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More Less | | EUR | | PRO-level points: 12, Questions answered: 26, Questions asked: 70 | Sample translations submitted: 1 Spanish to English: Bronchogenic carcinoma in patients undergoing solid organ transplant. The role of surgery
General field: Medical
Detailed field: Medical (general) | Source text - Spanish
Introducción
Es conocido que los pacientes sometidos a un trasplante de órgano sólido tienen un riesgo mayor de presentar un proceso neoplásico que la población general, el cual aumenta con el tiempo de supervivencia tras el trasplante y sería consecuencia de la terapia inmunosupresora1. , la incidencia de carcinoma broncogénico (CB) en pacientes con trasplante de órgano sólido es controvertida2. En la pasada década, determinados trabajos pusieron de manifiesto una elevada tasa de CB en pacientes sometidos previamente a trasplante cardíaco[3] and [4]. estudios más recientes han mostrado una incidencia similar a la acontecida en pacientes no trasplantados[2], [5] and [6]. El pronóstico de estos pacientes es muy desfavorable debido, a que el diagnóstico se establece en un estadio avanzado de la enfermedad[2] and [6].
El objetivo de nuestro estudio es conocer la incidencia de CB en los pacientes trasplantados en nuestro hospital y el papel de la cirugía en estos pacientes.
Hasta diciembre de 2006, en el Hospital Universitario La Fe, 3.596 pacientes han sido sometidos a un trasplante de órgano sólido; 24 (0,7%) pacientes desarrollaron posteriormente un CB. La incidencia, según tipo de trasplante, fue de 10 entre 1.539 (0,6%) sometidos a trasplante renal, 9 de 1.249 (0,7%) trasplantes hepáticos, 4 entre 498 (0,8%) trasplantes cardíacos y 1 de 311 (0,3%) trasplantes pulmonares. Se clasificó en estadio clínico I a 6 (24%) pacientes, y se sometieron a tratamiento quirúrgico. Se desestimó a 4 pacientes para cirugía por criterio funcional y 14, por criterio oncológico (4 con carcinoma microcítico, 5 en estadio IIIB y 7 en estadio IV).
La valoración preoperatoria incluyó: estado clínico general —Eastern Cooperative Oncology Group (ECOG)—, bioquímica básica, electrocardiograma (ECG), espirometría, tomografía computarizada (TC) toracoabdominal y cerebral y tomografía por emisión de positrones (PET). El diagnóstico de CB se estableció antes de la cirugía mediante fibrobroncoscopia o punción transparietal. El fallecimiento por CB o por otra causa fue el evento terminal para el cálculo de la supervivencia, que fue estimada mediante el método de Kaplan-Meier. La fecha de observación quedó establecida el 1 de mayo de 2008.
Las características clínicas, quirúrgicas, histológicas y de evolución quedan recogidas en las Tabla 1 and Tabla 2. Todos eran varones, con una media de edad de 58,6 (intervalo, 47–66) años. En todos ellos se comprobó una historia de tabaquismo de más de 30 años/paquete. Había 3 pacientes ex fumadores y 3 fumadores activos en el momento en que fueron diagnosticados de CB; 2 pacientes presentaron tos, en uno, acompañada de expectoración hemoptoica y en los demás fue un hallazgo casual; 3 habían sido sometidos a trasplante hepático; 2, renal y 1, cardíaco. El intervalo entre trasplante y diagnóstico de CB fue de 38,2 (intervalo, 13–61) meses. Se realizó una neumonectomía, tres lobectomías y dos resecciones en cuña. El carcinoma epidermoide fue la estirpe histológica más frecuente. La media del tamaño tumoral fue 3,6 (intervalo, 1,3–6) cm. Un tumor fue clasificado en estadio IA patológico; cuatro, en IB y uno, en IIB por invasión de la pleura parietal.
Ningún paciente falleció durante el periodo perioperatorio y sólo uno presentó hemotórax que se resolvió mediante drenaje endotorácico. La media de estancia fue 8,5 (intervalo, 7–11) días. El régimen de inmunosupresión fue mantenido continuamente. En el seguimiento posterior, 1 paciente falleció por metástasis de CB, otro por sepsis, otro por insuficiencia renal crónica y 3 permanecían vivos. La probabilidad de supervivencia a los 5 años fue del 40%; la mediana quedó establecida en 5 años (fig. 1).
Determinados carcinomas observados frecuentemente en la población, como el carcinoma escamoso de piel o el carcinoma in situ de cérvix uterino, presentan una incidencia significativamente mayor en la población trasplantada. On the contrary, en otros carcinomas, incluido el CB, no parece objetivarse este hecho1. Determinados autores no han comprobado una mayor incidencia de CB en pacientes trasplantados con respecto a la población general[2], [5] and [6]. In our experience, aunque la tasa de CB fue relativamente baja (0,7%), fue mayor que la observada en nuestro medio en pacientes no trasplantados (0,05%–0,1%)7. En la pasada década, algunos autores observaron una elevada tasa de CB en pacientes sometidos a trasplante cardíaco[3] and [4]. However, coincidimos con otros autores en que no hay una relación entre el hecho de padecer un CB y el tipo de trasplante realizado, y sí con la historia previa de tabaquismo2.
