤体处方剂量:中心剂量24～30 Gy,平均26 Gy;周边剂量16～28 Gy,平均16.5 Gy.并依据患者病情给予相应对症治疗.结果 随访中瘤体缩小或消失86例(87.8%),保持稳定7例(7.1%),瘤体增大5例(6.3%).中位生存期11.9个月.存活2年者25例(25.5%).结论 SRS是治疗颅内转移瘤的有效方法.依据患者原发癌及病情,进行科学的相关治疗能够提高患者生存期及生活质量.     

头、体伽玛刀联合治疗肺癌合并脑转移瘤 50例临床分析

目的探讨头、体伽玛刀联合治疗肺癌合并脑转移瘤后肿瘤局部控制情况及患者生存期。方法回顾2003年3月~2005年3月,应用旋转式头、体伽玛刀治疗的50例原发性肺癌伴脑转移瘤。31例患者治疗前经过痰细胞学检查、支气管镜检查、肿瘤穿刺活检或手术后病理明确诊断。鳞癌13例,腺癌10例,小细胞癌5例,腺鳞癌3例。70%的患者肺癌伴纵隔淋巴结转移。结果47例随访3~24个月,平均随访12.5个月。除2例患者因脑内肿瘤未控制3个月内死亡,6个月生存35例,生存率为70%(35/50);12个月生存率为37%(10/27),生存率超过24个月为21.4%(3/14)。总的肿瘤局部控制率93.5%。结论头、体伽玛刀联合治疗肺癌伴脑转移瘤安全有效,改善患者的生活质量,延长患者的生存时间,可作为首选治疗方法。     

姑息性伽玛刀治疗老年脑转移瘤

目的 总结姑息性伽玛刀治疗老年(≥65岁)脑转移瘤患者的治疗效果. 方法 福建医科大学附属协和医院伽玛刀治疗中心自2004年3月至2010年3月共治疗134例老年脑转移瘤患者,共治疗212次,治疗病灶403个,平均中心剂量及边缘剂量分别为(29.3±8.4) Gy和(15.9±4.8) Gy.Kaplan-Meier方法计算患者的中位生存期,Cox回归分析影响伽玛刀治疗效果的临床因素. 结果 获影像学随访的372个病灶中,完全消失66个(17.7％),部分缓解174个(46.8％),无变化94个(25.3％),部分进展38个(10.2％).Kaplan-Meier分析显示患者中位生存期为10.9个月.影响伽玛刀治疗效果的因素为治疗前KPS评分、脑转移预后分级(RPA分级)、转移瘤数目和原发肿瘤的控制情况. 结论 伽玛刀治疗老年脑转移瘤是安全有效的姑息性治疗手段,有助于维持患者良好的生活质量.     

卒中样表现脑转移瘤的影像学特征及预后研究

目的：分析卒中样表现脑转移瘤的影像学特点及预后的影响因素。方法选取2011‐03—2013‐05我院诊治的60例卒中样表现脑转移瘤患者,均进行C T或M RI检查,分析卒中样表现脑转移瘤患者的影像学特征,分析原发肿瘤部位、K PS全身功能评分、病理类型、脑转移瘤的数目、部位及不同治疗方式等对预后的影响。结果60例脑转移瘤患者中肺癌43例,乳腺癌5例,肝癌3例,肾癌4例,其他原发癌症5例;脑转移瘤的发生部位有多处,单纯脑膜转移患者较少;颅外器官转移者33例,无颅外器官转移者27例;原发灶发现前呈卒中样表现,多数患者具有神经功能障碍体征。影响脑转移瘤患者预后的因素主要为原发肿瘤部位、脑转移瘤数目、治疗方式、有无颅外器官转移等因素。结论卒中样表现脑转移瘤采用CT检查能够有效反映病理特征,对于预后判断有一定的参考价值,为临床指导脑转移瘤预后恢复提供了参考依据。     

伽玛刀治疗肺癌脑转移瘤疗效及影响疗效的相关因素分析

目的探讨伽玛刀治疗肺癌脑转移瘤疗效及影响疗效的相关因素。方法回顾性分析2007年1月至2010年1月期间在我院采用伽玛刀治疗的116例有病理学证实的肺癌脑转移瘤患者的临床资料,其中男性76例,女性40例。根据肿瘤的大小、位置及肿瘤周边正常组织的耐受情况,小病灶(直径﹤3.0cm)直接选择伽玛刀一次性治疗,周边剂量12～18Gy,45%～70%等剂量曲线为处方剂量。对于较大肿瘤病灶(直径≥3cm但≤4cm)选择伽玛刀二次剂量分割治疗,两次治疗间隔6～8小时,周边剂量7～9Gy,40%～50%等剂量曲线为处方剂量。结果随访116例患者,随访期6～45个月,肿瘤控制率95%,中位生存期14.8个月,1年生存率63%,2年生存率25%。KPS评分在1个月内达到90分以上者占92%。结论伽玛刀是治疗肺癌脑转移瘤安全有效的方法,其疗效与肿瘤大小、位置、治疗剂量及肺癌的病理类型有关。     

