Department of Medicine, Institut Gustave Roussy, Villejuif; University of Paris XI, Kremlin Bicêtre.
Intensive Care Unit, Institut Gustave Roussy, Villejuif, France.
Ann Oncol. 2010 Aug;21(8):1585-1588. doi: 10.1093/annonc/mdq021. Epub 2010 Feb 24.
Patients with extensive lung metastases from nonseminomatous germ-cell tumours (NSGCTs) and dyspnoea at presentation are at high risk of acute respiratory distress syndrome (ARDS) and death within the first weeks after chemotherapy induction. This syndrome is linked to acute intra-alveolar haemorrhage related to early tumour necrosis, which in turn, can be complicated by pulmonary infection promoted by neutropenia. The management of these patients was modified at Institut Gustave Roussy in 1997 to try to avoid this complication.
Data concerning all patients with lung metastases from NSGCT and dyspnoea or a partial pressure of oxygen (pO(2)) <80 mmHg treated from 1980 to 2006 in our institution were collected. Patients were treated in a specialised intensive care unit. From 1980 to 1997, the first chemotherapy cycle consisted in a full-dose regimen. After 1997, a 3-day reduced induction regimen of EP (cisplatin 20 mg/m(2)/day and etoposide 100 mg/m(2)/day) was used, with bleomycin and two additional days of EP being postponed to day 15, with the regular BEP regimen being started at day 21.
Twenty-five patients with poor-risk disseminated NSGCT according to the International Germ Cell Consensus Classification Group had extensive lung metastases plus dyspnoea at presentation (n = 6), a pO(2) <80 mmHg (n = 2), or both criteria (n = 17). Median human chorionic gonadotrophin was 200 000 UI (range 11-8 920 000), and 18 of 25 (72%) patients also had nonpulmonary visceral metastases. During the 1980-1997 period, 13 of 15 patients (87%) developed ARDS, 10 of whom died, and only 4 of 15 (27%) patients were long-term survivors. In contrast, during the 1997-2006 period, only 3 of 10 patients (30%) developed ARDS (P = 0.01), 2 of whom died, and 4 of 10 (40%) eventually survived.
Initial reduction of chemotherapy doses during the first cycle of chemotherapy for poor prognosis NSGCT with extensive lung metastases seems to prevent the risk of early death due to ARDS.
广泛肺转移的非精原细胞瘤生殖细胞肿瘤（NSGCT）患者，以及有呼吸困难症状的患者，在化疗诱导后最初数周内有发生急性呼吸窘迫综合征（ARDS）和死亡的高风险。这种综合征与肿瘤早期坏死相关的急性肺泡内出血有关，而中性粒细胞减少引起的肺部感染又会使情况复杂化。1997 年，古斯塔夫·鲁西研究所对这些患者的治疗方案进行了修改，以试图避免这种并发症。
收集了 1980 年至 2006 年期间在我院接受治疗的所有有肺转移且呼吸困难或氧分压（pO(2))<80mmHg 的 NSGCT 患者的数据。患者在专门的重症监护病房接受治疗。1980 年至 1997 年，第一化疗周期采用全剂量方案。1997 年后，采用 EP（顺铂 20mg/m(2)/天和依托泊苷 100mg/m(2)/天）3 天的低诱导方案，博来霉素和另外两天的 EP 推迟到第 15 天，第 21 天开始常规 BEP 方案。
根据国际生殖细胞共识分类组，25 例有不良预后的播散性 NSGCT 患者有广泛的肺转移并伴有呼吸困难（n=6）、pO(2)<80mmHg（n=2）或两者兼有（n=17）。人绒毛膜促性腺激素中位数为 200000UI（范围 11-8920000），25 例患者中有 18 例（72%）还存在非肺部内脏转移。在 1980-1997 年期间，15 例患者中有 13 例（87%）发生了 ARDS，其中 10 例死亡，仅有 15 例患者中的 4 例（27%）长期存活。相比之下，在 1997-2006 年期间，仅有 10 例患者中的 3 例（30%）发生了 ARDS（P=0.01），其中 2 例死亡，最终有 4 例（40%）患者存活。
对于有广泛肺转移且预后不良的 NSGCT 患者，在第一个化疗周期中减少初始化疗剂量，似乎可以降低因 ARDS 导致的早期死亡风险。