En revisiones anteriores, se ha constatado que, approximately el 90% de los pacientes trasplantados que luego presentaron un CB eran o habían sido fumadores, la mayoría eran varones y la media de edad era 50–60 años[2], [5] and [6]. Estas observaciones, que coinciden con nuestra experiencia, ponen de manifiesto que no hay diferencias en la aparición de un CB en la población trasplantada con respecto a la población general, lo que podría cuestionar el papel del tratamiento inmunosupresor como principal factor etiológico, máxime si se tiene en cuenta que cuando se ha observado un CB en pacientes con trasplante pulmonar, se trataba de trasplante unipulmonar y el tumor, como sucedió en nuestro caso, se manifestó en el pulmón nativo. Ahmed et al8, en una serie de pacientes sometidos a cirugía cuyo resultado, en términos de supervivencia, se asemeja al de nuestra serie, consideran que si bien el tabaquismo es el principal factor de riesgo, la inmunosupresión parece tener un papel importante, sobre todo en pacientes trasplantados y seguidos a largo plazo, es el caso de los pacientes con trasplantes renales, en los que también parece aumentar la incidencia de CB aun sin antecedentes de tabaquismo. En este sentido Bellil et al9, en una reciente revisión, también comentan el aumento de incidencia de CB en pacientes trasplantados, en que el tabaco vuelve a ser el principal factor de riesgo, si bien la inmunosupresión podría condicionar tanto el aumento en la incidencia como la agresividad tumoral en el momento del diagnóstico.
Cuando se establece el diagnóstico de CB, aproximadamente en dos tercios de los pacientes el tumor está en un estadio avanzado, por lo que son pocos los pacientes tratados con cirugía2. Esta observación podría ser consecuencia del efecto del tratamiento inmunosupresor en el crecimiento y la diseminación tumoral, como se ha demostrado experimentalmente10. On the other hand, no es infrecuente la confusión diagnóstica al etiquetar un CB como un proceso infeccioso[11] and [12]. En una reciente revisión, Bagan et al6 han comprobado que el 38% de los pacientes con trasplante cardíaco que luego desarrollaron CB fueron sometidos a cirugía completa. In our experience, la tasa de pacientes clasificados en estadio I clínico (25%) no es significativamente menor que la apuntada en nuestro medio7, lo que también cuestionaría el papel de la inmunosupresión en la agresividad tumoral.
La mediana de supervivencia en pacientes sometidos a cirugía curativa está en torno a los 23 meses, condicionada por el estadio patológico y la comorbilidad del paciente trasplantado, y también condiciona la morbimortalidad perioperatoria6. La mediana de supervivencia en nuestra serie fue 60 meses, con una morbilidad asumible y sin mortalidad perioperatoria.
To conclude, y en nuestra experiencia, la incidencia del CB en pacientes sometidos a trasplante de órgano sólido es algo mayor que en la población no trasplantada. However, la tasa de los pacientes diagnosticados en estadios precoces y que pueden beneficiarse del tratamiento quirúrgico no difiere de la de los pacientes no sometidos a trasplante. Finally, la cirugía puede ofrecer resultados aceptables en estadios precoces, con una morbimortalidad perioperatoria asumible.
| Translation - English
Introduction
It is well known that patients subject to a solid organ transplant run a greater risk of presenting a neoplastic disease than in the general public, which increases with survival time after the transplant as a consequence of immunosuppression therapy1. However, the incidence of bronchogenic carcinoma (BC) in solid organ transplant patients is controversial2. In the past decade, certain papers have manifested a high rate of BC in patients previously subject to heart transplants[3] and [4]. On the contrary, more recent studies have shown a similar incidence to that displayed in non-transplant patients[2], [5] and [6]. The prognosis of these patients is quite unfavourable due, mainly to the fact that diagnosis is established in an advanced stage of the disease[2] and [6].
The aim of our study is to determine the incidence of BC in our hospital’s transplant patients and the role of surgery.
Patients and methods
Until December 2006, in the University Hospital La Fe, 3,596 patients have undergone solid organ transplants and 24 (0.7%) patients subsequently developed BC. The incidence rate, according to type of transplant, was 10 out of 1,539 (0.6%) subject to kidney transplant, 9 out of 1,249 (0.7%) liver transplants, 4 out of 498 (0.8%) heart transplants and 1out of 311 (0.3%) lung transplants. Six patients (24%) were classified as clinical stage I and they were submitted to surgical treatment. Four patients were rejected for surgery based on functional criteria and 14 due to oncological criteria (4 with microcytic carcinoma, 5 in stage IIIB and 7 in stage IV).