影响脑转移瘤伽玛刀治疗效果相关因素分析

目的　探讨影响伽玛刀治疗脑转移瘤治疗效果的因素。方法　用伽玛刀治疗脑转移瘤 2 72例共 396个病灶。中心剂量 2 5～ 70Gy ,周边剂量 1 0～ 35Gy;靶点数 1～ 1 1个。并对肿瘤体积、数目、照射剂量、原发灶控制和全脑放疗等影响疗效因素进行统计分析。结果　本组病例随访 1 0～ 46个月 ,平均 2 4个月。 396个病灶完全缓解 32 6个 (82 3 % ) ,部分缓解 38个 (9 5 % ) ,无变化及进展 32个 (8 2 % ) ,平均生存期 (1 3 6± 7 9)个月。原发灶控制好者、伽玛刀治疗前后结合放疗、化疗者 ,其生存期较长。结论　伽玛刀是治疗脑转移瘤安全可靠的手段之一。并发症少、有效率高。伽玛刀治疗脑转移瘤的疗效主要与病灶体积、周边剂量等密切相关。肿瘤体积小于 1 5cm3,周边剂量大于 1 8Gy时 ,完全缓解率较高。     

肺癌脑转移瘤血管生成拟态现象与病人预后分析

目的探讨肺癌脑转移瘤是否存在血管生成拟态(Vasculogenic mimicry,VM),并分析肺癌脑转移瘤VM与病人预后的关系。方法回顾性分析60例病理确诊为肺癌脑转移瘤的病例资料,应用CD34-PAS双重染色法检测脑转移瘤中是否存在VM。总结可能与预后相关的因素,包括病人年龄、性别、原发灶部位、病理类型、转移灶部位、大小、数目、治疗方法、肿瘤切除程度、KPS评分等。结果 22例脑转移瘤中发现VM,阳性率36.6%。病人术前KPS评分70分、年龄60岁、术后行综合治疗的病人预后较好,而VM阳性或阴性病人预后无差异。多因素分析提示:病人术前KPS评分和术后综合治疗为病人预后良好的独立预后因素。结论肺癌脑转移瘤中存在VM,VM存在与否与肺癌脑转移瘤病人预后无相关性,而病人脑转移瘤术前KPS评分70、术后行综合治疗为病人良好预后的因素。     

Diagnostic Difficulties and Treatment Implications

Summary: Differentiation between types of epileptic seizures has been aided in recent years by the introduction of intensive neurodiagnostic techniques and the development of increasingly detailed classification systems. Paradoxically, these developments have not simplified the task of matching the appropriate antiepileptic drug to a particular seizure type. It is reasonable to assume that anticonvulsant drugs will have different effects on different types of seizures, but faulty, circular reasoning can enter the picture if one also assumes that responses of seizures to different drugs signify different seizure types. There are several examples of differential diagnoses that can fall prey to this problem, including the diagnosis between partial seizures with secondary generalization and generalized tonic-clonic seizures, and the diagnosis between complex partial seizures and absence seizures with automatisms, among others. Considerations of etiology in future classification systems can further complicate the problem: should one then choose an anticonvulsant drug on the basis of individual seizure type or on the basis of the type of epilepsy? Ramifications of this issue extend even to the drug approval process. Official sanction is not given for use of a drug for a seizure type not included in the original efficacy studies, even if later scientific evidence shows that seizure type to be related to a type that is included. New trials must be undertaken. These problems arise from how we choose to classify seizures.     