Preoperative assessment included: general clinical state — Eastern Cooperative Oncology Group (ECOG) —, haemogram, basic biochemistry, coagulation, electrocardiogram (ECG), spirometry, thoracoabdominal and cerebral computerised tomography (CT) and positron emission tomography (PET). The diagnosis of BC was established before surgery via fibrobronchoscopy or transparietal puncture. Death from BC or another cause was the terminal event for survival calculation, estimated using the Kaplan-Meier method. Observation date was established as 1st May 2008.
Results
The clinical, surgical, histological and evolution characteristics are detailed in Table 1 and Table 2. All male, with an average age of 58.6 (range, 47-66). They all had an over 30 year history of smoking one packet/day. There were three former smokers and three active smokers at the time of BC diagnosis; two patients had a cough, one accompanied by blood expectoration and the BC was an incidental finding in the remaining cases; three had undergone liver transplants; two had kidney transplants and one had a heart transplant. The interval between the transplant and BC diagnosis was 38.2 (range, 13-61) months. A pneumonectomy, three lobectomies and two wedge resections were performed. The most frequent histological type was the epidermoid carcinoma. The average tumour size was 3.6 (range, 1.3-6) cm. One tumour was classified as pathological stage IA, four as stage IB and one as IIB due to parietal pleural invasion.
No patient died during the perioperative period and only one had a haemothorax which was resolved with intrathoracic drainage. The average hospital stay was 8.5 (range, 7-11) days. The immunosuppression regimen was maintained continuously. In subsequent follow-up, one patient died from BC metastasis, one from sepsis, one from chronic renal failure, and three remained alive. The probability of survival at 5 years was 40%, and median survival was established at 5 years (fig. 1).
Discussion
Certain carcinomas frequently observed in the population, such as squamous cell carcinoma or carcinoma in situ of the uterine cervix; present a significantly higher incidence rate in the transplanted segment. By contrast, in other carcinomas, including BC, there is no evidence of this1. Certain authors have not substantiated a greater incidence of BC in transplant patients with respect to the general population[2], [5] and [6]. In our experience, although the BC rate was relatively low (0.7%), it was higher than that observed in our institution in non-transplant patients (0.05-0.1%)7. In the past decade, some authors have observed a high rate of BC in patients subject to heart transplants[3] and [4]. However, we agree with other authors in that there is no relation between suffering BC and the type of transplant undertaken, but it is related to a previous history of smoking2.
It has been confirmed in previous check-ups that, approximately 90% of the transplant patients that then manifested BC were or had been smokers, the majority were male and the average age was 50-60[2], [5] and [6]. These observations coincide with our experience and bring into relief that there are no differences in the appearance of BC in the transplanted population with regards to the general population. This could question the role of immunosuppression treatment as a main aetiological factor, especially keeping in mind that when a BC has been observed in lung transplant patients, it was in single lung transplants and the tumour, as occurred in our study, was on the recipient’s native lung. Ahmed et al8, in a series of patients subject to surgery with results, in terms of survival, similar to our series, consider that while smoking is the main risk factor, immunosuppression seems to also play an important role, especially in transplant patients followed-up in the long term. This is the case of kidney transplant patients, in which the incidence of BC also seems to have increased even without a background of smoking. In this sense, Bellil et al9, also comment on the increase in the BC incidence rate in transplant patients, in which smoking is once again the key risk factor; even though immunosuppression could condition both the incidence increase and the tumour aggression at the time of diagnosis.
When the BC diagnosis is established, the tumour is in an advanced stage in approximately two thirds of the patients, so very few patients are surgically treated2. This observation could be the consequence of the effect of immunosuppression treatment in tumour growth and spreading, as has been experimentally proven10. On the other hand, the diagnostic confusion of labelling a BC as an infection is not infrequent11] and [12]. In a recent review, Bagan et al6 substantiated that 38% of heart transplant patients that later developed BC underwent complete surgery. In our experience, the rate of patients classified at clinical stage I (25%) is not significantly lower than observed in our institution7, which also questions the role of immunosuppression in tumour aggression.
The survival average in patients subject to curative surgery is in the region of 23 months, conditioned by the pathological state and the comorbidity of the transplant patient and also conditions the perioperative morbid-mortality6. The survival average in our study was 60 months, with acceptable morbidity without perioperative mortality.
To conclude, in our experience, BC incidence in patients subject to solid organ transplant is slightly higher than in the non-transplanted population. However, the rate of patients diagnosed in early stages and who could benefit from surgical treatment does not differ from that of non-transplant patients. Finally, surgery can offer acceptable results in early stages, with satisfactory perioperative morbid-mortality. |
More Less | | Cosmetic Medicine, medical | | Bachelor's degree - UNSW & UCM | | Years of translation experience: 18. Registered at ProZ.com: Nov 2000. | | N/A | Spanish to English (bilingual upbringing)
English to Spanish (bilingual upbringing)
French to English ()
Spanish to English (Chartered Institute of Linguists)
English to Spanish (NSW University - BA Spanish & Latin American Studi)
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