Cognitive Dysfunction Associated with Antiepileptic Drug Therapy

Summary: Epilepsy is frequently associated with cognitive dysfunction. However, the reasons for this correlation are unclear. Possible influential factors include patient age; duration, frequency, etiology, and type of seizures; hereditary factors; psychosocial issues; and antiepileptic drug (AED) therapy. Whereas many of these factors are beyond the physician's control, AED therapy is one element that can be addressed in treatment decisions by recognizing the potential cognitive effects of particular AEDs. For example, phenobarbital impairs memory and concentration; phenytoin affects attention, problem solving ability, and performance of visuomotor tasks. In contrast, carbamazepine may affect concentration, while valproate would appear to have minimal effects on cognition. Moreover, cognitive effects of AEDs are amplified with coadministration of multiple anticonvulsants (polytherapy). A review of studies on the cognitive effects of monotherapy with AEDs, as opposed to those of polytherapy, provides evidence that drug-related cognitive dysfunction can be reversed if patients are switched to a simpler therapeutic regimen. Future research should be directed toward developing reliable measures for assessing and monitoring cognition, and understanding the particular cognitive side effects of each AED. Physicians also need to revise their opinions about which side effects are "tolerable" for epileptic patients.     

Carbamazepine Efficacy in Adults With Partial and Generalized Tonic-Clonic Seizures

Summary: Carbamazepine and phenytoin are drugs of choice in initial monotherapy for adult partial and secondarily generalized tonic-clonic seizures. These designations reflect the results of the Veterans Administration Epilepsy Cooperative Study Group of 1985. An earlier comparative study of carbamazepine and phenytoin by Ramsay and associates found both drugs equally effective in controlling new-onset seizures. Among the advantages of carbamazepine is that it causes relatively few cognitive and dysmorphic side effects. Its disadvantages are its unavailability in parenteral formulation and its metabolic autoinduction. The latter must be compensated for by planned dosage increases to maintain therapeutic plasma steady-state levels during the first 2 or 3 months of treatment. Carbamazepine is judged a drug of choice in the treatment of these secondarily generalized tonic-clonic seizures, and the drug of choice in children, adolescents, and women susceptible to the dysmorphic side effects associated with other anticonvulsant agents.     

Etiologic and Preventive Aspects of Epilepsy in the Child–Bridging the Gap Between Laboratory and Clinic

Summary: Four broad categories of basic phenomena are pertinent to developing ways to prevent epilepsy. These include mechanisms of epileptogenesis, ictal initiation and temporary entrainment by the seizure discharge of normally functioning brain, seizure propagation, and control mechanisms that function both to restrain the cascade of epileptic events culminating in a seizure and to arrest the epileptic event and restore the interictal state. In newborns and children, hypoxia-ischemia is a major factor leading to epileptogenesis, and several schemes are proposed to classify, quantify, and prevent hypoxic-ischemic encephalopathy. Control mechanisms must be better understood in order to develop prophylactic recommendations for epilepsy, and an experimental model of "kindling antagonism" may increase our understanding of these. Programs of prevention of seizures in children will evolve only if basic researchers and clinicians work productively together to develop an adequate understanding of factors important in epileptogenesis and antiepileptogenic control mechanisms.     

Predisposing and Causative Factors in Childhood Epilepsy

Summary: We review information from large studies of defined populations, examining the role of known factors and especially of prenatal and perinatal factors in contributing to nonfebrile seizure disorders of early childhood. We depend especially, but not exclusively, on the recently completed analyses from the Collaborative Perinatal Project of the National Institute of Neurological and Communicative Disorders and Stroke, the NCPP. About 4% of children in the NCPP who had at least one non-febrile nonsymptomatic seizure by the age of 7 years had a previous seizure during acute neurologic illness, such as meningitis or during the acute illness after trauma. Many such seizures should potentially be preventable. Of children with seizures, 10% had had a neonatal seizure and 13% had had a febrile seizure. Among the hundreds of prenatal and perinatal factors explored as predictors of childhood seizure disorders, the principal predictors identified were congenital malformations of the fetus, cerebral and noncerebral; family history of certain neurologic disorders; and neonatal seizures. In agreement with the British National Child Development Study, labor and delivery factors in the NCPP appeared to contribute very little to childhood seizure disorders. Maldevelopment, rather than damage at birth to an initially intact nervous system, appeared to be the more common mechanism. Most seizure disorders of early childhood remained unexplained by the large set of prenatal and perinatal characteristics examined.     

Anticonvulsant Drugs and Cognitive Function: A Review of the Literature

Summary: Alterations of cognitive function are separate from disturbances of behavior seen in association with epilepsy. The nature of the cognitive disability may to a certain extent depend on the seizure type. Partial seizures, mainly derived from a temporal lobe focus, impair memory tasks, while generalized seizures seem to have more effect on attentional abilities. A number of studies, reviewed in this paper, suggest that anticonvulsant drugs further impair cognitive function. Maximal impairments are seen in patients receiving polytherapy: rationalization of polytherapy improves cognitive abilities. Studies in children and adults have allowed differentiation of the effects of various commonly used antiepileptic agents. Maximal cognitive deficits are seen with. phenytoin, while phenobarbital and sodium valproate induce moderate disturbances, and carbamazepine seems relatively free from such toxicity. Further research is needed on the interrelationship between types of seizure disorders, types of anticonvulsant medications, and cognitive function.     

Effects of NMD A- and AMPA-Receptor Antagonists on Different Forms of Epileptiform Activity in Rat Temporal Cortex Slices

Summary: Lowering extracellular magnesium induces different patterns of epileptiform activity in rat hippocampus and entorhinal cortex. Short recurrent epileptiform discharges in the hippocampus are stable over time, whereas seizurelike events (SLEs) in the entorhinal cortex, the subiculum, and the neighboring neocortex develop into late recurrent discharges which are not blocked by clinically employed antiepileptic drugs. We tested the sensitivity of the different epileptiform discharge patterns to. /V-methyl-D-aspartate (NMDA)- and non-NMDA-receptor antagonists. As NMDA-receptor antagonist we used dextrorphan, ket-amine, and 2-aminophosphonovalerate (2APV); as α-amino-3-hydroxy-5-methyl-4-isoxazole-propionic acid (AMPA)-receptor antagonist we employed the quinoxaline derivative glutamate 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX). The findings show that the different patterns of epileptiform activity, including the late recurrent discharges, are sensitive to all NMDA-receptor antagonists. However, when dextrorphan was employed to suppress seizure-like events, later recurrent discharges did not develop during the remaining time course of the experiment. CNQX reversibly suppressed recurrent discharges in the hippocampus and SLEs in the entorhinal cortex. However, late recurrent discharges become insensitive to CNQX, even at a high concentration of 60 μM m. This finding suggests a prominent role for NMDA receptors in the generation of late recurrent discharges.     

The influence of comorbid depression on seizure severity

PURPOSE: To determine the relation between depressive symptoms and seizure severity among people with epilepsy. METHODS: A postal questionnaire was used to survey a nationwide community sample about seizures and depression. The Seizure Severity Questionnaire (SSQ) assessed the severity and bothersomeness of seizure components. The Centers for Epidemiological Studies-Depression scale categorized levels of depression. RESULTS: Respondents categorized as having current severe (SEV, n = 166), mild-moderate (MOD, n = 74), or no depression (NO, n = 443) differed significantly in SSQ scores (all p < 0.0001). People with SEV or MOD reported significantly worse problems than did those with NO depression for overall seizure recovery (mean, 5.3, 4.9, 4.5, respectively); overall severity (5.0, 4.5, 4.2); and overall seizure bother (5.3, 4.8, 4.4) (all p < 0.005). Cognitive, emotional, and physical aspects of seizure recovery also were rated worse among people with SEV than with NO depression (all p < 0.05). Symptoms of depression were significantly correlated with higher levels of all components of generalized tonic-clonic seizure severity (r = 0.33-0.48; all p < 0.0001), and partial seizures (r = 0.31-0.38; all p < 0.01). CONCLUSIONS: Clinically depressed people with epilepsy reported higher levels of perceived severity and bother from seizures, as well as greater problems with overall seizure recovery than did nondepressed people experiencing similar types of seizures. The pervasive influence of depressive symptoms on reports of seizure activity suggests that people with epilepsy should be screened for depression. These data highlight the importance of detecting and treating depression among people with epilepsy.     

Une phénoménologie de la dépendance à l'alcool. Une expérience primordiale de la « nostrité »

The phenomenological approach to alcoholism interestingly focuses on specific dynamics of interpersonal relationships displaying the founding of the Self from a primary “us” and its original basis in the human feast. Priorities for treatment intervention recommend to involve social setting and relationships of the patients, reaching their active participation to a motivational and long term group treatment, underlying the specific therapeutic effect of world exchanges. Biopsychosocial determination of alcoholism could be primarily based on components of interpersonal relationships. Regarding social background, drinking is one of the most famous supports for the achievement of the feast, a founding marker of present time. Taking an existential point of view, the feast appears as the heart of mankind because it presents a primary “us”, a plural state which indicates the beginning and founding of the Self from the others. During the feast, we regularly have to reach our Self from the “us” while avoiding two main dangers, drunkenness, an increase in the dizziness of upright verticality, and addiction, an opposite vertical surrender to alcohol and falling into in the alcoholic relapse, both situations imply a spatial domination and the disappearance of others. Treatment programs of alcohol addicts need to integrate the necessity of reaching the existential basic trust from the support of a group to the appropriation of the community which can be defined as an original “usness”.